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Download presentation (.pdf format)

A Meaningful

Quality Improvement Program

that meets AAAHC Guidelines

Beth Brown MS, ANP

Connie Hume-Rodman MD

ACHA May 30, 2012

1


I’ll be happy to give you innovative

thinking. What are the guidelines?

2


Objectives

• AAAHC criteria - 3 broad areas

• How Oregon State’s program meets criteria

• QI study examples

• Using EMR in our process

• Peer Review program


Student Health Services

Live well. Learn well. Be well.


AAAHC Compliance

3 – Year Cycle


AAAHC Guidelines

Broad – Based Program

• Clinical issues

• Cost of care

• Patient outcomes

• Administrative


Written Policy & Plan


Mission

8


Volunteer Committee


Includes

one physician


Goals and Objectives


Objectives 2010- 2013

•Benchmark studies

•National clinical guidelines

•AAAHC accreditation

•3 studies minimum


Goals 2011-2012

• Complete outstanding

studies

• Perform pertinent

studies & re-studies

• Continue prescription

writing error study


Goals 2011-2012

• Patient outcome

• Cost of care

• Student learning

• Administrative

• National

benchmark

Types of Studies


Goals 2011-2012

Peer Review

• Clinician

• Physical Therapy

• Nursing

• SANE


Student Satisfaction Surveys

-Internal/External

-Focused

-Urgent Care

-LGBT


Sources of Studies

• Peer Review

• Incident Reports

• Health & Safety

Committee


Studies from Individual

Departments

• Lab

• Pharmacy

• Physical Therapy

• Medical Records

• Clinicians

• Nursing

• Administration


Studies of Clinical Health Concerns

• Prevalent

diseases/injuries

• Concussion

• Depression


Internal benchmarking

Student Satisfaction

Surveys

Student Learning

Surveys

•Influenza Like Illness

•Nursing Advice Line

•Plan B

•Billing/Insurance


Link with risk management program

• Incident Reports

• Occupational Health


Annual Evaluation


Reporting


AAAHC Guidelines

10 Elements of QI Study Reports

24


Purpose and Description of Study

• Assessment of issue

• Reason for selecting

• Impact of topic


Goal of Study

• What results are satisfactory?

• Guidelines or benchmarks used.


Study Methods

• Data collected

• Data collection

process/tools


Findings

• Data analysis

• Comparison of data against goal


Interventions and Recommendations

“As you can see we have thought carefully

about ways of improving staff productivity.”


Evaluation and Conclusion

• Goal reached?

• Re-study?

• Inform staff


AAAHC Guidelines

Benchmarking


Relevant Performance Measures

National Clinical Guidelines

• Metabolic Syndrome

• Hypertension

• Concussion

• Depression


System for Data Collection and

Analysis

• ACHA Pap and STI Survey

• ACHA Clinical Benchmarking

Re-studies:

• Ottawa Rules

• Flu Shot Rates

• Peak Flows for Asthma

• Depression


Measuring Changes in Performance

Re-studies and Peer Review


Using Local, State or National

Standards

• NCHA Survey

- Gardasil vaccination rates


Incorporating Benchmarks

Using EMR to improve quality

• Centor Criteria

• Ottawa ankle rules

• Depression

-PHQ-9

• Concussion

-SCAT 2

• Animal Bite Reporting


Reporting Benchmark Results

• Annual Report

• Shared Drive

• Department Meetings

-ACHA Benchmarks


“First, I want to give you an overview of what I will

tell you over and over again during the entire

presentation.”


AAAHC Accreditation Requirements


Peer Review Purpose

FEEDBACK

• Individual

• Supervisors

• Collective

Practice


Procedure

• Quarterly

• Fall & Spring

-General

-Diagnosis

• Winter

-Screening


Process

• Random

assignment

• NP/PA

MD/DO DO/MD

PA/NP

• Forms

• Comments


Courtesy of OSU Archives P57:7675

Then

and

now…


Changes

• Tabulating Data

• Modifying forms

• Using EMR

“Regime change is never easy,

dear.”


Tabulating Data


General Indicator Checklist

1-Hx = Adequate history recorded.

2-PE = Adequate physical exam recorded.

3-Dx = Assessment and diagnosis supported by history/physical.

4-Tx = Treatment plan consistent with assessment and diagnosis.

5a-ED = Appropriate pt education discussed and recorded…

5b-Verb.Tx = Patient indicates or verbalizes understanding of treatment.

6-Rx = Appropriate meds prescribed and recorded.

7a- F/U Adv. = Follow up advice given and occurred if recommended.

7b-Verb.F/U = Patient indicates or verbalizes understanding of when to

return

8-Consult = Appropriate and timely consultation if indicated.

9-Tests = Diagnostic and therapeutic procedures are clinically necessary.

10-F/u tests = Timely follow up of findings/test results.

11-Med.List = Medication list was updated and confirmed.

12-Allergies = Allergies or NKDA noted on Allergy section.

13a-Med.Hx = All significant problems noted on the Medical History.

13b-Prob.List = All significant problems noted on the Problem List.

14-Rev.Hx = Past Medical History reviewed within the past year.

15-Lock = Was chart note locked within 2 working days of visit?


Modifying forms


Separate Screening & General

Indicators

Incorporate AAAHC indicators

Edit Indicator Checklist


Alcohol (Audit-C)

Screening Peer

Depressi

on

(PHQ-9)

Review

Checklist

Tobacc

o

BMI >

30


.

Using EMR


“We think you may be suffering from information underload.”


YOU DID IT!

• Thank you


eth.brown@oregonstate.edu

connie.hume-rodman@oregonstate.edu

linda.reid@oregonstate.edu

Oregon State University in

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