STRUCTURE, PROCESS AND OUTCOMES

A DISCUSSION ABOUT THE WHAT, WHEN, HOW AND WHY OF QUALITY ASSURANCE/QUALITY IMPROVEMENT

Jacki Witt, JD, MSN, WHNP-BC, SANE-A

DISCLOSURES

Watson, Afaxys and Agile Advisory Boards Thanks to Mike Policar, MD, MPH, for sharing his

expertise and data re: California PACT QA measures and to Susan Moskosky, Acting Director, OPA for sharing expertise and information regarding Title X

QUALITY?

4

Background: Title X Program Guidelines

•Original guidelines established in 1970 following the enactment of Public Health Service Act 42 U.S.C. 300 authorizing the establishment of the Title X program

•Current guidelines were updated in 1980 and in 2001

•Address largely legal and regulatory requirements of Title X program

Two parts to the guidelines under development

1) Program Requirements:

Defines program requirements for grantees funded under the Title X program – primarily statutory and regulatory.

2) Guidance for Providing Quality Family Planning Services

Recommends how to provide family planning services in an evidence-based manner

Program Guidelines

Program Requirements

Recommendations for

Providing Quality FP

Services

Purpose of the Title X Program Guidelines

To assist current and prospective grantees in understanding and utilizing the family planning service grants program:• Grant application and award process• Project management & administration• Financial management• Clinic management and clinical service

requirements

Although primary target audience of the guidelines is Title X grantees, these guidelines serve as a “standard of care” for other stakeholders

New Opportunities

The Title X guideline revision has occurred in the context of the Affordable Care Act:

Increased access must be accompanied by improved quality

Emphasis on accountability, health outcomes and evidence-based approach

Standards needed on which to base performance measurement

Why develop national family planning recommendations?

To support consistent application of quality care across settings and provider types

To translate research into practice, so the most evidence-based approaches are used

Conceptual Framework Improved QUALITY of care

improved RH outcomes

Quality care is safe, effective, client-centered, timely/accessible, efficient and equitable (IOM 2001)

Also addresses choice of methods, information given to clients, technical competence, interpersonal relations, mechanisms to encourage continuity (Bruce 1990, Becker 2007)

Goals of the Title X Guidance Revision Process

1. Utilize best evidence to design preventive services

2. Prioritize provision of core family planning services Allow flexibility for recommended services Avoid services where harms exceed benefits

3. Support client decisions re: services received or declined

4. Remove barriers to care for the client and provider

5. Improve clinic efficiency6. Anticipate changes in source of primary care

arising from the Affordable Care Act

Relationship to other U.S. guidelines

1. U.S. Medical Eligibility Criteria for Contraceptive Use (CDC)

Safety of contraceptive practice

2. U.S. Selected Practice Recommendations (CDC)

Contraceptive management, e.g., exams needed, missed pills, etc.

3. Quality family planning services (Title X/CDC)

Focus on how to deliver services, e.g., counseling, outreach, QA/QI, special populations, other services

Platform to highlight key practice implications of MEC and SPR

MMWRMay 28, 2010

Focus on safety in women with a variety of medical conditions

MMWRJune 21, 2013

Focus on efficacy in women and men using contraceptives

U.S. Selected Practice Recommendations for Contraceptive Use, 2013

Removing unnecessary barriers can help patients access and successfully use contraceptive methods

Several medical barriers to initiating and continuing contraceptive methods might exist, such as Unnecessary screening examinations and tests

before starting the method (e.g., a pelvic examination)

Inability to receive method on the day of the visit Difficulty obtaining continued contraceptive

supplies (e.g., pill packs dispensed at one time)

Evidence Based Guidelines for Family Planning

CDC MEC2010

CDC SPR2013

CDC STD TreatmentGuidelines 2010

Title X Guidance2013

ContraceptivePractice

STD Practice

F screeningM screeningPreconceptionFertility enhancementPreg determination

Strengthening Clinical Aspects of Care

Framework for Family Planning and Related Preventive Services

Other Preventive

Health Services

Family Planning Services

• Contraceptive services

• Pregnancy testing

• Achieving pregnancy

• Basic infertility services

• Preconception health

• STD Services

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Contraceptive Services

AchievingPregnancy

Basic infertility services

Preconception

health services

Related preventive

health services

STD

services

Clients should also be offered these services, as needed

Clients should also be offered or referred for these services, as needed

Determine the need for services

Acute careChronic care managementPreventive services

Reason for visit is related to preventing or achieving pregnancy

Initial reason for visit is not related to preventing or

achieving pregnancy

If needed, provide services

Pregnancy testing and counseling

Assess need for services related to preventing or achieving pregnancy

If services are not needed at this visit,

re-assess at subsequent visits

Flow Diagram of Family Planning & Related Services

Contraceptive Services

Remove medical barriers to contraceptive use!!!

Offer a full range of FDA-approved methods

Use a tiered approach to counseling, with the most effective methods mentioned first & embedded within counseling framework described earlier

Consider whether client is at low or high risk of unintended pregnancy Low: using long-acting reversible methods or

more effective methods with an established history of continuation

High: using a less effective method and/or has a history of poor rates of continuation

Clinical Barriers to Contraceptive Services

Lack of awareness of family planning guidelines

Unnecessary screening tests Limits on same day availability of

methods Inappropriate restriction on U.S.

Medical eligibility criteria Category-3 methods

Diversion of limited time from family planning services to provide non-reproductive primary care

Summary

The new family planning guidelines should:

Improve the quality of family planning services in the U.S.

Encourage more research to strengthen the evidence base for specific strategies and services

Provide a platform to expand other essential preventive services to women and men

QUALITY ASSURANCE/IMPROVEMENT

PLAN → DO → STUDY → ACT→

What are we trying to accomplish?

How will we know a change is an improvement?

What changes can we make that will result in improvement?

Selecting Indicators for YOUR Clinic

Use evidence based resources to determine indicators for quality care

Examination Needed for

Blood pressure OC, patch, ring

Clinical breast examination None

Weight (BMI) (weight [kg]/ height [m]2 Hormonal methods

Bimanual examination, cervical inspection IUC, cap, diaphragm

Glucose, Lipids None

Liver enzymes None

Thrombogenic mutations None

Cervical cytology (Papanicolaou smear) None

STD screening with laboratory tests None

HIV screening with laboratory tests None

Under 21 years old

21-29 years old

30-65Years old

>65 years old

Hyst, benig

n

USPSTF2012

[D] Every 3 y Co-test: Q5Cytology: Q3

None* [D]

Triple A2012

None Every 3 y Co-test: Q5Cytology: Q3

None* None

ACOG2012

“Avoid” Every 3 y Co-test: Q5Cytology: Q3

None* None

hrHPV test

Never Reflex only

Co-test or reflex

None None

* If adequate prior screening with negative resultsCo-test: cervical cytology plus hrHPV testCytology: cervical cytology (Pap smear) alone

Quality Indicators(from CA Family PACT)

Must meet all of the following criteria

1. Clinically relevant topic2. Intervention that will measure an outcome

or a process to improve outcomes3. Objectively measurable4. Performance is under the influence of the

provider5. Ability to compare provider performance to

peer group or benchmark (or both) over time intervals

Indicators

Quality indicators Chlamydia screening rates < 25 years

old Chlamydia screening rates > 25 years

old Utilization indicators

Annual reimbursement per client Annual office visits per client % of visits coded at highest level

New patients (99204) Established patients (99214)

Indicators Quality indicators

Cervical cytology intervals Utilization indicators

Number, percentage and demographics of patients leaving with a method

Patient volume trends over time• Total Clients • Teen Clients• Male Clients • New Clients

Provider Profile Indicators

Family planning quality metrics Access to Tier 1 contraceptives

Use of Tier 1 contraceptives as a percentage of all clients using a method in FY

Initiation of Tier 1 contraceptives as a percentage of all clients initiating a method in FY

Below average number implies poor access Percent of clients using Tier 3 methods only

during Y Above average number implies poor counseling or poor access to higher Tier methods

Framework for Quality Improvement

CONTINOUOUS

QUALITY IMPROVEM

ENT

P - D - S - A Plan

Choose indicators How will data be collected, by whom,

etc. How will results be disseminated?

Do Collect data

Study All members of the team have input

Act Initiate a new system for tracking

Routine Cancer Screening in Women Age 18-20 21-25 26-29 30-39 40-49 50-59

Cervix CA•Cytology•Co-testing

NoneNone

Q 3 yrsQ5 yrs

CBE•ACS

None Q 3 yrs Annual with MG

Mammogram•ACS•USPSTF

None Hi Risk [I]

AnnualQ2y [C] Q2y [B]

Colorectalcancer None Hi Risk

[A]

ACOG: Am College of Ob-GynACS: American Cancer Society

CBE: Clinical breast examCDC: Centers for Disease ControlUSPSTF: US Prev Services Task Force

Routine STI ScreeningAge 18-20 21-25 26-29 30-39 40-49 50-59

CT (Both) Annually Targeted

GC (Both) Targeted

HIV

-Both Once, then Hi risk only

Syphilis- Both

Hi Risk

Vag trich- CDC

2010

Hi Risk

Hepatitis C- CDC

2012

Once, then Hi risk only

Routine Metabolic ScreeningAge 18-19 20-25 26-29 30-39 40-49 50-59

BP <Q2 yrs

BMI <Q2 yrs

T2DM•ADA•USPSTF

Hi RiskHTN [B]

Q3yHTN[A]

Lipids•ATP•USPSTF

Q5 yrsHi Risk

ATP: Adult Treatment PanelCHD: coronary heart disease

Plan for Data Collection

WHO WHAT WHEN HOW

Plan for Dissemination of Results The more the merrier Not punitive Emphasis is on improvement

of processes, outcomes and efficiency

All focused on bottom line, not just management

Dissemination of Family Planning Recommendations At MMWR now, expected release by end

of 2013 Key federal agencies

Title X providers, 4400 clinics serving 5 million low income clients/year

Community Health Centers, 1100 clinics serving 19 million low income clients/year

Major professional organizations, such as: American Academy of Pediatrics American College of Ob/Gyn American College of Family Medicine

References

Deming, WE. The New Economics for Industry, Government, Education. (1993 )