Your Quality Improvement Plan
Your Health Care Plan
………………………………………………………………..and stuff like that
Marti Wolf, RN, MPH
Clinical Programs Director
North Carolina Community Health Center Association
Session Description

Clinical Quality measures are popping up in many
areas and under many identities- Meaningful Use,
Patient Centered Medical Home, UDS, FTCA and
others. A good organizational plan for quality
improvement integrates all areas of operations and
all of the forms quality takes while minimizing
effort.
Objectives

What’s a Health Care Plan?

What’s a Quality Plan?

Clinical UDS???

Meaningful Use

Medical Home
Words From HRSA
Quality is a focus area nationally
and at HRSA
 Assessment of QI plans showed
areas for improvement
 Invest in your QI infrastructure
Clinical quality and beyond
 Focus on implementation
This work never ends

Benefits of an Effective QI Plan

Roadmap for HC organization
 Leadership,
focus, & prioritization
 Efficient coordination of staff &
resources
 Better outcomes

Satisfy external requirements
 HRSA,
State
 Third-party quality accreditation and
recognition
5
Benefits of QI Plan
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Federal Tort Claims Act deeming
 Health centers and free clinics
 ECRI resources
Data collection and analysis
 UDS, patient survey, EHB
Health Information Technology
 Adoption, meaningful use, health info exchange
Quality
 Third party quality recognition
 Aligning technical assistance for PCMH
transformation
 CMS
QI Plan- Define Quality
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Phillip Crosby- Doing the right thing right the first
time and every time.
Ensuring Quality is a Risk Management Plan
Institute of Medicine Definition of Quality:
The degree to which health services for individuals
and populations increase the likelihood of desired
health outcomes and are consistent with current
professional knowledge. STEEEP
Quality

Safe

Effective

Patient-Centered

Timely

Efficient

Equitable
QI Plan
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2-3 pages
General Concepts
Written = Commitment
What do you mean by Quality?
Provides Structure for your QI Program
 Quality
 Who
Improvement Committee
is on the Committee
 Terms of Service?
 Ad hoc members?
 How often do they meet?
 Documentation (agenda, minutes)
QI Plan

Methodology
 Lean,
6 Sigma, PDSA,
 Root Cause Analysis, etc, etc, etc

Data Collection Plan
 How
data is collected
 Internal and external sources of data
 Core components (stay general)
 Patient
satisfaction
 Staff satisfaction
 HRSA measures
 Other regulatory measures
 Business Plan measures
QI Plan

Content/Authority
 QI
activities in all areas of operation
 Audits
 Frequency

Use of Date
 QI

purpose (not punitive)
Communication Plan
 Staff
 Board
 Management
 Patients
Quality: FTCA Deeming

Federal Program Requirement in the Health
Center Program
 Quality
Improvement/Assurance Plan: Health
center has an ongoing Quality Improvement/
Quality Assurance (QI/QA) program that
includes clinical services and management,
and that maintains the confidentiality of
patient records. The QI/QA program must
include:
 Continued-
next slide…
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a clinical director whose focus of responsibility is to support
the quality improvement program and the provision of high
quality patient care;
periodic assessment of the appropriateness of the utilization
of services and the quality of services provided or proposed
to be provided to individuals served by the health center;
and such assessments shall:
be conducted by physicians or by other licensed health
professionals under the supervision of physicians;
be based on the systematic collection and evaluation of
patient records;
and identify and document the necessity for change in the
provision of services by the health center and result in the
institution of such change, where indicated.
(Section 330(k)(3)(C))
Elements of your Quality Plan:
FTCA recommended
1. QI teambuilding and responsibility across a range
of staff types
2. Self-assessment of areas to target
3. Setting concrete goals
4. Identifying strategies for improvement
5. Data collection and analysis
6. Evaluation and dissemination of lessons learned
7. Integration with operations and other quality related
activities
IHI Triple Aim
Quality of
Care
Patient
Experience
Cost of
Care
Perspectives on
Quality
Medical
Administrative
Patient
Quality

Results of Quality
 Improved
Outcomes
 Improved
efficiency and productivity
 Staff
and patient satisfaction
QI includes
Risk Management
 Credentialing and Privileging
 Current clinical standards of care
 Provider credentials and privileges
 Risk management procedures
 Patient grievance procedures
 Incident management
 Confidentiality of patient records

Demonstrating Quality

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Patient Centered Medical Home
 Patient Centered Health Home Initiative
Meaningful Use
Quality -
Food for Thought
Consistency requires you to be
as ignorant today as you were
a year ago .
-Bernard Berenson
Health Care Plan/Clinical UDS

PAL 2010-12 for the 2011 measures that will be
reported when you submit in 2012

Trimester of entry into care

LBW

2 year old immunization

Diabetes- A1c

HTN- BP <140/90
ENOUGH TO TRACK!
2011 Clinical UDS New and Revised Measures
2010 UDS manual- clinical measures start on p 49
http://bphc.hrsa.gov/healthcenterdatastatistics/reporting/
call archive
http://bphc.hrsa.gov/healthcenterdatastatistics/reporting/2010m
anual.pdf
Program Requirements #8
HCP Template
RISK MANAGEMENT
Disclaimer
Risk Management
is like
liver.
The more you chew it,
the bigger it gets.
Risk Management
PROTECT
AGAINST
LOSS
“Identify and plan for potential and actual risks… in terms of
facilities, staff, clients, financial, clinical and organizational wellbeing”. (NACHC, 2003)
RM in Ambulatory Care
“Identify and plan for potential and actual
risks… in terms of facilities, staff, clients,
financial, clinical and organizational wellbeing”. (NACHC, 2003)
RM in Ambulatory Care

How to pay for losses

Policy and Procedures

Review and evaluation of effectiveness

Annual employee training

System of anonymous reporting

Methods for investigating

Corrective actions
RM in Amb Care: Hot Topics
Credentialing and Privileging
 Medical Records

 Confidentiality
 Backup
(paper or electronic)
 Documentation
 Legibility
Meaningful Use CORE - EP

Eligible Professional (EP) Core Objectives (All 15
Must Be Implemented)
1. Use computerized prescriber order entry (CPOE) for
medication orders directly entered by any licensed health care
professional who can enter orders into the medical record per
state, local, and professional guidelines.
2. Implement drug–drug and drug–allergy interaction checks.
3. Maintain an up-to-date problem list of current and active
diagnoses.
4. Generate and transmit permissible prescriptions electronically.
5. Maintain active medication list.
Meaningful Use CORE - EP
6. Maintain active medication allergy list.
7. Record all of the following demographics: preferred
language, sex, race, ethnicity, and date of birth.
8. Record and chart changes in the following vital signs:
height, weight, blood pressure, calculate and display
body mass index (BMI), and plot and display growth
charts for children 2–20 years, including BMI.
9. Record smoking status for patients 13 years old or
older.
10. Report ambulatory clinical quality measures to the
CMS or, in the case of Medicaid EPs, the states.
Meaningful Use CORE - EP
11. Implement one clinical-decision-support rule relevant to
specialty or high clinical priority along with the ability to track
compliance with that rule.
12. Provide patients with an electronic copy of their health
information (including diagnostic test results, problem list,
medication lists, medication allergies) upon request.
13. Provide clinical summaries for patients for each office visit.
14. Capability to exchange key clinical information (for example,
problem list, medication list, allergies, and diagnostic test
results) electronically among providers of care and patient
authorized entities.
15. Protect electronic health information created or maintained
by the certified EHR technology through the implementation of
appropriate technical capabilities.
EP Menu Objectives
(Must Implement 5 of 10)
1.
Implement drug formulary checks.
2.
Incorporate clinical laboratory test results into EHR as structured data.
3.
4.
5.
6.
7.
8.
9.
10.
Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities,
research, or outreach.
Send patient reminders per patient preference for preventive/follow-up care.
Provide patients with timely electronic access to their health information (including lab results, problem list,
medication lists, and allergies) within 4 business days of the information being available to the EP.
Use certified EHR technology to identify patient-specific education resources and provide those resources to
the patient, if appropriate.
The EP who receives a patient from another setting of care or provider of care or believes an encounter is
relevant should perform medication reconciliation.
The EP who transitions a patient to another setting of care or provider of care or refers that patient to
another provider of care should provide summary care record for each transition of care or referral.
Capability to submit electronic data to immunization registries or immunization information systems and
actual submission in accordance with applicable law and practice.
Capability to submit electronic syndromic surveillance data to public health agencies and actual submission
in accordance with applicable law and practice.
Clinical Quality Measures for EPs
(Must Report 6 Total; 3 of 6 From Core or Alternate Set and 3 of 38 From
Additional Set)
Core Set

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Hypertension: blood pressure measurement
Preventive care and screening measure pair: tobacco-use
assessment and tobacco cessation intervention
Adult weight screening and follow-up
Alternate Core Set



Weight assessment and counseling for children and adolescents
Preventive care and screening: influenza immunization for
patients 50 years or older
Childhood immunization status
Additional Set (minus oncology)
1.
Diabetes: eye examination
2.
Diabetes: urine screening
3.
Diabetes: foot examination
4.
Diabetes: poor hemoglobin A1c control (>9.0%)
5.
Diabetes: hemoglobin A1c control (<8.0%)
6.
7.
8.
9.
10.
Diabetes: low-density-lipoprotein (LDL) cholesterol management and
control
Diabetes: blood pressure management
Diabetic retinopathy: documentation of presence or absence of
macular edema and level of severity of retinopathy
Diabetic retinopathy: communication with the physician managing
ongoing diabetes care
Primary open-angle glaucoma: optic nerve evaluation
Additional Set
11. Heart failure (HF): angiotensin-converting-enzyme inhibitor or
angiotensin receptor blocker therapy for left ventricular
systolic dysfunction (LVSD)
12. HF: β-blocker therapy for LVSD
13. HF: warfarin therapy for patients with atrial fibrillation
14. Coronary artery disease (CAD): β-blocker therapy for
patients with prior myocardial infarction
15. CAD: oral antiplatelet therapy
16. CAD: drug therapy for lowering LDL cholesterol
17. Ischemic vascular disease (IVD): blood pressure management
18. IVD: use of aspirin or another antithrombotic
19. IVD: complete lipid panel and LDL cholesterol control
Additional Set
20. Asthma assessment
21. Asthma pharmacologic therapy
22. Use of appropriate medications for asthma
23. Controlling high blood pressure
24. Antidepressant medication management: effective acute
phase treatment and effective continuation phase treatment
25. Appropriate testing for children with pharyngitis
26. Chlamydia screening for women
27. Cervical cancer screening
28. Breast cancer screening
29. Colorectal cancer screening
Additional Set
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30. Smoking and tobacco-use cessation, medical assistance:
advising smokers and tobacco users to quit, discussing smoking
and tobacco use cessation medications, and discussing smoking
and tobacco use cessation strategies
31. Initiation and engagement of alcohol and other drug
dependence treatment
32. Prenatal care: screening for human immunodeficiency virus
33. Prenatal care: anti-D immune globulin
34. Low back pain: use of imaging studies
35. Pneumonia vaccination status for older adults
Resources
HEALTHY NORTH CAROLINA 2020: A BETTER STATE OF HEALTH
HTTP://WWW.PUBLICHEALTH.NC.GOV/HNC2020/
INSTITUTE FOR HEALTHCARE IMPROVEMENT
HTTP://WWW.IHI.ORG/IHI/TOPICS/IMPROVEMENT/IMPROVEMENTMETHODS/MEASURES/
IMPROVING CHRONIC ILLNESS CARE
HTTP://WWW.IMPROVINGCHRONICCARE.ORG
2011 NEW AND REVISED CLINICAL MEASURES
HTTP://WWW.CMS.GOV/QUALITYMEASURES/03_ELECTRONICSPECIFICATIONS.ASP
An Introduction to Quality Assurance in Health Care.
Avedis Donabedian. 2003. Oxford University Press
The Improvement Guide.
Jerry Langley, et al.1996. Jossey-Bass Publishers.
Continuous Quality Improvement in Health Care.
McLaughlin and Kaluzny
Resources

Meaningful Use Stage 1 Clinical Quality Measures
http://www.hrsa.gov/healthit/meaningfuluse/MU%20Stage1%20CQM/index.html