Rapid Cycle Improvement Model Applied To Chlamydial Screening in Teens

A Partnership Between:Kaiser Permanente Northern California

& University of California, San Francisco

Mary-Ann Shafer, MDDivision of Adolescent Medicine

UCSF

Supported by the Agency for Health Care Research and Quality& the Centers for Disease Control and Prevention

ObjectivesObjectives

• Increase chlamydial (CT) screening of sexually active teen girls to meet HEDIS guidelines

• Develop, implement and evaluate a systems-based intervention that capitalizes on existing clinic resources while addressing barriers to CT screening using a rapid cycle approach

BackgroundBackgroundFacts About Facts About Chlamydia trachomatis (CT)Chlamydia trachomatis (CT)

• CT-most common reportable STI in teens

• Most asymptomatic-in males and females

• NAATs- 90-95% sens & spec feasible

• National Guidelines annual CT screen (e.g. CDC, USPSTF, AAP, ACOG, AMA)

• Only 25% of eligible population being screened

JAMA December 11, 2002

Learning ObjectivesLearning Objectives

• Review the development, implementation and evaluation of a systems-based rapid cycle clinical improvement intervention (CPI) to increase CT screening

• Discuss the application of the CPI model to different clinical settings including identifying and overcoming barriers to success

Rapid Cycle Rapid Cycle Applied To CT Applied To CT ScreenScreen• Recruit teamRecruit team• Problem solve at Problem solve at monthly monthly meetingsmeetings• Apply solutions Apply solutions && assess each assess each monthmonth• Repeat, sustainRepeat, sustain

Time in months

% C

han

ge in

STD

Scre

en

ing

Rate

S t a t u s Q u o

Rapid CycleRapid CycleChangesChanges

Step 1: Step 1: • Set GoalSet Goal• Define measureDefine measure• Identify barrier(s)Identify barrier(s)• Decide solutionDecide solution• Try it outTry it out

Time in months

% C

han

ge in

STD

Scre

en

ing

Rate

S t a t u s Q u o

Rapid CycleRapid CycleChangesChanges

Step 2Step 2• Assess trialAssess trial• Identify next barriersIdentify next barriers• Decide solutionDecide solution• Try it outTry it out

Time in months

% C

han

ge in

STD

Scre

en

ing

Rate

S t a t u s Q u o

Rapid CycleRapid CycleChangesChanges

Step 3Step 3• Assess trialAssess trial• Identify barriersIdentify barriers• Decide solutionDecide solution• Try it outTry it out• Repeat “cycles”Repeat “cycles”• Sustain gainsSustain gains

Time in months

% C

han

ge in

STD

Scre

en

ing

Rate

S t a t u s Q u o

Rapid CycleRapid CycleChangesChanges

Setting for Rapid Cycle ApplicationSetting for Rapid Cycle Application

Setting

Large HMO in Northern California: KP

• 10 pediatric clinics randomly assigned: 5-well care intervention and 5 control groups

• 2 of 5 intervention clinics target both well and urgent care visits

Methods

Urgent-Care Visit

• Same/next day visit

• Sick/non-ER visit

• 10 minute visit

• Same physical setting as WCV

• Same providers & staff as WCV

KP Pediatric Setting cont.

Well-Care Visit

• Appointment required

• Physical exam (every 2-3 yrs)

• 20 minute visit

Engage

Team Building

Re-Design Clinical Practice

Sustain the Gain

Clinical Practice Improvement Model

Clinical Practice Improvement Model

Engage

Team Building

Re-Design Clinical Practice

Sustain the Gain

•Leadership

•Best practices

•Define gap

•Raise Awareness

Engage

Team Building

Re-Design Clinical Practice

Sustain the Gain

•ACTeam•Skill building•Tool Kit

Clinical Practice Improvement Model

Engage

Team Building

Re-Design Clinical Practice

Sustain the Gain

•Customize•Measure success

Clinical Practice Improvement Model

Engage

Team Building

Re-Design Clinical Practice

Sustain the Gain

•Monitor performance•Time series analysis•Continuous improvement

Clinical Practice Improvement Model

Urines To Lab

MD/NPVISIT

RoomPatient

MA refrigerates FVUs A enters teen name, confidential # in clinic log book LRunner takes FVU to lab

MD/NP obtains sex hx

If sexually active, MD completes CT lab slip WWWrites confid. # on chart

MA collects FVU on all 14-18 yo F TTeen takes FVU sample to exam room

CueCharts

ID eligible teensC

Charts are stamped with cue

Follow-Up

RN contacts CT + teen: confid. #

Teen comes to clinic for Rx

RN enters Rx in STD log book

Site Specific Flow Chart

1. Cue Charts

IIdentify eligible (target) population (14-18 y teens) Charts stamped with cue

(Y2P!)C

2. Room Patient

MMA collects FVU on all 14-18 yo

TTeen takes FVU sample to exam room

a

C

3. VISIT

CMD/ NP obtains sexual hx IIf sexually active, MD completes CT lab slip

WWrites confidential phone number on chart

C

4. Urines to Lab

CMA refrigerates FVUs MA enters teen name,

confidential phone number in log book

LRunner takes FVU to lab

C

5. Follow-up

RN contacts CT + teen: confidential phone number

Teen comes to clinic for Rx

RN enters Rx into STD log book

C

Clinician’s Top Barriers to CT Screening in Primary & Urgent Care Settings

1. CONFIDENTIALITY: How separate parent?

2. TEEN SEX HX: How do I ask these things?

3. PRIORITIES: How competes in urgent care?

4. JOB DESCRIPTION: Is this part of my job?

5. PAYMENT: Who’s responsible?

6. POSITIVE CT RESULT: What do I do now?

Confidentiality Universal urine collection

Teen’s sexual history Teen-friendly rooming policy

Site Teen Health Champion

Anonymous chart reviews

Priorities for limited time Re-think visit priorities

Payment – copays Waived to protect teens small price to pay!

Positives tests FU protocol in place

Key Barriers Sample Solutions

RESULTS Female CT Screening Rates*Pediatric Well-Care Visits (14-18 yo)

*Chlamydia Screening Rate = #CT Tests/(#Well Care Visits *Sexual Activity Rate

0%

20%

40%

60%

80%

Pre-Test 1-3 4-6 7-9 10-12 13-15 16-18

% o

f Sex

ually

Act

ive

Fem

ales

Scr

eene

d

ExperimentalControl

Intervention Time Period in Months

RESULTS: Female CT Screening Rate in Urgent Care Pilot Sites

0

10

20

30

40

50

60

70

2000 2001 2002 2003

Year Clinic AClinic B

% S

A F

emal

es

Scre

ened

for C

T

A

A

A

B

B

B

Results of Intervention Evaluation

• Dramatic improvement in well & urgent clinics

• Sustainable & cost-effective

• Clinic differences in approachrate of improvement varies

• One solution does not fit all even within HMO

Implications

• Rapid cycle quick, customized & sustained

• Effective in different settings- well, urgent care & may be applied as a quality assurance tool

• Capitalizes upon existing resources & staff

• Small changes LARGE effects

• Gives chronically over-worked staff sense of importance, success & control over workplace