APPLYING QI TO MATERNAL
CHILD HEALTH: INITIAL STORIES
FROM THE NNPHI QI AWARD
PROGRAM
Belinda Johnson-Cornett, Osceola County Health Department
Brittany Boyer, Clark County Health Department
Early Access Prenatal Care
Eliminating Barriers by Improving Processes
Belinda Johnson-Cornett, MS, RN-BC, MBA
Administrator
Osceola County Health Department
We will talk about…

Osceola County Health Department
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Why we choose this project…Health Status Indicators

AIM Statement

QI Project…thus far

Key Lessons Learned
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Osceola County
Quick Facts

Located in east Central Florida

Walt Disney World
• across both Osceola and
neighboring Orange County

Population of 270,000 residents
• daily average of 99,000 overnight visitors
• can swell seasonally to 138,000

Volume of world-wide tourists = huge
potential impact on public health
• Increased demand for epidemiological,
environmental, and public health
preparedness services
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Osceola County Health Department
Our Mission:

“protect & improve the health of all
residents in Osceola County”
From Our 2008-2013 Strategic Plan:

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monitor & improve the community’s health
status
improve access to health care services
integrate a culture of organizational
performance excellence
The Joint Commission Accreditation
in Ambulatory Care
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Background – Health Disparity
Osceola has a majority population (57%)
considered more likely to suffer from health
disparities:

Hispanic / Latino – 46%

Black / African American – 11%
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Background – Health Status Indicators
Late entry into prenatal care (after 1st trimester)
 Hispanic / Latino – 20%
 Black / African American – 26%

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Both worse than national benchmark -16%
Both equal to or worse than national severe
benchmark – 20%
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Background – Health Status Indicators
Low birth weight
 Hispanic / Latino – 8%
 Black / African American – 13%

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Both worse than national benchmark - 6%
Black / African American worse than national
severe benchmark – 10%
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Background – Health Status Indicators
Infant Mortality (per 1,000 population)
 Hispanic / Latino – 10
 Black / African American – 17


Both worse than national benchmark - 7
Both worse than national severe benchmark – 9
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Fetal & Infant Mortality/Morbidity
Review

FIMMR committee set up as part of 2008-2013 Strategic
Plan objectives

Researched Osceola’s poor birth outcome indicators

Results:
13% of mothers had no prenatal care
Highest fetal/infant deaths in 2 zip codes
In these 2 zip codes - 66% health disparate population
55% Hispanic / Latino
11% Black / African American
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Our QI Project
…based on our prenatal health indicators
GOAL = Improve access to prenatal care
Our Improvement Theory Prediction:
“IF…we reduce barriers to accessing care…
THEN…we will have a positive impact on
1.Women obtaining earlier prenatal care
2.Reducing poor birth outcomes
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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.
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9-Step Process Management Methodology / PDCA
STEPS
1. Identify Improvement
Opportunities & Prioritize
2. Team Development & Process
Owners
“What are we trying to accomplish?”
ACTIONS & QI TOOLS
1.1 Identify Problem Area/Opportunity (Brainstorm)
1.2 Prioritize Opportunity (Prioritization Matrix)
2.1 Determine Process Owners
2.2 Determine Goal / Aim Statement
2.3 Develop Process Management Plan (Action Plan)
3.1 Examine Current Approach (Process Map)
P
L
A
N
3. Examine Current Approach
“How will we know a change is an
improvement?”
3.2 Analyze/Display Baseline Data (Line Graph)
3.3 Determine Root Cause(s) (Fishbone)
3.4 Develop Measures/Indicators (In-Process &
Outcome)
3.5 Revise Aim Statement
4. Identify Potential Solutions
“What change can we make that will result
in an improvement?”
5. Develop Improvement Theory
4.1 Identify solutions (Brainstorm)
4.2 Pick Best Solution (one most likely to accomplish
Aim)
5.1 Develop Improvement Theory (If…Then
Statement)
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9-Step Process Management Methodology / PDCA
STEPS
D
O
6. Implement Process
6.1 Just Do It!
7. Monitor Performance
7.1 Collect/Analyze/Display Data (Line or Bar Graph)
C
A
C
T
ACTIONS & QI TOOLS
7.2 Set Baseline results; develop target measures
8. Identify Opportunities
8.1 Revise process flow and test
9. Take Action
9.1 Fix Obvious Problems
9.2 Identify Root Cause(s) for difficult problems
9.3 Standardize Process
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Develop Process Map
QI Tool – Input/Output Diagram
Inputs
Pregnant woman
needs prenatal care
Activities
(In-Process)
1. Pregnancy test
2. Eligibility appointment
Outputs
Pregnant woman gets
prenatal care
3. Eligibility determined
4. Provider appointment
Outcome
Better chance for healthy pregnancy and healthy baby!
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Process Flow Chart
Pregnancy
test
Eligibility
Prenatal
Workup
Nurse
•Testing
•Healthy Start
Screening
•Provider Selection
•Schedule Eligibility
appointment
•Financial Screening
•PEPW
•County Pay
application
•Schedule Nurse
Work-up Visit
•Lab Testing
•Prenatal History
•Education
•Schedule Provider
visit
Provider
Visit
•1st prenatal
care
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Process Issues / Problems

Too many appointments - inconvenient to clients

Prolonged access to care

Delay caused clients to seek care elsewhere

Inefficient use of staff time and scheduling

Loss of revenue due to non-billable nurse workup visits
if client chooses not to return for provider visit
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Root Cause
QI Tools used:
 Brainstorming
 Fishbone Diagram
Determined Root Cause…
Artificially imposed barriers to make system work
for the agency…not necessarily for the patient!
• I.e. too many separate, specialized visits
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Revised Process Flow
Pregnancy
test
Provider
Visit
Eligibility
Prenatal
Workup
Nurse
•Testing
•Healthy Start
Screening
•Provider Selection
•Schedule Eligibility
appointment
•Financial Screening
•PEPW
•County Pay
application
•Schedule 1st provider
Visit
•Lab Testing
•Prenatal History
•Education
•Schedule Provider
visit
•Prenatal History
•Education
•Lab testing
•Complete physical
exam
•Schedule routine
follow-up visits
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AIM Statement

By November 2012,
improve access to prenatal care
services

by increasing percentage of pregnant
women receiving their initial prenatal
medical exam within 2 weeks of a
positive pregnancy test

from baseline of 4% to 75%
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P-D-Check-A
•
•
Step 7: Monitor Performance
Reflects Baseline (4%) & Target (75%)
Data used to help identify process problems & needed interventions
% 1st prenatal exam within 2 weeks of pregnancy test
100%
Good
90%
Target 75%
80%
70%
60%
50%
Dropped Nurse
Work-up visit
40%
30%
Revised elig.
schedules
Started Early
Access Clinic
22%
17%
15%
13%
11%
Jan
Feb
Mar
Apr
20%
10%
Added 1
elig. staff
4%
0%
Dec
2011-2012
May
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Next Steps

Continue to monitor performance data

Identify tweaks to improve our process

Revisit our in-process indicators to ensure we
are measuring the right things

Consider revision of AIM Statement
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Key Lessons Learned
…or 30 seconds of advice

Use a systematic process management methodology
to ensure the team stays on track
We are using our 9-Step Process Management
Methodology with PDCA as our QI project roadmap

Resist the temptation to conclude too quickly that
you have found the Root Cause of the problem.
Really dig for those root causes…they often are wellhidden!
You may have to dig again!
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…30 seconds MORE of advice
• Your ability to actually measure whatever measures you
decide on, will result, in part, in how effective your effort
to improve will be.
We are re-evaluating our in-process measures
I.e., number of days pregnancy test to eligibility and
eligibility to 1st provider visit –
 doesn’t account for patient-imposed variables (such as no-show
or choosing appointment further out)
May decide to do random checks for “next appointment
availability” instead – a more accurate measure of how the
system is working
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Contact for further information:
Belinda Johnson-Cornett, MS, RN-BC, MBA
Administrator – Osceola County Health Department
Belinda_Johnson-Cornett@doh.state.fl.us
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Applying QI to Maternal and Child
Health: Initial Stories from the NNPHI QI
Award Program-Prenatal Care Coordination
(PNCC)
Presented By:
Brittany Boyer, RN BSN
Clark County Health
Department
Outline
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Background of Clark County, Wisconsin
Prenatal Care Coordination (PNCC) Program
Overview
Reason For Choosing PNCC for A QI Project
Aim Statement
Completed Work Thus Far
• QI Tools Utilized
Challenges
Key Lesson(s) Learned
Anticipated Goals/Results
Questions/Comments
Clark County, Wisconsin


Very rural county- located in the heart of Wisconsin
Characterized by rustic roads, grazing cattle, an abundance of wildlife,
agricultural land, forests, lakes, parks, atv/dirtbike/snowmobile/horseback riding
trails, numerous recreational activities, historic sites, residential communities,
and outstanding businesses and industry
Clark County, Wisconsin

Total county population = 34,412 people
–
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Estimated that 1/3 of our total county population is
comprised of Amish or Mennonites-poses unique public
health nursing considerations, challenges, and opportunities
2011: 243/585 births were Amish/Mennonite = 42%
Prenatal Care Coordination
(PNCC) Program Overview

What is PNCC?
–
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A Medicaid and BadgerCare Plus benefit that helps pregnant women get
the support and services they need to have a healthy baby
Introduced in 1985 as a Medicaid benefit to impact low birth weight and
prematurity
Services include:
 Outreach and assistance finding services in the client’s community
 Initial assessment
 Providing personal one on one support-listening to client concerns,
answering questions, developing a personalized confidential plan of
care from pregnancy, to delivery, to the postpartum/newborn care
stage
 Providing nutrition counseling and health education on a variety of
topics
 Ongoing care coordination and monitoring
Prenatal Care Coordination
(PNCC) Program Overview

What is the goal of the PNCC program?
–

Improve birth outcomes among women who are deemed at
high risk for poor birth outcomes bases on the Prenatal
Care Coordination Pregnancy Questionnaire
Who is eligible for services?
–
Medicaid-eligible pregnant women with a high risk for
adverse pregnancy outcomes during pregnancy through the
first 60 days following delivery
Prenatal Care Coordination
(PNCC) Program Overview

Who are the coordinators?
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Where do we receive referrals from?
–
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4 Public Health Nurses who provide services in
Clark County
Women, Infants, Children (WIC) program, local
hospitals, high schools
Clark County PNCC enrollment
–
–
2010: 33 clients
2011: 25 clients
Prenatal Care Coordination
(PNCC) Program Overview

Benefits of PNCC Program-Women Enrolled in
Program
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Single women less likely to deliver low birth weight babies
(LBW) (Baldwin et al., 1998)
More likely to seek support from family, friends, have a labor
support person, and involve father of baby (Olds et al., 1986)
Teen mothers have reduced rates of LBW births (Hardy et al., 1987;
Korenbrot et al, 1989; Olds et al., 1989; Baldwin et al., 1998)
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Increased weight gain (Olds), increased vitamin use (Piper et al, 1996)
More medical prenatal visits (Hardy)
Receiving psychosocial assessment & intervention reduced
risk of LBW baby (Wilkinson et al., 1998)
Reduction in preeclampsia (Hardy et al., 1987)
Significant reductions noted in smoking behaviors (Olds et al., Middelton
& al.; Reicketts et al. (2005)
Reason For Choosing PNCC
for A QI Project
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
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The provision of PNCC (Prenatal Care Coordination) services
has been occurring in Clark County for many years
Program has not been evaluated or updated for quite some
time
Realized several improvement opportunities exist
Had several other QI projects in mind, however the PNCC
program was our priority focus
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Important program that makes a significant impact
Wanted to ensure our program was being conducted in the most
evidence based manner
Saved our brainstorm list of other potential QI projects and will
initiate those in the future
Reason For Choosing PNCC for A
QI Project

Became aware of program inconsistencies among staff
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Lack of staff adhering to the State of WI Medicaid Prenatal Care
Coordination Services Handbook
Current policy and procedure is outdated and not reflective of upto-date evidence-based practices
Outdated program forms
No clear billing guidelines in place
Recognition of staff turnover/lack of staff orientation to PNCC
program
Lack of communication/resource sharing
No PNCC flow sheet/checklist in place to ensure consistency and
chart compliance
Aim Statement

By November 30, 2012, after the Clark County Health Department’s
prenatal care coordination (pncc) policy and procedure has been
updated reflecting the WI Medicaid Prenatal Care Coordination
Services Handbook, program forms have been updated/revised, pncc
flow sheet checklist developed, and staff training conducted on the
pncc revisions, 100 % of the pncc client charts will be in compliance
after a chart review process.
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Sub Aim Statement

This improvement will improve billing practices since all
required forms and information will be update and in
compliance. This will result in an increase in Medicaid
reimbursement for the pncc program from a current level in
2012 (being determined) by 5 % in 2013.
Completed Work Thus Far
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Described the current process
 Developed a flowchart on the PNCC process
 Involved all staff members and their input
Collected data on the current process
 Found 0 % of PNCC chart audits are in compliance
 Realized the department had a significant staff turnover rate
– Developed a run chart
– From 2008-2009 the health officer, program assistant, and 3
PHN’s left
– Since 2009, 3 New PHN’s, a program assistant, and a new health
officer started
– 2010, 1 PHN left
– 2011, 1 PHN left, 1 new PHN started
– 2012, 1 new PHN started
 Documented length of current charting process
– Time staff are spending on the process
Completed Work Thus Far
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Identified possible causes
 Developed a fishbone diagram
– 4 major cause categories included: people, resources/materials, time,
training/orientation
Identified potential improvements
 Update policy and procedure to reflect WI Medicaid PNCC handbook guidelines
 Update all program forms
 Develop chart audit flow sheet/checklist form
 Train staff on the new PNCC program revisions
Developed improvement theory
 By November 30, 2012, after the Clark County Health Department’s prenatal
care coordination (pncc) policy and procedure has been updated reflecting the
WI Medicaid and BadgerCare Prenatal Care Coordination Services Handbook,
program forms have been updated/revised, pncc flow sheet checklist developed,
and staff training conducted on the pncc revisions, 100 % of the pncc client
charts will be in compliance after a chart review process.
Developed a detailed action plan
 Identified what needs to be done, who is responsible, and when it should be
completed
 Developed with staff members
Action plan is in process
Challenges

Time
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Lack of time to dedicate to program due to other public
health nursing duties/responsibilities
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Learned to dedicate a designated time each week (even 30
minutes) to work specifically on the QI project
Divided tasks among staff members to decrease work load
burden
Lack of experience using QI tools
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Utilized the public health memory jogger pocket guide of tools
for QI (concise-user friendly)
Used the NNPHI website-public health performance
improvement toolkit
Key Lesson(s) Learned
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Have patience
Don’t procrastinate
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Can’t do everything yourself
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Wealth of resources-take advantage of them
Can’t expect change to occur over night
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Involve all respective staff members/ask for help with duties
Don’t hesitate to ask for assistance for questions/feedback
Use QI tools/resources available
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Dedicate a designated time each week to work specifically on QI
projects to stay on task
Little steps do make a difference and add up over time
There is always a program/process that can be improved
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Realized QI work needs to be a continuous process
Anticipated Goals/Results
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Measurable objective in the aim statement
will be met
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By November 2012, 100 % of the PNCC client charts will be
in compliance after a chart review process
Therefore hoping to adopt-standardize the improvement
Celebrate our success and hard work
Continue the momentum
–
Start next potential QI project
Questions/Comments
References
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Department of Health Services-Division of
Care Access and Accountability-P1046
State of Wisconsin Medicaid Prenatal Care
Coordination Services Handbook