Dr. Genevieve Brauning Hawgood
Angela B. Allen, MA
Associate Director of Administrative Services
UNC Charlotte Student Health Center
Compare PDSA and AAAHC 10-point QI Rubric
Discuss implementing a QI initiative
How to get people interested
How to identify areas for QI
Demonstrate a QI study, step-by-step
Discuss the importance of follow-up
What is Quality Improvement and why is it
important?
QI Acronyms
The Task of Quality Improvement
Getting Buy-in and Finding Topics
Models of Quality Improvement
PDSA
AAAHC 10-point Model
Pap Smear Guideline Adherence at UNC
Charlotte’s Student Health Center
Quality improvement programs are not just to
pacify accreditation associations.
The purpose of QI in a health care setting is to
improve patient outcomes.
The important components are:
Identifying issues or areas in which the organization
is lagging behind goals or benchmarks,
Implementing corrective actions,
Ensuring they have the desired impact, and
Communicating these results to stakeholders.
Why do we have to do this?
Everybody gets annoyed when processes don’t
make sense
Employees like to have a say in policies &
procedures
Numbers help make your case
Which kind of spiral do you want?
Accreditation bodies make you!
Finding Topics
Use your QI Committee members
List of possible topics
• What changes need
to be made?
• Does there need to
be another cycle?
• Analyze Data
• Compare Results to
Predictions
• Summarize what was
learned
Act
Plan
Study
Do
• Objectives
• Predictions
• Plan to carry out the
study (who, what,
where, when)
• Plan for data
collection
• Carry out the Plan
• Document
Observations
• Record Data
10 simple, and acronym-free, steps
Structured framework for identifying problems,
crafting solutions, and following through with
implementation
1.
2.
3.
4.
5.
State your problem and explain
why it is important.
Identify measurable internal
and/or external benchmarks. Set
performance goal.
What data will you collect & how.
Collect data and describe.
Analyze data.
6.
Compare data to benchmarks and
performance goals. Is there really a
problem? No? Back to step one.
7. Identify and implement corrective
actions.
8. Re-measure.
9. Goals met? If not, go back two
steps.
10. Communicate findings.
Can’t find a problem?
Some places to look:
Work flow and wait times
Patient satisfaction
Staff morale
Follow up and/or tracking problems
Problems identified in peer review
Disease management
Adherence to treatment guidelines
What was the problem & why was it important?
Historical practice of providing Pap Smear to
sexually active women, regardless of age.
November of 2009, new guidelines published by
The American College of Obstetricians and
Gynecologists.
Suspected that unnecessary Pap tests were still
being conducted at the Student Health Center.
Importance of new guidelines in reducing false
positives, unnecessary tests & trauma.
Where to find Benchmark data:
Internal data sources
EMR
ACHA-PSAS or other patient satisfaction survey
External data sources
CORE or NCHA
ACHA Benchmarking Committee
Centers for Disease Control or State Health Department
http://www.health.ny.gov/statistics/chac/national.htm
Participation in surveillance networks
Setting a realistic goal
Our Benchmarks and Our Goals
Our external benchmarks:
From the Centers for Disease Control:
In 2000, 76.4% of women aged 18-21 had received a Pap Test
By 2010, this number had dropped to 52.5%
From the University of Virginia College Health Surveillance
Network (CHSN):
National data from the 2011-2012 academic year indicated that
only 2% of women under 21 were receiving Pap Tests
In the southern region, 3.71% were receiving Pap Tests
Our internal benchmarks:
Pulling data from January & February 2011, we found that
23 women under age 21 scheduled pap test. Of these, 21
of them received a pap (91%), so we were at an abysmal
compliance rate of 9%.
Our Benchmarks and Our Goals
Our Goal:
Clearly, we had a long way to go!
We were nowhere near either CDC, national, or
regional benchmarks.
We set a lofty goal of 95% compliance (only 5% under
21 receiving unneeded pap tests)
This was a big goal, given our current compliance, but
was actually a bit under the CHSN benchmarks.
What data do you need to collect?
Is aggregate data sufficient or do you need to drill
down to certain demographics
Can you just look at the numbers, or will you need to
review individual records?
Where are the data?
EMR
Internal Survey
In your paper file storehouse 
How will you collect them?
If you have EMR, do you know how to pull the reports?
If you don’t, do you have willing data geeks?
Who will collect them?
Do you just need data folks or do you need a clinical
person to review the files?
What we needed and how we got it
We needed:
Number of women under 21 who were scheduled
for P&P at the Student Health Center.
Number of women under 21 who received pap
tests at our facility.
If any of the women under 21 receiving a pap had a
medical history that would justify it.
This was not just a data driven report, it
required a clinical review
This is why the time frame for our internal
benchmark was so limited.
Run the reports
Describe the data you pulled
Don’t try to analyze at this step, just tell your
audience about what you have.
Our Data
For our internal benchmark, we had pulled a
report from January and February of 2011.
For our first data point, we pulled the same
report for January & February of 2012.
There were 34 women under 21 scheduled for P&P
appointments during this time frame
Of these, 8 women actually had pap tests done.
None of the 8 had a medical history that would
indicate a pap test.
Could be as simple as percentages
Could need to break out by demographics
Could need to enlist the help of your resident
stats geek
Our Analysis
For our study, we were just dealing with
percentages so there wasn’t much analysis to
do. The bulk of the work was in reviewing each
file for important history.
So, 8 out of 34 women under age 21 had a pap
done despite the fact that there was no medical
reason for doing a pap.
This is 23.5% receiving an unnecessary pap, or
75% compliance with the guidelines.
Do we have a problem?
Not all hypotheses are correct
“No problem” is still a valid finding
If no problem:
Pat yourself on the back for doing a good job
Go back to step one
If there is a problem, congratulations! You’ve
found something useful to try to fix.
Move on to Step Seven
Did we have a problem to correct?
Our goal, based on our benchmarks was 95%
compliance.
Although our compliance had increased
dramatically from 2011 (9% compliance) to
2012 (75% compliance), we were still short of
our goal.
So, yes, we had a problem that needed to be
addressed.
The time to brainstorm about solutions is when
you know you have a problem
Now that you’ve identified the issue, what do
you think might work?
You have an idea? Give it a shot!
Implement ONE corrective action at a time
Our corrective action
We believed that the problem was clinic-wide.
The guidelines were a dramatic departure from
conventional wisdom.
We decided that the best way to combat this
problem was to design a training:
What are the guidelines?
More important, why?
What is the danger of continuing as we were?
You implemented one corrective action
You gave it some time to work
Did it work?
Re-measure
Collect data again, like you did in step four
Analyze again, like you did in step five
Our second collection of data
Dr. Brauning presented the training to our entire
staff in March of 2012
In April of 2012, we ran another report to see if
there had been any changes in the incidence of
pap tests for patients under 21.
Between 4/1/2012 and 4/30/12, 41 patients
under the age of 21 were scheduled for a P&P.
Of these, only 7 were given a pap test.
You implemented a change & gave it some time
You re-measured and analyzed again
Did it work?
No? Back to step seven and brainstorm another
intervention
Yes? Congratulations, you’re almost done!
Did we meet our goals?
So, out of 41 women under 21 that were
scheduled for a P&P, only 7 had one (7.3%).
This meant that we were now at 92.7%
compliance.
We were climbing, but we weren’t there yet.
Back to Step 7
Step 7: Part two – Back to Brainstorming
The Problem:
Providers understand the guidelines
Maybe, as we thought originally, the students are
part of the problem.
Time to educate the students.
The Solution:
Create an information sheet for students.
Create a checkbox in EMR that documents provider
review of info sheet with students.
Step 8: Part Two – Re-measure … Again
We felt that the student education piece might
take a bit more time to work.
We also wanted to wait until we could compare
the same time frame as we had used in the first
two reports.
For our 3rd data point, we pulled the same
report as before for January & February of 2013
Step 9: Part Two - Did we meet our goals?
During January & February of 2013, 61 women
under 21 were given an appointment for a P&P
Only 4 received a pap test
Of these, 3 women had a history of abnormal pap
tests. So there was only one pap test given that
didn’t conform to the guidelines.
This is 1.6%, equating to a compliance rate of
98.4%
Did we meet our goals?
YES!!
Finally, on to Step 10
You worked hard
You got results
Make sure somebody knows … make sure
everybody knows!
Who needs to know?
Employees
Supervisors
Management Team
University Leadership
Accreditation Organization
How we communicated our success
Management Team has been on board with this
process from the beginning
However, once these goals were met, the
communications needed to be expanded:
Staff were informed via a congratulatory email
Management team was informed of the final
success of the project
The university will be informed on our annual
institutional effectiveness report
We are informing you