WIPHL Clinic Guide and Checklist
(Please maintain an updated copy for your records and submit an electronic copy to WIPHL 2
weeks prior to launch of services @ Lilly.irvin-vitela@fammed.wisc.edu)
GENERAL INFORMATION/QUALITY IMPROVEMENT TEAM
CLINIC NAME
Clinic Address
Main Phone Number
Fax Number
WIPHL UMBRELLA
ORGANIZATION
Who participates on the WIPHL QI
teams?
Each clinic is unique and each WIPHL QI team
has a somewhat different composition. As a
general rule of thumb, it is helpful to include
representation from each area of the clinic
that is impacted by WIPHL programming. One
thing that is consistent is that each team has
a clinic champion, a clinic co-facilitator, a QI
co-facilitator,
and
a
health
educator.
Successful teams also have engagement from
front-end staff, and nursing staff.
CLINIC DIRECTOR
The
clinic
director
is
someone
who
understands the objectives of the WIPHL
Program and is committed to leveraging
resources to deliver SBIRT services to
patients within their clinic or site.
Name & degrees
Phone number
E-mail address
CHAMPION
The clinic champion is someone who is able to
champion the project in the clinic. This person
should have insight into the clinic culture and
be
able
to
influence
the
successful
implementation of WIPHL initiatives.
Name & degrees
Position/role
at clinic
Phone number
1
E-mail address
CLINICAL CO-LEADER
This person should be someone at the clinic
who has the time and skills to dedicate to cofacilitating
the
monthly
WIPHL
implementation team meetings and help
manage the successful implementation of
PDSA
cycles.
Name
Phone
E-mail address
QI CO-LEADER
This person is either a staff member of the
clinic or an outside consultant who provides
technical assistance with WIPHL quality
improvement
efforts.
This
person
is
responsible
for
co-facilitating
monthly
implementation team meetings, documenting
PDSA
cycles,
and
providing
technical
assistance to implementation team members,
and communicating with the WIPHL project
manager
about
implementation
plans,
barriers, strategies, and best practices.
Name
Phone
E-mail address
Other Implementation Team Members
(Suggest having 4 to 8 members to represent various groups of staff)
Name & Credentials
Role at Clinic
E-mail address
2
DESCRIPTION OF PATIENTS TO BE SERVED
Total number of
visits per year
Unduplicated current
patients
AGE
Age 12 and less (%)
Ages 13 to 17 (%)
GENDER
Ages 18 to 64 (%)
Female (%)
Ages 65 and up (%)
Male (%)
LANGUAGE
ETHNICITY
Hispanic (%)
Able to participate in
English (%)
Hmong only (%)
Non-hispanic (%)
Spanish only (%)
Other: (%)
____________________
RACE
White/Caucasian (%)
HEALTH INSURANCE
Asian-American (%)
Private (%)
Black/AfricanAmerican (%)
Indian/Native American
/Native Alaskan (%)
Hawaiian/Pacific
Islander (%)
Other (%)
Public (%)
None (%)
Number of pregnant
women seen per year
Most of our patients are
residents of
________________
________________
county/counties.
3
INSTITUTIONAL ARRANGEMENTS
IRB STATUS- The UW Madison has
declared WIPHL to be IRB exempt as it
is a service project not a research
project.
Does an IRB oversee your clinic?
If yes, have you checked with your IRB
about their need to review your plans to
participate in WIPHL?
Have you submitted a protocol to your
IRB?
What is this project’s status
with your IRB?
______ Yes
______ No
______ Yes
______ No
______ Yes
______ No
______ Approved
______
Not
______ Exempt
approved
or
exempt
______ Pending
If you intend to conduct research on the
data your clinic collects regarding WIPHL,
please send the coordinating center a copy
of your IRB application for our records.
DO YOU HAVE A WRITTEN
______ Yes
______ Pending
CONTRACT WITH YOUR UMBRELLA
ORGANIZATION?
Documentation
Please include send an executed copy of the contract
to the coordinating center.
DO YOU HAVE SIGNED BUSINESS
ASSOCIATE AGREEMENTS WITH:
UW Department of Family Medicine and ______ Yes ______ Pending
Population Health Institute
Your umbrella organization
______ Yes ______ Pending ______ No need
Symphony Corporation (computer system ______ Yes
design and maintenance)
Pacific Interpreters (WIPHL language line) ______ Yes
______ Pending
______ Pending ______ No need
4
HEALTH EDUCATOR
Health Educator’s
_____ Clinic ______ Umbrella Organization
employer
Anticipated start
of training
Health Educator will attend entire three-week
______ Yes ______ No*
training, including all ten days in Madison and week-long
training at your site.
Health Educator will perform WIPHL functions only
______ Yes ______ No*
Has your top Health Educator applicant been interviewed and ______ Yes ______ No*
approved by WIPHL Health Education Manager?
Would you like interview questions?
______ Yes
______
Does the health educator understand the shared supervisory No*
relationship between your clinic and the WIPHL coordinating
center?
Once hired, has the health educator reviewed the HE
______ Yes ______ No*
expectations with their clinic-based supervisor in addition to
the clinic personnel expectations?
______ Yes ______ No*
Name of Health Educator
Professional Licensure or Certification
(none necessary)
(A) Full-Time Equivalent (1.0 or less)
(B) Full-Time Salary*
(C) Actual Salary – (A) x (B)
(D) Benefit Rate
(E) Actual Benefits – (A) x (D)
(F) Total Compensation – (C) + (E)
Will the Health Educator’s
office space have …
Privacy for sensitive interviews
______ Yes
______ No*
Telephone access
______ Yes
______ No*
Internet access
______ Yes
______ No*
5
BRIEF SCREENING PLAN AND PREPARATION
Note – The WIPHL Health Educator will provide feedback and brief referral only to patients
whose brief screens are positive for alcohol and drug use. Clinics will need to provide brief
feedback and referral to patients whose brief screens are negative for alcohol and drug use but
are positive for other health risk behaviors.
SCREENING TOPICS
Would you like your patients screened for:
Tobacco Use
___ Yes ___ No
Exercise
___ Yes
___ No
Weight
___ Yes
___ No
Nutrition
___ Yes
___ No
Depression
___ Yes
___ No
Violence
___ Yes
___ No
If
so,
would
you
like
WIPHL
provide
the
following
materials
help with brief feedback …
___ Yes ___ No
___ Yes
to
to
___ No
Note: Patients who screen positive for depression
and risk of violence will need immediate brief
assessment and triage, because they may be
at risk for imminent, serious harm.
You must submit your brief screen for approval prior to printing or
administering the screening instrument. The AODA questions
cannot be modified.
TARGETED PATIENTS
Please specify the eligibility criteria for
screening. Note: Initially, we will need to
exclude individuals under 18 years old.
What screening modes will you plan to use? If so, for whom? Please specify detailed eligibility
criteria for each.
Face-to-face
___ Yes ___ No
screen by staff
Written questionnaires ___ Yes ___ No
IVR system
___ Yes
___ No
Please submit your brief screen to Lilly at the WIPHL Coordinating Center for final
approval prior to having screens printed. lilly-irvin@fammed.wisc.edu
6
BRIEF SCREENING PLAN AND PREPARATION (CONTINUED)
For IVR screening
Would you like to
____ Yes ____ No
enter appointment data
manually via a secure
website?
Would you like to
____ Yes ____ No
upload computer
appointment data to
the WIPHL
central database?
If so, who will be in charge of data entry?
Name: _______________________________
Phone: _______________________________
E-mail address: ________________________
If so, who will be in charge of programming?
Name: _______________________________
Phone: _______________________________
E-mail address: ________________________
For written questionnaires
Would you like
____ Yes ____ No
WIPHL to design these
for you?
Does your clinic need ____ Yes ____ No
a Spanish version of
the brief screen?
If yes, please send WIPHL a mock-up design or
a description of the design you would like.
For face-to-face staff interview
Would you like
____ Yes ____ No
WIPHL to design
written guides for you?
If yes, please send WIPHL a mock-up design or
a description of the design you would like.
7
DETAILED BRIEF SCREENING PROCEDURE
FOR IVR BRIEF SCREENING
Before each day, the Health Educator will receive a list of patients whose brief screens are
positive for alcohol and drug use. How will such patients be directed to the Health Educator
when the Health Educator is …
…
idle?
…
seeing another
patient?
…
on the phone
with another patient?
FOR BRIEF SCREENING BY WRITTEN QUESTIONNAIRE
Who will be responsible for replenishing the
supply of written questionnaires?
Where will the questionnaires be kept?
Who will determine which patients are to
receive the questionnaire, and how?
Who will give out the questionnaires to patients?
Who will collect the completed questionnaires?
Where will the completed questionnaires go?
How will patients whose alcohol and drug
screen is positive be directed to see the Health
Educator when the Health Educator is …
…
idle?
…
seeing another patient?
…
on the phone with another patient?
8
DETAILED SCREENING PROCEDURE (CONTINUED)
FOR BRIEF SCREENING BY INTERVIEW WITH CLINIC STAFF
Who will be responsible for replenishing the
supply of written interview forms?
Where will blank interview forms be kept?
Who will determine which patients are to be
screened, and how?
Who will conduct the interviews?
Where will the completed interview forms go?
How will patients whose alcohol and
drug screens are positive be directed to
see the Health Educator when the Health
Educator is …
…
idle?
…
seeing another patient?
…
on the phone with another patient?
Who will provide brief feedback and referral for
patients whose brief alcohol and drug screens
are negative?
Where and how will this be recorded?
Where will feedback/patient education materials
be kept?
Who will be responsible for replenishing the
feedback/patient education materials?
If you are screening for depression
and/or violence risk, how will patients
who screen positive receive immediate
further assessment and triage?
9
ORIENTATION, TRAINING, AND INITIAL IMPLEMENTATION
On what date do you plan to start providing
WIPHL services?
On what date do you plan to train clinic staff in
their roles, and how?
______ Yes
______ No
Possible dates/times when staff, providers, and
Would you like a presentation from the WIPHL key decision-makers can be available at the
Coordinating Center explaining the project prior clinic
to launch of services?
_______________________________________
_______________________________________
_______________________________________
How will you be sure to reach all the necessary
staff?
On what date do you plan to orient healthcare
providers and others in the clinic, and how?
How will you be sure to reach everyone?
How will you insure ongoing communication
and updates about implementation and service
delivery?
What is your initial plan for clinic flow and
making active hand-offs of patients who screen
positive for alcohol and/or drugs to the health
educator?
We need explanations/descriptions of how other
clinics have successfully handled this.
______ Yes ______ No
We have attached a flow diagram of how a
patient will receive WIPHL services.
______ Yes ______ No
10
QUALITY IMPROVEMENT/CULTURAL COMPETENCE
At the end of each month, the WIPHL central office will need to know how many patients were
eligible for screening. We will use these numbers to calculate the percentage of eligible patients
who underwent screening.
How will
_____ By computer Who will perform this analysis?
this analysis
be performed?
_____ By hand
Name:
Please explain
______________________________
Who will e-mail
this information to the
central WIPHL office?
Phone
_______________________
number:
E-mail
_______________________
address:
Name:
______________________________
Phone
_______________________
number:
E-mail
_______________________
address:
Is there a set meeting time where WIPHL QI issues can be part of the agenda? (Please explain)
We will institute a regular monthly meeting for WIPHL QI. (Please explain)
We understand the key indicators of access to WIPHL services and quality.
We would like an orientation to quality improvement and Plan Do Study Act cycles.
The person from our QI team who will participate in regular WIPHL Cultural Competence
Committee meetings and work as a resource to our team to address disparities in health outcomes
is_______________________________________________________.
11
INFORMATION TECHNOLOGY- Please send a copy of your organization’s acceptable use
policy for technology.
Health Educator Tablet
We will be using the WIPHL/Symphony Health ____Yes ____No
Educator Software
Who is providing the health educator tablet?
___WIPHL___Clinic ___Umbrella Organization
IT contact person for the clinic
______________________ Name
______________________ Number
______________________ e-mail
______________________ availability
We will not run competing software applications ____ Agree ____Disagree
on the health educator tablet.
We will make the tablets available via remote ____ Agree ____ Disagree
access to Symphony and the WIPHL
Coordinating Center to update health educator
software or address software concerns.
We will provide hardware support to the health ____ Agree ____ Disagree
educator and notify the coordinating center if
tablet problems are associated with the software.
Tablets will be used only for work related ____ Agree ____ Disagree
activities.
Video Conferencing Equipment
We would like to utilize video conferencing Participate in WIPHL technical assistance and
equipment to
continuing education.
____Yes ____No
Administer/receive WIPHL patient services.
____Yes ____No
Access behavioral health services for clinic
patients.
____Yes ____No
We will work with the WIPHL Coordinating Plan Implementation
Center and SKC, their vendor, to
____Yes ____No
Support Roll-out of Equipment Installation
____Yes ____No
Receive training on the equipment from SKC
____Yes ____No
Installation punch list
(See attached SKC Pre-Installation Checklist)
12