Performance Improvement in
Community Health Centers
Sponsored by the
National Association of Community Health Centers
Presented By Shoreline Health Solutions, LLC
Trudy Brown Ripin, MPH
Molly K. Gwisc, MPH
President & Founder
Associate
Presentation Goals
 Understand Performance Improvement methodology, as well as
practical techniques for quality improvement.
 Effectively use the PI model in a new start Community Health
Center
 Review case studies to demonstrate PI in real scenarios
 Understand proactive and reactive performance improvement
strategies
Improving Performance

How do we know we are providing high quality care
and services?

Do we set and achieve appropriate and realistic
goals?

How do we measure improvement?
What is Performance Improvement?
 Performance Improvement (PI) is a continuous,
systematic process for improving the agency’s care,
service and operations.
Why do Performance Improvement?
 Methodological way to ensure high quality care & patient safety
 Tells you if changes worked
 PI model gives you concrete steps to simplify a complex process
 BPHC and JCAHO require it
What If We Don’t Measure?
 You won’t know if the change WORKED
 You won’t know WHICH PART of the change worked
 You could make things WORSE
 Others may NOT BELIEVE the change worked
Selecting a PI Project
 Triggered by a specific incident
 Based on existing data trends
 Prioritizing: High Risk, High Volume, Problem Prone
 Directly impacts patient care or patient satisfaction
Key Elements of a PI Model
1.
Establish baseline
2. Set benchmark
3. Make change
4. Measure your change
5. Follow-up
FOCUS - PDSA
 PDSA is one of many models for PI
 Four - step cycle to plan and measure change
 FOCUS component maps out Pre-Work to PDSA
FOCUS
Find a process to improve
Organize a team
Clarify what is currently happening (baseline data)
Understand where and why problems occur
Select the process improvement and benchmark
PDSA
Plan the Performance Improvement strategy
Do a trial run, collect data as you go
Study your results
Was there a measurable improvement?
If not, go back to PLAN until benchmark is achieved
Act! Ongoing monitoring for sustained improvement
Operational PI Examples
 Patient Wait Time
 Patient Satisfaction
 Staff Satisfaction
 Claims Denial
 Collections
Operational PI Case Study
Improving Patient Wait Times
F Chose wait times in response to patient demand - patient complaints
O Formulated team involved in areas of wait time – included a clinical
provider, medical assistant, registration staff, billing staff, senior
management
C
U
S
Collected baseline data through wait time study
Understood problem areas by clarifying where delays occur - delays
occurred at registration, waiting in exam room, and billing
Selected to de-centralize intake as first process improvement –
benchmark is reducing wait time by 20 minutes.
Operational PI Case Study
Improving Patient Wait Times
P Plan thoroughly developed and outlined by team
D Plan implemented in pediatrics
S Data collected and not at benchmark – repeat cycle
A Benchmark achieved!! Implemented changes in all
departments
High Level Integration
 An effective PI program incorporates all data
sources through a central PI Committee and
integrated PI Program infrastructure.
PI Committee Structure
 Select Representative Members
 Integrate into all sites
 Meet regularly
 Appoint PI Coordinator
 Complete assignments between meetings
 Select 1-2 PI Priorities Annually
 Appoint PI Teams
 Ensure Ongoing Monitoring
 Review Key Data Trends From All Sources
Components of PI Program
Proactive Strategies




Peer Review
Chart Completeness Review
Informed Consent – High Risk Procedures
Patient Satisfaction
Reactive Strategies



Incident Tracking
Patient Complaint Tracking
Sentinel Event Response
Peer Review
• Providers Review Each Other’s Charts
• Standardized Audit Tool
• Identify Trends
• Report Results to Staff and Leadership
Peer Review Goals
 Review Individual Trends Over Time
 Review Clinical Practice Trends
 Answer Specific Clinical Questions
Chart Completeness Review
 Evaluates Medical Record Documentation
 Checklist is Standardized
 Usually Done Monthly
 Can Be Done By Non-Clinical Staff
High Risk Procedures – Informed Consent
• What is a High-risk Procedure?
 Risk Of Serious Complications
 Examples Include Perforation & Infection
• Informed Consent Needed
 Understand Benefits & Risks
 Be Informed Of Alternatives
 Good Clinical Care
 Liability Protection/ Risk Management
Patient Satisfaction Program
 Components of a Comprehensive Pt Satisfaction
Program
 Surveys
 Staff Training
 Patient Suggestion/Comment Box
 Patient Complaint Tracking System
Incident Tracking
 Documenting the Event
 Incident Review
 Resolving the Incident
 Identifying Trends
Patient Complaint Tracking
• Identifies customer service and communication problems
• Utilizes same process as Incident Tracking
 Rapid response to each complaint
 Feedback to patient describing agency response
 Complaint patterns indicate systemic problems
 Structured response to systems problems
Sentinel Event Response
 What is a sentinel event?
 Near Miss
 Do Not Wait for a Trend
 Root Cause Analysis
Clinical PI Examples
 Triage:
 Child with 104 degree fever scheduled for next day
appointment
 Walk-in patient left waiting for 2 hours when should have
been sent to ER
 Evaluation
 Missed Diagnosis
 Mis-Diagnosis
 Labs not ordered
 Treatment
 Wrong medication prescribed
 Perforation during IUD insertion
Clinical PI Examples
 Lab Issues
 Patient given wrong person’s test results
 Lab tests ordered, but never done
 Results never come back from outside lab
 Controlled Substances
 Stolen prescription pads / forged prescriptions
 Patient seeing multiple providers / pharmacies to obtain
controlled substances
Clinical PI Examples
 Chart Documentation
 Illegible handwriting
 Provider seeing patient without chart
 Phone/ Communication
 Provider never receives patient message
 Language and cultural barriers
Clinical PI Case Study
Follow-Up for Abnormal Labs
F Identified problem through incident tracking.
O Team included Medical Director, Nurse Coordinator, Medical
Assistant, Lab Tech, staff person receiving mail / fax / delivery of lab
results.
C Baseline data collected via lab testing log, 3 week period reviewed.
U Problem areas included use of multiple outside labs, high volume,
part-time clinicians, no clear person in charge of process.
S Identified responsible person to track all abnormal labs. Benchmark
set at 100% follow-up rate within 24 hours of notification.
Clinical PI Case Study
Follow-Up for Abnormal Labs
P Plan thoroughly developed and outlined by team.
D Implemented for three providers
S Data collected: 24-hour follow-up achieved for 95% of
cases. Not at benchmark – repeat cycle.
A Benchmark achieved!! Implemented changes for all
providers.
Resources
 NACHC
www.nachc.org
 BPHC
www.bphc.hrsa.gov
 JCAHO
www.jcaho.org
 Institute for Healthcare Improvement
www.ihi.org
 Your State’s Primary Care Association/Organization
 Contact us with questions
(Trudy or Molly, Shoreline Health Solutions)
[email protected] or (860) 395-5630
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Performance Improvement for Community Health Centers