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
beth.brown@oregonstate.edu connie.hume-rodman@oregonstate.edu linda.reid@oregonstate.edu Oregon State University in