2010 Measured Reflection is the first publication of clinical data by Women s Healthcare Associates, LLC. It is intended to provide our partners,

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2 2010 Measured Reflection is the first publication of clinical data by Women s Healthcare Associates, LLC. It is intended to provide our partners, payers, patients, employees and prospective clinicians with a clear and transparent perspective on our practice. It also serves as a clinical benchmark for ourselves as we strive for continuous improvement and high reliability.

3 2011

4 Women are impacted by the health care system perhaps more than any other group not only as patients, but as mothers, wives and caregivers for ailing and aging family members. Reproductive and preventive health are among their priority issues. Impact of Health Reform on Women s Access to Coverage and Care, The Henry J. Kaiser Family Foundation, December, 2010

5 JANUARY 2011 The meaning of quality in health care is evolving. Previously, we put significant weight on our patients perception of quality (i.e., their experiences of health care) or our own highly variable standards to determine how well we were doing. The evolution taking place nationally is that, in addition to measuring the satisfaction of our patients, we assess data on medical outcomes combined with measures of efficiency to reach a determination of value. This analysis benefits all parties. Patients become better informed, more knowledgeable consumers of health care. Health systems and insurance plans are able to hold health care providers accountable. And, perhaps most importantly, health care providers gain a more accurate understanding of how they re really doing, creating the desire to meet ever higher standards. Achieving quality in health care according to evolving definitions is dependent on transparency. With the high volume of litigation and the health care industry s risk management mindset, this has historically been a touchy subject. Within a health care organization, transparency can often make people uncomfortable. It is only within a culture of continuous learning and improvement that transparency is embraced, not feared. From the outset, Women s Healthcare Associates, LLC has sought to create a culture of continuous learning where integrity and professionalism are central values. Our focus is to continually evaluate and discuss what we do. Our success in this area depends on our ability to sustain a culture where people are comfortable acknowledging shortcomings or areas that can be improved and bringing new ideas forward. We are fortunate at Women s Healthcare Associates to have the staff and technology required to continually measure, evaluate and create systems for improvement. More importantly, we are fortunate that we have people for whom being of service, doing the right thing and delivering quality health care is second nature. Even with the right culture, people and resources, evaluating clinical outcomes for an outpatient OB/GYN practice is difficult. There exist very few national benchmarks by which to compare ourselves; the ones that do exist are vague, at best. In this respect, Women s Healthcare Associates is proud to be breaking new ground. INTRODUCTORY LETTER 2010 Measured Reflection is our first publication of clinical performance data. By reviewing it, we hope you ll join us in the effort to assure health care in America continues to be among the highest quality in the world by any definition. 5 Brian Kelly, MBA Chief Executive Officer Damon Warhus, MD President Daniel Schrinsky, MD Medical Director

6 We find women to be very responsible consumers of health care and very willing to participate in their care. Our goal is to consider the perspective of our patient, offer recommendations and work together to find the best solutions.

7 TABLE OF CONTENTS PRACTICE OVERVIEW QUALITY AT WOMEN S HEALTHCARE ASSOCIATES, LLC OBSTETRICS GYNECOLOGY INITIATIVES TABLE OF CONTENTS ACKNOWLEDGEMENTS

8 Women s Healthcare Associates Values Statement Through our commitment to our shared values, we promote the health and wellbeing of women: Service to Others Integrity Professionalism Teamwork Fun

9 practice OVERVIEW working collaboratively to improve the health and lives of women Women s Healthcare Associates, LLC, is the largest private OB/GYN practice in Oregon. It is an obstetrics and gynecology practice that includes the subspecialties of maternal fetal medicine, minimally invasive surgery and urogynecology, as well as a number of key support and supplementary services. Our services are unified by our focus on education and The Patient Experience. OVERVIEW 9

10 OVERVIEW long history, long-term relationships Women s Healthcare Associates, LLC has been serving women on Portland s Westside for more than 11 years. We have grown, adding clinicians, services and locations as a result of our commitment to serving our communities and partnering with the Providence and Legacy health systems. Our commitment to the care of women in the entire Portland area goes back much further than the last decade, as illustrated in the timeline below. Throughout our continual growth and evolution, the clinicians of Women s Healthcare Associates value above all the long-term relationships we have developed with our patients and their families, meeting their women s health care needs throughout all phases of life. the right people Great vision without great people is irrelevant The main point is to first get the right people on the bus before you figure out where to drive it. People are not the most important asset. The right people are. Jim Collins, Good to Great 10

11 People are the foundation of our success The health care industry is full of smart people. We meet with dozens of them in our offices every year. Smart is not enough; we live by our values and hire those outstanding individuals whose intelligence is matched by their commitment to working collaboratively in teams, finding the best solutions and sustaining our culture, including our commitment to quality. This is how we define the right people at Women s Healthcare Associates those who enable us to rise from the level of good to truly outstanding. Finding the right people could be considered our first priority because those individuals are behind the systems, decisions and daily interactions that drive our culture and reputation. They are the foundation of the relationships we enjoy with hospital systems and other business colleagues that enable us to advocate effectively on behalf of our patients. Frequently, our clinicians serve in positions of significant responsibility on the medical staffs in the Providence and Legacy health systems, as well as in a number of professional organizations. In 2010 we were recognized by Oregon Business magazine as one of the 100 Best Companies to Work for in Oregon. This honor was received as a result of a survey of our own employees and demonstrates that our commitment to patients is mirrored by our commitment to staff at all levels of the organization. Facilities and Technology that support our mission We consider several factors when investing in our facilities and technology. High quality patient care is our top priority; therefore, we invest in state-of-the art equipment, including monitoring, testing and medical imaging technologies. These medical imaging technologies include ultrasound, digital mammography, bone densitometry and laboratory technologies. We implemented an electronic medical record (EMR) in 2007 and, with the help of our own Information Technology (IT) team, continue to refine our system to provide access to important information at the point of care, to establish consistent work flows that are proven to lead to optimal outcomes and to collect relevant data that we can use to evaluate our performance. Communication is an essential part of high quality care. In addition to our EMR, we invest in phone and computer infrastructure that facilitates our communication and the coordination of patient care internally, with clinicians outside Women s Healthcare Associates and with our patients. Beyond the infrastructure and technologies that directly support clinical care, we recognize the importance of our environment as an outward demonstration of our commitment to quality, both for our patients and our staff. We maintain facilities that are appealing, modern and consistent throughout our organization. OVERVIEW 11

12 The importance of the patient-clinician relationship cannot be underestimated in the OB/GYN setting where we meet women in some of the most emotional, intimate and life changing circumstances they will experience.

13 QUALITY AT WOMEN S HEALTHCARE ASSOCIATES The definition of quality in medicine is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. 1 Our directive is, put simply, to assure the best possible outcomes for the greatest number of our patients in accordance with the best available science in our community of peers. We take this mission very seriously and understand that many things impact outcomes, including the patient s experience of their medical care and the trust, communication, understanding and, ultimately, cooperation that result from a positive experience and patient-clinician relationship. The importance of that relationship cannot be underestimated in the OB/GYN setting where we meet women in some of the most emotional, intimate and life-changing circumstances they will experience. At Women s Healthcare Associates, we regard quality as our collective responsibility. Our search is always for the best answers and quality issues receive broad commitment across all levels of our organization. Quality is woven into everything we do and the grassroots feedback we receive from our staff adds tremendous value. In addition to the broad commitment and culture of collaboration that make it possible for us to address quality issues, quality improvement is championed at the highest levels of our organization. Leadership is provided by our Quality Improvement (QI) Committee, which is chaired by our Medical Director and facilitated by our full-time Quality Improvement Coordinator who is a Certified Professional in Healthcare Quality (CPHQ). The committee is comprised of clinicians from throughout the company, including Certified Nurse Midwives, OB/GYN Physicians and Perinatologists. It also includes the lead nurses from each of our clinical locations. The QI Committee was established by and is accountable to the Management Committee of Women s Healthcare Associates. QUALITY The focus of the QI Committee is on continuous improvement rather than untoward events and problems. This shifts the emphasis from punishment to processes, systems and education designed to minimize variance and improve outcomes. The committee s efforts are driven by data data identified and collected on our internal practices and outcomes, as well as studies and reports from other sources Measured Reflection documents our ongoing work in quality improvement, providing a benchmark and helping to enhance the atmosphere of accountability to our patients and partners in the medical community Lohr, KN Ph.D. and Schroeder, SA M.D., A Strategy for Quality Assurance in Medicare, New England Journal of Medicine 1990; 322:

14 We are committed to education and feel that knowledge empowers women to make choices that are in the best interest of their health and that of their unborn child. We value the lifelong professional relationship that often begins while caring for a woman and her family during and following pregnancy.

15 Obstetrics At Women s Healthcare Associates, we provide a broad range of care to meet the unique needs and preferences of our pregnant patients. Our obstetric care clinicians include Certified Nurse Midwives, OB/GYN physician/surgeons and Maternal Fetal Medicine Specialists. While there are differences in the models of care and emphases of our obstetric care providers, we adhere to consistent standards and practices. We follow evidencebased guidelines and work to establish systems and decision models to assure optimum outcomes for each patient. We are committed to education and feel that knowledge empowers women to make choices that are in the best interest of their health and that of their unborn child. We value the lifelong professional relationship that often begins while caring for a woman and her family during and following pregnancy. If a medical condition or complication of pregnancy arises that requires consultation, comanagement or transfer of care to another clinician, we work together with the highest professional respect to assure the safety of our patients. All of our patients benefit from the expertise of our most specialized obstetric clinicians; all anatomy and genetic screening ultrasounds are reviewed by one of our Maternal Fetal Medicine Specialists. All of our patients have access to the best available science in prenatal genetic screening. Referrals for further genetic testing or consultation, if indicated, are seamless and the resulting plan of care is coordinated and immediately integrated into the patient s medical record. OBSTETRICS 15

16 OBSTETRICS Early Prenatal Care Steps to a Healthy Pregnancy and Beyond In 2010 Women s Healthcare Associates introduced a new process for educating women earlier in their pregnancies. Rather than scheduling first appointments at 8-10 weeks of pregnancy, we are scheduling an initial prenatal nurse intake visit with patients within two weeks of the patient s first call to our office. This typically occurs at five to six weeks of pregnancy. 16 Trusted provider of obstetrical care The recession that began in 2008 has had a substantial impact on obstetrics throughout the country. The US birthrate is at its lowest level in a century. The volume of obstetric patients at Women s Healthcare Associates is down 12% from 2009 levels. Despite this decline, we remain a provider of choice in Portland s Westside communities, as illustrated by the proportion of deliveries managed by our clinicians at each of the three primary hospitals in which we work. In addition to collecting specimens for initial lab tests, the intake visit focuses on standardized, evidence-based education regarding lifestyle, nutrition, smoking cessation and healthy weight gain. It also provides education about key decisions patients will be asked to make at their first clinician visit regarding prenatal genetic screening. Providing basic education in advance enables more individualized counseling when a woman sees her clinician for the first time. The new intake process provides earlier access to care, earlier education regarding steps to a healthy pregnancy and increases our patients level of confidence. In conjunction with the new intake visit and in response to the requests of our patients, we have transitioned much of our obstetric education materials to CD-ROM format.

17 participating in the national discussion on cesarean section Cesarean section is the most commonly performed surgical procedure in the United States. Rates vary due to a number of factors, including patient risk factors and practitioner practice patterns. Because cesarean sections affect so many women, there is a push to establish meaningful measures that will reflect quality and manage cost. Women s Healthcare Associates, in partnership with Providence Health System, is actively participating in these efforts locally and nationally. Women s Healthcare Associates performs c-sections at a rate consistent with regional, state and national rates. We continuously evaluate our outcomes in the area of cesarean section and how delivery mode impacts patient safety and satisfaction is the most recent year for which comparison statistics are available. Regional and State data was obtained from the State of Oregon Public Health Department Center for Health Statistics. National data was obtained from the US Department of Health & Human Services National US Birth Statistics for 2008, Vol. 58 Number 16, April 6, Leading Edge Obstetrical Ultrasound All obstetric patients at Women s Healthcare Associates have access to the highest quality, most technologically advanced ultrasound services available. We voluntarily participate in the American Institute of Ultrasound in Medicine s (AIUM) accreditation program, which includes review of our maternal-fetal medicine practice every three years. We have more than 15 sonographers on staff who are registered in the specialty of obstetrics with the American Registry of Diagnostic Medical Sonographers (ARDMS) and have many years of specialized experience. All anatomy and genetic screening ultrasounds performed at Women s Healthcare Associates are reviewed and interpreted by one of our Maternal Fetal Medicine Specialists who have extensive training and experience in the evaluation of obstetric ultrasounds. Our sonographers and Maternal Fetal Medicine Specialists work very closely together. When an anomaly is discovered during an ultrasound study, a perinatologist is often consulted immediately and the patient is offered same-day counseling. OBSTETRICS 17 Examples of traditional and 3D ultrasound performed at Women s Healthcare Associates.

18 OBSTETRICS 18 timely and accessible Prenatal Genetic Screening Women s Healthcare Associates offers prenatal screening for chromosomal abnormalities to all obstetric patients through our Northwest Perinatal Center. OB/GYN practices outside of Women s Healthcare Associates also send their patients to Northwest Perinatal Center as a recognized center of excellence in genetic screening and diagnosis. The group performs an average of nearly 3,000 screening tests each year that include a nuchal translucency measurement, an important early pregnancy component of the risk assessment for Down syndrome. Our sonographers are credentialed each year under the Maternal Fetal Medicine Foundation s Nuchal Translucency Quality Review (NTQR) Program to assure the measurements they obtain are high quality and statistically valid. Our high volume, combined with the external proficiency review under the NTQR program, lead to results that are accurate and reliable. reaching out to new mothers following birth Women s Healthcare Associates works diligently to assure the health of mother and child throughout pregnancy, delivery and beyond. While we strive to provide postpartum care to all of our patients, there is a small percentage who move from the area before the postpartum visit or do not return for some other reason. Still, we have provided postpartum care for 96% of our patients over the last three years. In the weeks immediately following birth, our trained nurses reach out to the new mother to assure she and her family have access to all the resources they need, the mother s recovery is proceeding smoothly and care of the infant at home is going well. Our postpartum office visits, which normally occur at approximately six weeks postpartum, include a depression screen, which is compared to a baseline screen performed at 30 weeks, education regarding contraception and an overall evaluation of the mother s health. Our clinicians also assure pediatric care of the newborn is in place. The continuity of care from pregnancy through birth and beyond supports optimal outcomes for both mother and baby. In June of 2010 Women s Healthcare Associates transitioned from the First Trimester Screen to the Sequential Screen as our standard of care. Like the First Screen, sequential screening assesses risk for Down syndrome and trisomy 18, as well as open neural tube defects. Part 1 of the Sequential Screen includes a blood sample and a nuchal translucency measurement taken between the 11th and 14th week of pregnancy. Part 2 consists of a blood sample taken between 15 and 22 weeks. The initial risk assessment allows us to offer earlier diagnostic testing to those families who are classified as high risk. The second risk assessment improves the accuracy by offering a better detection with a lower screen positive rate.

19 the art and science of Nurse Midwifery The Certified Nurse Midwives of Women s women with the education and support they Healthcare Associates provide complete prenatal need to cope with the physiological changes and postpartum care, as well as well-woman inherent in pregnancy and birth and to make gynecology. They manage low-risk births independently, decisions that are right for them and their famcian and are supported by their physiilies. They also recognize that each woman s partners should a physician consultation family and social situation is unique and seek or surgical intervention become necessary during to understand and address how that impacts labor or birth. They have master s degrees, her experience. have completed accredited nurse midwifery A key aspect of midwifery care at Women s programs and are licensed both as registered Healthcare Associates is bedside labor support. nurses and nurse practitioners in the state of The intuitive value of labor support has been Oregon. They have full access to the advanced validated by numerous scientific studies. Women who choose labor with continuous support technology of Women s Healthcare Associates and use it judiciously when it is in the patient s from a caregiver are less likely to request pain best interests. medication, less likely to have a cesarean section, Our midwives focus on pregnancy and birth less likely to have a forceps or a vacuum as a normal part of life. They seek to provide delivery and report more satisfaction. 1 Recognition for midwifery The midwives of Women s Healthcare Associates were recognized in 2010 by the American College of Nurse- Midwives for achieving the highest rate of breastfeeding continuation at six weeks postpartum among similar midwifery practices. This patient-centered, collaborative approach continues after the childbearing years, with many women choosing to return to their midwife for contraception, annual exams and menopausal management. OBSTETRICS Data for WHA Midwives is based on 2008 statistics collected among the midwifes at our Peterkort South office, which operates as a pure midwifery practice rather than as a mixed model. National midwifery data reflects the 50th percentile of midwifery practices participating in the American College of Nurse-Midwives Benchmarking Initiative for National averages are from a variety of sources, including the American College of Obstetricians and Gynecologists, the CDC and Listening to Mothers II study and are from 2007 and National data is provided as a general comparison; it is recognized that the midwifery patient population is generally self selected and of lower risk than the national population as a whole Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD DOI: / CD pub2

20 OBSTETRICS 20 integrated high risk obstetrics and prenatal genetic services The subspecialty board-certified Maternal Fetal Medicine Specialists and Certified Genetic Counselors of Northwest Perinatal Center provide prenatal genetic screening and diagnosis, consultation and management for a variety of chronic maternal medical diseases, fetal conditions and complications of pregnancy. It is a referral-based practice and the only private highrisk obstetric practice in the region. Approximately 30% of referrals are from Women s Healthcare Associates clinicians. The balance are from OB/GYN physicians and midwives throughout Northwest Oregon and Southwest Washington, demonstrating the high regard with which the clinicians of Northwest Perinatal Center are held by the regional obstetric community. Our Maternal Fetal Medicine Specialists have also been recognized nationally through lectures, the presentation of scientific papers and participation in collaborative clinical research. Common conditions managed by Northwest Perinatal Center include maternal diabetes and hypertension, abnormalities in fetal growth or amniotic fluid volume and preterm labor or preeclampsia. Less common, but potentially severe, complications managed by the group include congenital heart disease and maternal fetal blood group abnormalities. In addition to consultations during pregnancy, the clinicians at Northwest Perinatal Center frequently meet with women before conception to assure optimal maternal health before pregnancy. Most conditions are managed in the outpatient setting; however, in-hospital care prior to delivery is sometimes required. In many instances care is provided in consultation with a woman s primary obstetric provider. In others, the complexity or severity of the condition leads to transfer of care for the duration of the pregnancy, including delivery. The group has strong collaborative relationships with a number of specialists and arranges an average of 40 on-site consultations each month in the areas of pediatric cardiology, urology and neonatology. Consultations with adult specialists in cardiology, pulmonology and critical care, as well as nephrology, are also arranged, as necessary. Recognized Clinical Leaders Positions of leadership Clinicians of Women s Healthcare Associates are recognized as leaders through the positions they hold in regional health systems: Steve Girolami, MD, Medical Staff President at Legacy Meridian Park Medical Center Mark Tomlinson, MD, Regional Director of Obstetric Services for Providence Health Services Anna Karlsson, MD, OB/GYN Department Chair at Providence St. Vincent Medical Center Susan Hobson, MD, PhD, Gynecology Section Chair at Providence St. Vincent Medical Center Lisa Pew, MD, Chair of OB and Pediatrics Department at Legacy Meridian Park Medical Center David Johnson, MD, President Elect of Medical Staff at Providence Newberg Medical Center Gary Hoffman, MD, Women s and Children s Division Chief at Providence St. Vincent s Medical Center

21 The Certified Genetic Counselors at Northwest Perinatal Center facilitate genetic screening education and help families make decisions regarding whether to undergo invasive diagnostic testing, including amniocentesis and chorionic villus sampling (CVS). Our Maternal Fetal Medicine Specialists perform an average of nearly 650 of these invasive diagnostic procedures each year. The rate of pregnancy loss related to genetic amniocentesis (procedures performed in the second trimester as part of genetic diagnosis) experienced by our patients is approximately 1 in 500 procedures 2, compared to a risk of pregnancy loss of 1 in 200 procedures cited by the American College of Obstetricians and Gynecologists (ACOG) in its patient literature. In some uncommon conditions, fetal cord blood sampling and in utero fetal transfusions through the umbilical cord are done. The CVS program at Women s Healthcare Associates was reinitiated in 2010 after a brief interruption due to staffing changes. We look forward to presenting outcomes related to this procedure in future editions of Measured Reflection. OBSTETRICS During amniocentesis and CVS, a sample is collected and grown in a special culture in the laboratory. Specialists then arrange pairs of chromosomes to create the fetal karyotype, shown at the right, to determine the presence of certain genetic (chromosomal) abnormalities, such as trisomy 18 and Down syndrome WHA pregnancy loss rate related to the procedure is defined as miscarriage within four weeks of amniocentesis and is based on genetic procedures performed in 2008 and 2009.

22 Nearly one-in-five American women ends her childbearing years without having borne a child, compared with one-inten in the 1970s. More Women Without Children, by Gretchen Livingston and D Vera Cohn, Pew Research Center, June 25, 2010

23 Gynecology Within the context of an OB/GYN practice, gynecology can sometimes be overshadowed by the urgency of obstetrics. While pregnancy is often the stage of life at which we begin seeing women, we recognize it is but one stage and the needs of our patients change over time. The nurse practitioners, Certified Nurse Midwives and OB/GYN physicians who provide gynecologic care at Women s Healthcare Associates believe the science and practice of gynecology is significant and unique. It affords us two unusual opportunities: to care for women during all stages of life, each of which has very different considerations, and to develop meaningful, longstanding professional relationships. We find women to be very responsible consumers of health care and very willing to participate in their care. Our goal is to consider the perspective of our patient, offer recommendations and work together to find the best solution. We practice within evidencebased guidelines as we suggest screening and preventive measures or offer recommendations for the treatment of various conditions. Education is a very important component of our care. Our newly established Wellness Journal on our website is a blog written by our clinicians that includes topics for women in all stages of life. GYNECOLOGY 23

24 GYNECOLOGY Comprehensive Annual Screening Exams are the cornerstone of health maintenance Comprehensive annual screening exams are the cornerstone of maintaining wellness and early diagnosis of many conditions. The annual screening exam gives patients an opportunity to ask questions and the clinician an opportunity to provide education regarding healthy lifestyle, disease prevention and recommended health maintenance screening. Our Stay Healthy educational handout provides women with up-to-date information on recommended health screening tests by age group; nutrition, calcium and vitamin D requirements for good bone health; cancer screening; and other helpful information. We perform more than 17,000 annual examinations each year focusing on education and the maintenance of health at all ages. In addition to these preventive exams, we see women for nearly 24,000 gynecology visits annually to discuss specific problems. 24 Northwest Gynecology Center addresses the needs of all women In 2009, Women s Healthcare Associates launched Northwest Gynecology Center, a practice devoted solely to gynecology. We did so not as a quality improvement measure per se, but in response to feedback we received from patients who were not interested in childbearing and looking for a different type of experience. Although our patients are able to receive the same high quality gynecology care from the OB/GYN clinicians throughout Women s Healthcare Associates, we believe having separate clinics focused on only gynecology enhances the care experience for that segment of our patients seeking gynecology only care. Through establishing Northwest Gynecology Center, we have been able to grow and expand several of our subspecialty services, including minimally invasive surgery and urogynecology. Providing these services within our organization increases the level of care coordination among clinicians for women who need subspecialized care. This eliminates redundant lab work, imaging studies and barriers to communication that might otherwise be present. We also increase opportunities for learning and mentorship through the presence of sub-specialized clinicians within Women s Healthcare Associates, all of which increases the quality of care we deliver throughout our practice.

25 mammography and dxa Women s Healthcare Associates began offering mammography on our Peterkort campus in 1993 and dual x-ray absorpitometry (DXA) a decade later in We now offer both services at our Tualatin campus, as well. Gynecological Health and Wellness for women of all ages Women s Healthcare Associates provides many services to assure comprehensive gynecologic health and wellness for the women we serve. These include education regarding family planning and contraception; health screening exams for cervical, breast and bone health; screening exams for infections; and immunizations that include Human Papilloma Virus (HPV) and flu vaccines. We also excel in the diagnosis and treatment of a wide variety of gynecologic problems, including menstrual disorders, uterine fibroids, PMS/PMDD, polycystic ovarian syndrome, symptoms of perimenopause and menopause, osteoporosis and pelvic floor problems, including urinary incontinence. Embracing New Cervical Health Screening Guidelines Women s Healthcare Associates follows the 2009 American College of Obstetricians and Gynecologists (ACOG) guidelines regarding cervical screening, i.e., pap smears. The new screening guidelines are confusing to some women who are used to the mantra of annual pap smears. Our clinicians are dedicated to explaining the new guidelines to patients with reassurance that they are based on the latest scientific evidence and do not compromise safety. Our electronic medical record (EMR) assists in assuring consistent, evidenced-based care that helps us reduce screening frequency in patients that are low risk while maintaining vigilance in screening high risk patients. As part of our cervical health recommendations, we educate patients on HPV and offer vaccines for those under age 26. Our systems enable us to track the vaccine series to assure its completion and maximize protec- GYNECOLOGY 25

26 GYNECOLOGY tion against the types of HPV causing the large majority of potentially serious abnormalities, as well as assess our performance in delivering this important preventative measure. Mammography Leads to Earlier Detection and Improved Survival Women s Healthcare Associates offers high quality, on-site digital screening mammography at our Peterkort and Tualatin campuses. Our patients find it very convenient to schedule their mammogram and annual gynecology exam at the same time. We follow the American Cancer Society guidelines regarding frequency of mammography. Our full-time mammogram technicians are licensed Radiologic Technologists registered in Mammography who each have more than 30 years of experience in breast imaging. Our DXA scans are interpreted by one of four Women s Healthcare Associates clinicians who are ISCD board-certified Bone Densitometrists. They provide a detailed consultation report on each DXA scan, considering the patient s medical history, so the ordering clinician has a clear understanding of the results and recommendations for management. These clinicians are also available to see patients in consultation, working with the patient to develop treatment and management options that best meet the individual s needs and lifestyle. We utilize the latest scientific evidence incorporating the FRAX fracture risk algorithm and National Osteoporosis Foundation guidelines. 26 Women s Healthcare Associates contracts with highly respected, specialized radiologists in the community to read our screening mammograms. We maintain a referral network to facilitate follow-up diagnostic imaging, biopsy, surgery and other treatment, when necessary. Bone Density Scanning Assists in Developing Personalized Treatment Plans On-site bone density scanning is offered at our Peterkort and Tualatin campuses. We are dedicated to providing outstanding bone densitometry imaging and reporting. Our technicians are highly trained and certified through the Oregon Board of Medical Imaging. We maintain precision testing that meets International Society of Clinical Densitometry (ISCD) standards. This assures we can accurately report whether a change seen on serial bone density tests is truly an increase or decrease in density rather than a random measuring error. advancements in understanding and technology As in all areas of medicine, a more in-depth understanding of many conditions, coupled with some remarkable new technologies, has led to significant improvements in our ability to care for women. This improved understanding of a number of gynecologic conditions, such as menstrual disorders, urinary incontinence and pelvic organ prolapse, has driven the development of technologies to support that understanding. The technology that has developed side by side with our knowledge has resulted in a significant improvement in outcomes, as well as less disruption to the lives of those we treat. Office Diagnostic Tools Assist in Determining Root Cause Ultrasound is a valuable and cost-effective tool for evaluating the cause of gynecological symptoms, such as pelvic pain or unusual vaginal bleeding. The sonographers at Women s Healthcare Associates who perform gynecological ultrasound are registered to do so by the American Registry of Diagnostic Medical Sonographers. The images they obtain

27 are read and interpreted by designated OB/GYN physicians within our practice who report the results to the ordering physician. We regularly perform hysteroscopy (a direct visual look inside the uterus) in our offices as another diagnostic tool. The use of the hysteroscope allows us to help resolve a number of uterine conditions at the same or future time. GYNECOLOGY 27

28 GYNECOLOGY 28 Office Surgery Provides Comfort and Convenience Without Sacrificing Quality and Safety In late 2007, Women s Healthcare Associates launched an in-office surgical program allowing our patients access to selected procedures previously performed exclusively in the hospital. The ability to accomplish these procedures with uncompromising quality and safety was the non-negotiable prerequisite. Using minimal or moderate (intravenous) sedation, we now offer endometrial ablation, dilatation and curettage, hysteroscopy and hysteroscopic sterilization, as well as other minor procedures at both the Tualatin and Peterkort campuses. Our office staff is dedicated and specifically trained to work in the unique office surgical setting. We have established comprehensive protocols that are followed with attention to every detail. Performing these procedures in our offices is less costly than doing so in a hospital setting and offers the comfort and convenience of an environment with which our patients are familiar. As importantly, our patients have reported outstanding satisfaction related not only to their outcomes, but also their comfort and experience. In February 2010, Women s Healthcare Associates received accreditation from the Oregon Medical Association (OMA) for our in-office procedures requiring moderate conscious sedation. The accreditation was the culmination of an intense process that began formally in The process involved an evaluation of all written protocols and procedures and a review of cases. In addition, an on-site inspection of our facilities, equipment, emergency response capability, staffing and qualifications was conducted. This certification demonstrates our commitment to high-quality, safe in-office surgical options. Appropriate follow up is of the utmost importance for our in-office surgery patients. We work diligently to make sure our clinical staff follows consistent protocol with respect to follow up. WHA began performing office surgery in the 4th quarter of 2007.

29 Patient satisfaction high with office surgery I just wanted to take a quick minute to let you know how pleased I am with the procedure performed yesterday in your office... The best part (aside from your incredible staff of nurses) was the short duration of the entire event. Outside of prep and recovery, I don t think that it was even 10 minutes. I felt so very good post procedure that I was out having lunch with my family within the hour. From Our Patients --Office Surgery Patient Minimally Invasive Approaches Reduce the Impact of Gynecological Surgery Women s Healthcare Associates has long been a leader in the field of minimally invasive gynecologic surgery. Our clinicians have been among the first in the Portland area to provide many advanced procedures and we continue to be on the cutting edge of new surgical technology. Our gynecologic surgeons are involved in training local surgeons, resident physicians and fellows who are interested in learning advanced surgical skills. As part of our commitment to providing patients with the latest in surgical innovation, Women s Healthcare Associates has the only private practice, fellowshiptrained minimally invasive gynecologic surgeon in the Portland area. Many of our patients benefit from minimally invasive procedures, such as laparoscopic hysterectomy, that were once performed using large incisions. Minimally invasive approaches enable patients to return to daily activities much more quickly. Shorter hospital stays and less blood loss, infection and pain medication are also important benefits of minimally invasive surgery. As in all surgical procedures, patient safety is our utmost priority. Surgical practice, techniques and technology change over time. The surgeons at Women s Healthcare Associates seek to stay current in surgical best practice through self study, mentorship and, for advanced laparoscopic surgery, internal credentialing. As part of our quality improvement efforts, we have a subcommittee that is dedicated to developing guidelines for internal credentialing for certain advanced laparoscopic surgeries, including: Laparoscopic supracervical hysterectomy Total laparoscopic hysterectomy Laparoscopic myomectomy or surgery requiring laparoscopic suturing Robotically-assisted surgery Internal credentialing for advanced laparoscopic surgery gives the surgeons of Women s Healthcare Associates an avenue for pursuing greater expertise consistent with their interests and skills, while at the same time ensuring GYNECOLOGY 29

30 GYNECOLOGY patient safety. The credentialing process involves sustained, focused attention and effort through working with mentor surgeons, obtaining focused Continuing Medical Education (CME) on an ongoing basis, having a teachable attitude and recognizing one s own limits. Credentialed surgeons will be required to maintain minimum case loads and will have their rates of complication reviewed annually by our QI committee. A key component of the credentialing process is the role of the mentor surgeon. These are surgeons within Women s Healthcare Associates who are internally credentialed and recognized as capable, available and dedicated to supporting the success of other surgeons within the organization. Their role includes pre-operative consultation, surgical assistance and post-operative debriefing. The goal of this process is to maximize learning opportunities for all involved, ensure hospital and support systems are optimized and promote continuous quality improvement. 30 Specialists in Urogynecology Address Our Patients Most Personal Needs Through our clinicians at Northwest Genecology Center, Women s Healthcare Associates offers dedicated specialists in urogynecology and pelvic reconstructive surgery. We evaluate and treat the full spectrum of pelvic floor disorders, such as urinary incontinence and voiding disorders, fecal incontinence and defecatory disorders, pelvic support relaxation and pelvic organ prolapse, and pain with intercourse. early intervention yields better outcomes Women who experience mild urinary stress incontinence following childbirth benefit from early intervention, such as physical therapy. Treatment is highly personalized for each patient and we are committed to exhausting all appropriate conservative options prior to pursuing surgical interventions. When surgery is the treatment of choice, we are able to offer surgical approaches to meet the unique needs of each patient, including transvaginal and robotic assisted laparoscopic minimally invasive approaches. We are developing a program that emphasizes early and proactive intervention for our obstetric patients experiencing symptoms of urinary incontinence following childbirth, or who are at risk for anal incontinence due to a higher order obstetric laceration. Our program will include screening our postpartum patients for pelvic floor disorders at their six-week postpartum appointment so that we can actively intervene The female pelvic anatomy is complex, as illustrated here. Our physician/surgeons continually look for the safest and most effective surgical approaches to restore function and improve quality of life.

31 at an early stage; evidence has shown that early intervention with pelvic floor strengthening can decrease the rate of postpartum urinary incontinence. Patients who exhibit symptoms postpartum will receive a referral to physical therapy or to our urogynecologists. We will follow patients with a validated pelvic floor symptom questionnaire after physical therapy to assess their results and continue interventions if symptoms persist. We know that loss of control of stool or gas is socially and psychologically devastating. Women who have sustained a higher order obstetric tear, or who have an operative vaginal delivery, are much more likely to suffer from anal incontinence. We will be proactively following these patients to assure that they have optimal healing of their repair. Followup will include a phone call from one of our advice nurses to assure they have had a soft bowel movement within 48 hours of discharge. If not, they will receive further instructions or be seen by a physician. These patients will also receive additional pelvic floor evaluation by a urogynecologist, be given guidance on pelvic floor protection and strengthening and receive a referral to physical therapy, as indicated. Counseling regarding mode of delivery for subsequent pregnancies will also be offered. This careful follow up allows for the additional attention necessary to support and educate women with significant obstetric pelvic floor injury to give them the best immediate and long-term outcomes possible. Our clinicians are also actively involved in education related to urogynecology and the prevention of injuries to the pelvic floor. We participate in medical resident education at Providence St. Vincent Medical Center and outreach to internal medicine and OB/GYN physicians regarding diagnosis of pelvic pain and treatment of incontinence. GYNECOLOGY 31

32 Innovation has profoundly improved health quality and life expectancy. Innovations in health care practices, techniques, management, and public health have increased life expectancy so rapidly that half the babies born in developed countries in 2007 will live to be at least 103 meaning that, life expectancy, just 49.2 years in 1900, has doubled over the last century. Innovation Policy on a Budget: Driving Innovation in a Time of Fiscal Constraint by R. Atkinson, D. Castro, S. Andes, S. Ezell, D. Hackler and R. Bennett, The Information Technology and Innovation Foundation, September 2010

33 Initiatives In our effort to continuously learn and improve, we dedicate ourselves to initiatives strategically selected to best serve our patients. These initiatives become integral to our practice over time. We consider and select initiatives according to the following criteria: Aligns with the mission statement and strategic plan of Women s Healthcare Associates. Adds value to the care we provide by increasing patient satisfaction, safety and quality of care and lowering costs, when possible. Improves the efficiency of our workplace. Helps to improve access to care for our patients. Improves clinician practice patterns and satisfaction. Measurement, evaluation and our ability to systematize clinical initiatives are also key considerations. In the chapter that follows we address these initiatives: The Patient Experience Electronic Medical Record Development The H1N1 Pandemic Response Central Laboratory Services Robotic Assisted Laparoscopic Surgery Internal Education / Clinical Case Conferences The Hospitalist Program INITIATIVES 33

34 INITIATIVES 34 The Patient Experience is an integral part of quality and outcomes The Patient Experience is the cornerstone of all initiatives at Women s Healthcare Associates. Formalized in 2004, our commitment to The Patient Experience has made our value of service to others meaningful, guiding us in providing a healthcare experience that is uplifting and enriching through the quality and connection of relationships. We believe that a positive patient experience contributes to the quality of care our patients receive and the medical outcomes we are able to achieve in working with them. Key tenets of The Patient Experience credo at Women s Healthcare Associates are to: be inviting, be authentic, be knowledgeable and be caring. Our commitment to The Patient Experience initiative goes far beyond the development of a credo. We chose to formalize its practice by implementing The Studer Group s Nine Principles of Service and Operational Excellence. Each year we prioritize principle(s) to fully integrate into our operations. Our first priority was the Five Fundamentals of Communication, designed to reduce patient anxiety and increase compliance, resulting in improved clinical outcomes and patient satisfaction. To date, every employee and clinician at Women s Healthcare Associates has been trained in the Five Fundamentals of Communication and is evaluated regularly to assure competency and improvement. We seek feedback on our performance from our patients in the form of a new patient survey where our customer service staff, clinical staff and clinicians are evaluated on each of the fundamentals. In 2010 our survey response rate was 32.5%. Our average score across nine quantitative questions was 3.51 out of four. We collect results on an ongoing basis and evaluate our performance each quarter. We realize that there are times we may be unsuccessful in meeting our patients needs. All staff have gone through training specific to resolving patient dissatisfaction. If unsuccessful, we have a formal patient complaint process that we encourage and facilitate. Every patient complaint is reviewed by our Quality Improvement Coordinator and Medical Director and receives follow up. For the period , we received less than one complaint for every 1,000 patient encounters. From Our Patients I have worked in healthcare for more years than I can count, but am new to Oregon. I am VERY impressed with the professional manner in which everyone conducted themselves. Comment, New Patient Survey

35 Leading the development of Electronic Medical Record content for women s health In 2006, following a careful evaluation of available systems and their relevance to our long-term strategic plans, Women s Healthcare Associates purchased and began implementing the GE Centricity Electronic Medical Record (EMR). Our goals in doing so included, among others, improving outcomes for our patients by defining best practices, decreasing variability and measuring and reporting results. Critical factors in our success to date have been the support of our executive champions, the broad commitment of our clinicians to improving information technology (IT) infrastructure and the ongoing involvement of clinical staff. Our IT support staff earns consistently high marks from all users. We have a Health Information Management Committee that oversees EMR planning, content and workflow development and clinical training. Until recently, our focus has been the optimization of content, clinical workflows, and electronic data interfaces to ensure that key data are accurately and consistently captured throughout the organization. This database will serve as an important foundation for achieving our objectives and improving patient outcomes. An early example of this is our first decision support tool introduced in 2010: the Cervical Cancer Screening Form, which tracks Pap smears and cervical biopsies and optimizes patient care by assisting clinicians in following established ACOG and American Society of Colposcopy and Cervical Pathology (ASCCP) care guidelines. Through these efforts, Women s Healthcare Associates has become a leader locally and nationally in the development of clinical EMR content for women s health. We have been approached by more than half a dozen OB/GYN practices in the region as a resource in the development of their EMR systems. We participated in GE s national Early Adopter Program for the latest soft- ware upgrade in the fall of We also work closely with Clinical Content Creators, LLC, the developer of many of the forms used in the EMR, in a national clinical quality improvement collaborative. As we move forward, principal areas of advancement will include continued creation of clinical content and decision support tools, attaining and reporting on federal Meaningful Use quality measures and further optimization of our EMR and health information technologies H1N1 Pandemic Response serves as a model for leadership in public health The novel H1N1 virus first discovered during the flu season created a very stressful environment for the healthcare community. Pregnant women were identified as a high risk population early in the season. The constant media attention, changing national recommendations, unknown factors and limited and delayed vaccine supply created concern and even fear among our patients, who called our offices daily for information. INITIATIVES Within this environment, Women s Healthcare Associates assumed a leadership role. We worked closely with local hospitals to coordinate our plans for an integrated response and consistent message before the vaccine even arrived. We sifted through hundreds of articles published by the Centers for Disease Control and Prevention (CDC) and developed internal guidelines, protocols and patient education materials, which we shared with the healthcare community. We worked effectively with staff in three different counties Yamhill, Washington and Clackamas to obtain vaccine in the timeliest manner possible. 35

36 INITIATIVES Because of our position as the healthcare provider of approximately 3,000 patients in the high risk category (pregnant women), it was imperative that we demonstrated our ability to handle the vaccine responsibly and disseminate it efficiently in order to be among the first groups to receive it when it became available. In addition to communicating effectively with county staff and completing all required documentation on or ahead of schedule, we set up flu clinics and gave the seasonal vaccine early. This enabled us to be ready to give the H1N1 vaccine as soon as it arrived. In addition, we documented every dose given and followed strict protocols regarding who was offered the vaccine on what timeline to reserve the initial limited supply for the highest risk groups. During the season, WHA s flu clinics delivered 3,620 doses of H1N1 vaccine and 1,514 doses of seasonal flu vaccine. 86% of our staff received the H1N1 vaccine and 78% got the seasonal vaccine. As more vaccine became available during the season, we opened our clinics to the families of pregnant patients, our non-pregnant patients and their families and non-patient caregivers in the community. Our response to the pandemic established the communication infrastructure that we used subsequently for the flu season and that will continue to serve the community into the future. 36 fully integrated Central Laboratory provides accurate and timely results Women s Healthcare Associates launched its Central Lab in April of It is considered a moderate complexity clinical laboratory and is used by our clinicians in the care and management of patients. We maintain current Clinical Laboratory Improvement Amendment (CLIA) certificates of compliance from the State of Oregon. Our lab certification includes general immunology, routine chemistry, urinalysis, endocrinology, hematology, ABO and RH Group, antibody and serology. Prior to launching the Central Lab, we worked with a consultant to establish policy guidelines, develop compliance manuals and guide the education and certification of a Lab Director and key staff, all whom are certified by the American Society of Clinical Pathologists. Ongoing Central Lab quality control activities include daily control studies, competency assessments and proficiency testing with specimens received quarterly from the College of American Pathologists. The lab processed 5,235 samples during the startup phase of January through June For the purpose of this illustration, we have divided the total evenly across each month. The Central Lab is a valuable resource for the clinicians of Women s Healthcare Associates. It provides accurate and timely laboratory results, information and support, with the needs of patients and clinicians as its first priority. The lab s computer system is fully integrated with our EMR system. The Women s Healthcare Associates Central Lab has handled an average of more than 57,000 samples each year since inception in 2008.

37 From the Wellness Journal Think of the robot as a very specialized instrument that allows surgeons to offer the benefits of minimally invasive surgery to a greater number of people with more complex cases. These benefits include lower risk of blood loss and transfusion, lower risk of infection and faster recovery and return to regular activities. In terms of gynecology, robotic-assisted surgery can be used to perform hysterectomies, surgery on the ovaries, myomectomies (procedures to remove uterine fibroids without a hysterectomy) and some pelvic support procedures to correct pelvic organ prolapse. Gary Burgoine, MD Robotic-assisted Laparoscopic Surgery extends the benefits of minimally invasive surgery to more patients One of the most recent innovations in minimally invasive surgery is the advent of robotics; more properly termed robotic-assisted laparoscopic surgery. Using uniquely wristed instruments and three-dimensional vision, the surgeon remotely operates from a bedside console while a robot manipulates the laparoscopic instruments. Robotics promises more precise surgical control and an ability to address conditions that previously would have required open abdominal surgery through a traditional large incision. In 2009, Women s Healthcare Associates physicians began performing robotic-assisted hysterectomies, myomectomies and pelvic support procedures with the goal of improving outcomes by reducing the length of hospitalization and significantly shortening a woman s surgical recovery. Women s Healthcare Associates has a dedicated team of surgeons who perform robotic surgery. This concentrates surgical cases among a smaller group, enabling those clinicians to achieve greater levels of expertise, improving quality and outcomes. We will continue to measure surgical outcomes, complications and hospitals stays to ensure safety and quality treatment for patients. Our goal is to use all medical resources appropriately, including advanced technology, to best serve our patients needs. While many procedures will continue to be performed with standard minimally invasive approaches and some will require access through a traditional surgical incision, the potential of robotic surgery will continue to expand in gynecology. INITIATIVES 37

38 INITIATIVES Internal Education/Clinical Case Conferences At Women s Healthcare Associates, we are continually looking at measures to improve how we deliver care to women. One of the most important means to accomplish this goal is continuing education. We have developed an educational conference series that serves to improve patient care while examining the quality of our work. Our clinical case conferences often feature local experts, both from within Women s Healthcare Associates and from the outside medical community, to cover a variety of topics in women s health. We take great pride in our commitment to the continuing education of our clinicians and staff to better serve our patients. Hospitalists provide continuous presence and focus in labor and delivery A significant national trend in obstetrics is the hospitalist or laborist model, which provides The benefits of a hospitalist program include: Improved safety and outcomes Reduced stress on nursing staff A consistent approach to practice guide- needs that arise on an urgent basis. The goal is timely evaluation, streamlined care and availability in emergencies. Women s Healthcare Associates will, in coop- the continuous presence of an OB/GYN lines eration with Providence St. Vincent Medical physician in the Labor and Delivery Unit. Reduced gaps in coverage during times of Center, soon employ a number of hospitalists The practice of obstetrics frequently presents multiple demands to staff labor and delivery and the emergency 38 unanticipated scenarios and emergencies and obstetric clinicians often have a number of competing responsibilities. The hospitalist concept focuses on the quality of hospital care for obstetric patients. It has taken hold in many areas within the country, and there are now more than 100 such programs in place at hospitals of various sizes. Hospitalists are OB/GYN physicians whose sole responsibility is the care of pregnant hospitalized patients. They are able to focus their knowledge and skill in labor and delivery. They work defined hours so the risks of fatigue are minimized. They work in concert with the patient s primary OB/GYN provider, meeting room every minute of every day. Our hospitalists will be well trained, experienced, committed to The Patient Experience and part of a team-based approach to the care of our patients. We are excited to pioneer this effort with our partners in the Providence system.

39 acknowledgements Within Women s Healthcare Associates, we consider our people to be our most valuable assets. We work in various ongoing and ad-hoc teams, and collaboration is critical to what we do. The team below is a willing and talented group. This document is a reflection of their hard work and we express our gratitude to each of them Quality Improvement Committee Anton Broms, MD Gary Burgoine, MD Cindy Campbell, LPN, CPHQ Jackie Davison, RN Danielle Dion, MD Shirley Fox, MD Lauren MacKenzie, CNM Liberato Mukul, MD Amy Palmer, RN Daniel Schrinsky, MD Mark Tomlinson, MD, MBA Denise Williams, RN Other Contributors Katherine Alvarado, MT, ASCP Steve Baier Marcella Boles Aundrea Caputo, CPC, COBGC Allard Bud Conger, MD Carole Cottet, WHCNP Stephen Girolami, MD Amber Grasmick Maggie Herscher Susan Hobson, MD, PhD Anita Jackson, SPHR Brian Kelly, MBA Thomas Lee, MD Jennifer Norberg Pam Pressly Anthony Taitano, MD Patty Uffelman

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