Documenting Current Screening Processes

Improvement FacilitationSession 1 Day 2

Objectives

• To understand why we document current screening processes

• To review and assess methods for documenting a provider’s or clinic’s currently screening practices

Why document “current” processes?

If you can’t describe what you are doing as a process, you don’t know what you

are doing.– W. Edwards Deming

Where are we starting from?

ASaP Screening Methods

Opportunistic

A process designed to identify patients who are due for screening when they come in for any appointment.

Screening Methods

OutreachA process designed to “comb” the panel for those who are due or overdue for screening, then use that list to invite patients for a screening appointment.

Vulcan Medical Clinic - example

• Dr. Shawn Webster (lead physician)• Suzie Mitchell (PCN RN/POET)• Participated in HSiA, TRaC II, EPICS IIb• Engaged TOP for screening process redesign (BP, Diabetes,

Obesity, COPD)

Physician

• Documents in chart

• Completes encounter

EPICS IIbVulcan Medical Clinic: Cancer Screening Process (Pre-intervention)

Escorts patient to

exam room

ClinicAssistant

• Selects HSiA template

• Addresses patient concerns

• Addresses Ca screening if patient asks

PHE?

As required:• Offers PAP• Offers mammo

req• Offers FOBT req

&/or• Refers for scope

Yes

No

Physician

Documents in chart to complete encounter

EPICS IIbVulcan Medical Clinic: Cancer Screening Process (Opportunistic)

Escorts patient to

exam room

POET

‘Mammo Due’ • prints req for pt

‘PAP Due’ • books appnt with physician or NP

ClinicAssistant

Checks ‘Rules’ on

Patient Chart

• Checks CA’s notes• Discusses with pt,

as needed• Colonoscopy

referral, as appropriate

Documentation• records in chart notes• SMART forms record automatically

‘Colorectal Due’• prints req for FOBT• makes note for physician

• reviews at request of CA• checks scanning

nomenclature• searches Netcare• corrects in chart • updates Rules, as needed

Discrepancy in chart?

• messages POET

For Example (EMR, Telus-Wolf)

EPICS IIbVulcan Medical Clinic: Cancer Screening Process (Outreach)

q. 3 months• Runs report of

women due for PAP

POET

Documents contact in patient

chart

Contacts Patients • phones to remind of screening due

ClinicAssistant

Reviews list for accuracy

Alerts POET of unrecorded PAPs

Exempts patients from

search rule, as appropriate

For Example (EMR, Telus-Wolf)

EPICS IIb Results% of age/gender appropriate patients to whom screening was offered

• 50 patient charts per review (October, December, March)

• Patients having presented for an encounter and due for screening

• Including outreach screening for cervical• Females (21-74 years), Males (50-74 years)

Chart Review Cervical Breast Colorectal

Pre-intervention 74% 85% 80%Post-intervention 94% 100% 88%Sustainability 100% 100% 100%

Documenting Current State

As with Vulcan’s journey, the first step is to establish where they currently are

PROCESS MAPPING

Simple Process Mapping

Step 1: Name the process

Step 2: Determine the starting point and the end point

Step 3: Brainstorm what happens between

Step 4: Arrange the steps in order

Example

Step 1: Name the process

“Preparing tea for mother-in-law”

Example

Step 2: Determine the starting point and the end point

Get kettle Present cup to M-i-L

Example

Step 3: Brainstorm what happens between

Plug kettle

in

Pour tea in cup

Pour milk in cup

Get milk

from fridgePlace tea bags in teapot

Get cup

Pour water in teapot

Wait 5 minutes

Remove tea bags

Wait for

whistle

Add sugar Remove lid

Add water

ExampleStep 4: Arrange the steps in order

Plug kettle in

Pour tea in cup

Pour milk in cup

Get milk from fridge

Place tea bags in teapot

Get cup

Pour water in teapot

Wait 5 minutes

Remove tea bags

Wait for whistle

Get kettle

Present cup to M-I-L

Add sugar

Open the box

Get the tea boxRemove lid Add water

Key Points

• Start and end steps are clearly defined (oval shape)

• Steps are all “actions” (start with a verb)

• Limit the time spent brainstorming – 15 minutes

• Request that one team member writes the steps on post-it notes

• Request that another team member positions the steps

• Take a picture of the post-its to capture the process

21

Map Current Screening Process

Patient greeted by reception

PHE?

Screening if patient

requests (physician)

MOA brings up

CPX template

MOA enters Ht/Wt

MOA measures

Ht/Wt

MOA rooms patient

Address confirmed

MOA leaves

Physician enters

Physician completes

CPX maneuvers

Completes exam, closes chart

No

Yes

BMFC

Blue Meadow Family Care – Current Screening Process

Greets patient

Confirms address

PHE?

Rooms patient

Screening if patient requests

Measures Ht/Wt

Opens CPX template

Records Ht/Wt

Leaves room

Enters roomCompletes maneuvers as per CPX

Finishes exam,

closes chart

No

Yes

Reception

MOA

Physician

BMFC

23

Discussion – Process Mapping

Dr. Doe (physician)

Dr. Green (physician)

Doreen (receptionist)

Maureen (office

manager)Chris

(MOA)

Your Name Here (IF)

I tried running a report on height & weight and got low numbers of screens.

I’m not really sure where to chart height and weight. There’s more than one place where they can go.

I think I only see a height and weight on about ½ of

my patients - I end up doing it myself!

BMFC

Alternate Option

25

Discussion – Guided Interview

Dr. Doe (physician)

Dr. Green (physician)

Doreen (receptionist)

Maureen (office

manager)Chris

(MOA)

Your Name Here (IF)

In reality, I only screen patients when they book a

PHE. Otherwise, I generally don’t think of it

unless prompted…We have room for improvement - even some patients who are here frequently aren’t getting screened.

Sometimes I discuss screening with patients, but I don’t always chart

what I’ve offered – especially if they decline.

BMFC

Discussion

• What differences did you note between the two methods?

• When do you think you might choose the simple process mapping method for ASaP?

• When do you think you might choose the guided interview method for ASaP?

McDonalds Patent Application“Method and Apparatus for Making a Sandwich”

Summary

• Part of the IF role is to guide clinic teams in documenting their current screening processes

• This establishes the starting point for developing or enhancing opportunistic and/or outreach screening processes

• Depending on the situation, simple process mapping or a guided interview method may be used