7/9/2012
Quality Improvement Committee (QuIC)
Annual Summary
2010-11
The Quality Improvement Committee (QuIC) administers the Quality Improvement (QI) program at SHS. The membership of this committee expanded this year, and has become more of a working committee rather than simply an oversight committee. Currently membership consists of eight members: Beth Brown, ANP (co-chair), Linda Reid RN, Associate Director of Nursing Services(co-chair), Connie Hume-Rodman, MD, Associate Director of Clinical Services, Catherine Thomasson, MD, Susan Keister, FNP, Aslan Noakes, RN, Haley Stuhr, RN, and Cindy Bellville, receptionist. The committee is currently following the three-year plan for the 2010-2013 cycle. In October, 2010, Student Health Services became reaccredited through the American Association of Ambulatory Health Care. There were no recommendations for the QI program from the Association during the survey.
Review of quality improvement activity for current academic year:
1. Clinician Peer Review - Spring 2010- General
General peer review with 5 revised indicators: 5b-Patient verbalizes understanding of treatment advice; 11-Was depression screening done on this patient in the past year; 11a-If depression screening was done, was appropriate action taken;13a-All significant past problems noted on the Medical History;13b-All significant problems noted on the Problem List.
Significant findings were of only 59% of patients having depression screening. The goal is 90%. Locking of chart notes within 2 working days decreased from 95.2% to 86.8%. We continue to struggle with documentation of patients’ verbal understanding of treatment plan and when to return to the clinic. These issues will continue to be monitored, and a discussion is planned at the clinician fall 2011 inservice.
2. Clinician Peer Review- Fall 2010- Urgent Care
This was another peer review on charts of patients seen through Urgent Care during the first 2 weeks of October 2010. Progress at documenting students’ verbal understanding of instructions and when to return to the clinic was noted. Depression screening was not measured in this peer review because we do not perform this screening on urgent care visits.
3. Clinician Peer Review- Gyn Fall 2010
Since not all clinicians see Urgent Care patients, a separate general peer review was completed during the first 2 weeks in October 2010 for these clinicians.
4. Clinician Peer Review- Winter 2011- Metabolic Syndrome
This study served two purposes, to conduct our usual Peer Review using the 17 standard indicators and to re-evaluate our care of patients who are at risk for Metabolic Syndrome by having a BMI>30. General Peer Review data was compared with 3 previous Peer Reviews where we found that we continue to do well in the areas of Patient Education and Follow-up advice. We still struggle however, with documenting patients’ verbal understanding of treatment advice and when to return to/call SHS (55% and 50% compliance respectively). At our clinicians’ Fall In-service, we will consider a presentation about how peer review is done including clarifying what constitutes “verbal understanding” in hopes of increased understanding of and compliance with this indicator.
The worst drop in performance was in the area of depression screening which fell from >95% to 46.3%. This was due for the most part, to problems with our “Smart Forms”. Our depression screening process will again be modified in Fall Term 2011, and clinicians will continue to discuss this issue.
The second piece of this peer review, risk for metabolic syndrome, showed a significant decline (to rates <60% compliance) in all indicators except measurement of BP and BMI. We made changes since the most recent Metabolic Syndrome Chart Review to have eCW codes for BMI>30 to avoid using the charged term obese. There was confusion about reviewing the whole chart for the Metabolic Syndrome indicators, as well as an increase in the number of indicators needing to be reviewed (from 21 to 26), which may create too much of a time burden on clinicians. Perhaps a chart review rather than peer review is the best way to restudy this issue.
5. Nursing Peer Review- Winter 2011- General
The nursing department added 2 indicators: 5b-patient verbalizes understanding of treatment advice and 7b-patient verbalizes understanding of when to return of contact SHS if needed. The “medicolegally defensible” indicator was removed.
The 2 new indicators had low compliance at 24% and 25%. Also nursing would like to increase the percent for allergy or NKDA documentation. Nursing plans to revise templates to include the new 5b and 7b indicators. Minimum physical exam criteria will be added to the positive strep screen protocol.
6. Animal Bites Restudy 4/10-4/11
This study was performed to assess all animal bite visits in the clinic over the past year and compare to the previous study. There were 16 animal bites, 1 was work related.
Results showed that documentation of animal bites is consistently excellent, and all criteria was met at 100%. This shows improvement in the two problem areas from last year (date of last tetanus check was 85%, prescription of antibiotic prophylaxis was 89%).
In last year's study, only 45% of animal bites were reported to Benton County Health Department. A new process was implemented where the clinicians would alert the occupational medicine nurse who would follow up with Benton County. This process helped bring the percentage of bites reported to 81%, a big improvement over last year.
The need to report animal bites will be reiterated to clinical staff at an upcoming meeting.
7. Ottowa Rules for Ankle X-ray Fall 2010
Ottowa rules was a topic for the ACHA Benchmarking studies, but OSU data was not available for the submission deadline. This study reviewed 25 charts from Fall Term with the Dx of ankle sprain or ankle fracture. Documentation of the Ottawa rules was noted and whether an Xray was done.
Thirteen patients had Xrays done or ordered, 12 did not. Of the 13 Xrays ordered, 77% (10/13) were compliant with Ottowa rules. 4/13 had no documentation of whether the patient could walk into the office or immediately after injury. 3/13 had no documentation of specific bony tenderness indicated by Ottawa rules. Only 1/13 had documentation of tenderness at 5th metatarsal base.
Of the patients without X-ray 8/12 had documentation that they could walk, 4/12 had documentation of no malleolar tenderness, 1/12 had documentation about metatarsal pain to palpation.
A brief clinical inservice was done and it was recommended to alter eCW to more easily document the Ottawa rules. The study will be repeated next year.
8. Plan B One-StepTM Student Learning Survey Feb/March, 2011
Plan B is a high volume medication dispensed at SHS pharmacy This survey was done by a pharmacy intern to assess students’ understanding of how Plan B works and how it will affect them. The information will be used to assess in which areas further teaching is needed. Two hundred students provided feedback on the survey questions given to them, 149 female and 51 male. 57% of the females had used Plan B, and 26% of males stated that their partners had used Plan B. Questions on the survey concerned correct usage of Plan B, how Plan B works and effects of Plan B on pregnancy.
Overall, females have a better understanding of Plan B than men do, but the mechanism of action and the affect on pregnancy is not well known to students. A poster about Plan B was made for students to look at outside the pharmacy. The areas where students seem to know the least will be good points to include while counseling patients who are picking up Plan B. The results of this study were also shared with the SHS NP/PA group. This study will be repeated next year by another pharmacy intern.
9. ACHA Clinical Benchmarking Fall 2010
OSU participated in 5 general areas of the first ACHA Benchmarking Survey (other than the ACHA Pap test and STI survey).
Results for OSU percent compliance compared to the average:
Pharyngitis (appropriate tx using Centor Criteria): OSU 80%, Average 43%
Bronchitis (avoidance of antibiotic treatment): OSU 60%, Average 59%
Depression (management ): OSU 23%, Average 16%
Asthma (monitoring peak flows): OSU 32%, Average 16%
Asthma (action plan): OSU 76%, Average 62%
Asthma (treatment): OSU 100%, Average 85%
Screening/Prevention (documenting allergies): OSU 92%, Average 93%
Screening/Prevention (offering a flu shot): OSU 32%, Average 38%
Screening/Prevention (screening for tobacco use): OSU 92%, Average 82%
Brief inservices on the above topics were held at clinician’s meetings. Interventions included: creating a template with Centor Criteria; making available screening tools for depression, instigating depression screening in the clinic using the PHQ-2 and PHQ-9 tools; adding depression screening to Clinician Peer Review; working on peak flow as a vital sign.
10. Gardasil Vaccination Rates
The Spring 2010 ACHA National College Health Assessment provided data that 33.2% of college students nationally and 35.6% of OSU students reported receiving HPV vaccination. A goal was established to increase OSU HPV vaccination rates. OSU received no cost vaccine from the State of Oregon. A media campaign to advertise Gardasil vaccine was developed. Clinicians were informed of the availability of Gardasil at SHS with the recommendation to include reviewing HPV vaccination status of patients and to offer the vaccine at routine health care visits.
This study evaluated clinician compliance with recommendation for Gardasil immunization through peer review, as well as the effectiveness of the SHS Health Promotion Gardasil vaccination media campaign.
There was 100% compliance in the 9 Gyn provider charts reviewed through peer review for Gardasil status being reviewed and for Gardasil being recommended if needed.
144 students presenting to SHS nursing for Gardasil vaccine identified how they found out about the vaccine. 36% found out through an SHS clinician and 19.4% found out from a friend. Other categories were smaller.
The plan is to perform peer review on charts of students presenting for STI screening to assess SHS clinician review and recommendation of Gardasil vaccine. It appears that the media campaign was successful, and the SHS Health Promotion Department will use the data collected to further develop the campaign. We will use the Spring 2010 ACHA/NCHA data to monitor vaccination rates in the OSU population.
11. Influenza Like Illness Student Learning Survey
This is a restudy of the Influenza Like Illness (ILI) Learning Outcome Study done Fall Term 2009. Twelve students with a diagnosis of ILI were called by a nurse within 4 weeks of their clinic visit, and asked questions to determine specific learning outcomes from that visit. There was an increase from 38% in 2009 to 45% in this study of students verbalizing 2 symptoms to watch for in case they might need to seek further medical care. This is still significantly below the 80% goal. Additionally, only 45% of students in this study received written instructions about their illness, as compared to 93% of students in 2009. Verbalization and practice of ways to minimize spread of illness met the 80% goal. The results of this survey will be shared with appropriate departments in order to further our patient education efforts around influenza. We may repeat this study during the 2011-2012 flu season, or we may choose another student learning topic.
12. Cost Analysis of Quantiferon Gold (QTF-G) vs. T-Spot testing for Latent TB infections.
This study was designed to compare cost and convenience of two different assays testing for latent TB infection in OSU students. Sensitivity and Specificity of the two different tests were examined as well to be sure that cost considerations would not overshadow testing accuracy. The T-Spot.TB had higher sensitivity and only marginally lower specificity than the QTF-G test and cost considerably less. After confirming insurance coverage for the T-Spot.TB test, we switched over from referring students out to GSRMC for QTF-G to obtaining specimens on site effective 4/11/11.
13. Hospital Transfers/911 calls Restudy: Fall through Spring term 2010-11
This was a re-study using identical criteria to the 2009-2010 hospital transfer study. Thirty five charts were reviewed which was the sum total of charts during the 2010-1011 academic year either with a diagnosis code of 99199- Hospital Transfer or charts identified by nursing as hospital transfers. In this study, nursing may or may not have been involved directly with documentation in each chart. We are again trying to evaluate quality and continuity of patient care/documentation to identify areas for improvement. Three specific criteria were identified for improvement in this study:
1. Documenting the time of a 911 call and the arrival of the EMTs. This occurred on only 1 out of the 3 911 calls in this study.
2. Documenting that forms were copied and either faxed or sent with patients. We have a referral to GSH-ER available in eCW and notes and labs can easily be sent if a referral is made.
3. Post ER follow up visit or phone call. A plan is in place to have clinicians create a phone encounter at the time a patient is sent to the hospital which can be assigned to nursing so the patient can be called the next day.
Only three of the hospital transfers necessitated 911 calls. Other patients were referred for imaging, needed urgent evaluation by a specialist, or needed specialized treatment that was unavailable at SHS. We need to continue to work to make transfers from SHS to the hospital as seamless as possible to provide excellent patient care. There is a template created by nursing to help in documentation of hospital transfer patients which may help in our documentation efforts. Reminding clinicians to create a GSH-ER referral, and a telephone encounter for nursing as a follow up will also help. We will continue to review hospital transfers. The criteria could be streamlined next year to make the study more focused on the areas needed for improvement.