HIV Screening for Pregnant Women

Part 1: Introduction

Part 2: Characteristics for Success: HIV Screening for Pregnant Women

Part 3: Implementation of Quality Measure: HIV Screening for Pregnant Women

Part 4: Improvement Strategies: HIV Screening for Pregnant Women

Part 5: Holding the Gains and Spreading Improvement

Part 6: Supporting Information

Part 2: Characteristics for Success: HIV Screening for Pregnant Women 

Organizations successful in improving HIV Screening for Pregnant Women pay close attention to those factors that have an impact on timely prenatal care. Although clinics may differ in specific work flow, documentation, and staffing models, organizations that experienced successful improvement efforts shared these three fundamental characteristics:

1. Clear direction
2. Functional infrastructure for quality improvement
3. Commitment from leadership

1. Clear Direction  

Successful organizations found that it is important to define clearly what they are trying to accomplish. Most often in improvement work, leadership defines an aim that guides an organization's efforts. An aim is a written, measurable, and time-sensitive statement of the accomplishments a team expects to achieve from its improvement efforts. The aim statement contains a general description of the work, the system of focus, and numerical goals. The aim statement includes a very specific indication of what success looks like and may include guidance that further frames the work, including methodologies to be used and budgetary and staffing limitations. Examples of tools used by QI teams to create their aim statements include an Aim Worksheet and Aim Statement Checklist. ⁽²¹⁾ Additional information, including tools and resources to assist an organization in developing its aim statement, can be found in the Readiness Assessment and Developing Project Aims module. A completed aim statement for the measure, HIV Screening for Pregnant Women , is shown in Example 2.1: Assessing the Aim Statement for Big Valley Health Care Organization (BVHCO) Using the Aim Statement Checklist.

The following hypothetical example provides an aim statement created by a QI team of a fictional center called the Big Valley Health Care Organization, and the checklist the team used to assess its completed aim statement. Using the Aim Statement Checklist to assess the QI team's aim statement provides reassurance that the team included the necessary components of the aim statement for its improvement project.

Other examples of aim statements for HIV Screening for Pregnant Women that an organization may consider are:

• • Ninety percent of prenatal patients will be offered HIV testing at their initial prenatal intake visits.
  • Seventy-five percent of prenatal patients will be tested for HIV prior to their third prenatal care visits.
  • One hundred percent of prenatal patients tested for HIV will have a signed consent form in their charts. (Note - a consent form is not required in every State.) CDC recommends opt-out, routine HIV screening of all pregnant women, and newborn testing if mother's HIV status is unknown. Currently, 22 States have opt-out testing of pregnant women, 30 have opt-in, and 10 States have newborn testing. ⁽⁸⁾

• Evaluating what others achieved provides appropriate context for choosing the numerical portion of an organization's aim. (21) In some cases, data is available to show average performance for a group of practices that focused on a particular measure. For example, the Indian Health Service (HIS) monitors HIV testing of pregnant women and has seen an increase in screening rates from 54 percent in 2005 to 76 percent in 2009, as shown in Figure 2.1.

  
  Figure 2.1: Indian Health Service's HIV Screening Rates from 2005 to 2009 for AI/AN Prenatal Patients

  
  The HIS goal for 2009 was to maintain the rate at 75 percent, but HIS' rate surpassed that goal with an increase to 76 percent. HIS has not established a 2010 goal for this measure.

  For some measures, it may be possible to find examples of benchmark data, which demonstrates the performance of a best practice. It is important to consider an organization's particular patient population when making comparisons to others' achievements. An organization may consider socioeconomic status or race/ethnicity of the population served, organizational size, payer mix, and other criteria in an effort to achieve an accurate comparison. Reviewing what others accomplished may help an organization to understand what is feasible to achieve. The numerical part of the aim should be obtainable, yet high enough to challenge the team to substantially and meaningfully improve. Additional guidance about setting aims can be found in the Readiness Assessment and Developing Project Aims module.

  Sources to consider when choosing an aim or making performance comparisons for the HIV Screening for Pregnant Women measure, include the HIS measure, Prenatal HIV Screening, which is the percentage of HIS pregnant women who are tested for HIV during their pregnancy. The 2009 goal for this measure is 75 percent. ⁽²²⁾ Sources of data for additional comparisons vary regionally but may include payers, managed care organization databases, State programs, and State or regional quality improvement programs.

2. Functional Infrastructure for Quality Improvement 

Successful organizations found that improvement work requires a systematic approach to measuring performance, testing small changes, and tracking the impact of those changes over time. This section describes four essential components of an infrastructure to support quality improvement efforts, including:

• • Quality improvement teams
  • Tools and resources
  • Organizing improvements
  • Building on the efforts of others by using changes that worked

• There is considerable variation in how this infrastructure for quality improvement is created and maintained. It is important that each component is addressed in a way that fits an organization.

  Quality Improvement Teams

  Multidisciplinary QI teams are typically tasked to carry out this work. For improvement focused on HIV Screening for Pregnant Women, it is important to include a provider who wants to focus on improving the rate of early prenatal care, i.e., a provider champion for improvement. ⁽²³⁾ In addition to the provider champion, other appropriate members of a QI team may include:

  • Nurses
  • Case managers
  • Patient outreach specialist
  • Patient navigator
  • Scheduling staff
  • Information specialist
  • Other staff involved in the patient care process, such as, receptionists, administrative staff, medical assistants, and health coaches

  It should be noted that patients can add great value to the QI process when prepared to participate in a meaningful way. The reference manual by the National Quality Center (NQC), A Guide to Consumer Involvement, has practical ideas to assist an organization on how to involve patients in its QI process. ⁽²⁴⁾

  There are no wrong answers here. Members of a team bring expert knowledge of the work they do for prenatal patients. Together, the team learns where and how its individual actions intersect and how each can have a positive impact on patients' HIV testing. The ability to think from a systems perspective and the will to improve early access to prenatal care are the primary prerequisites that contribute to a successful improvement team. A more advanced discussion on forming an improvement team can be found in the Improvement Teams module.

  Tools and Resources

  It is important that a QI team have the tools and resources necessary to achieve its established organizational aim. Some personnel may struggle shifting from the daily work of patient care to their roles on the quality improvement team. Those challenges can be straight forward, such as, coordinating meeting times or developing content for the meetings to support the team's quality improvement efforts. Successful QI teams learned that organizing meetings efficiently is essential in their improvement efforts. Tools such as Tips for Effective Meetings, can help a QI team to structure meetings that focus its scheduled time on improvement efforts. Another useful tool includes one that displays data in a way that makes sense to the team members. These types of tools are commonly used by improvement teams to remain focused on the work of improvement. The most important resource needs are uninterrupted time to focus on quality improvement and autonomy to test changes responsibly. Additional team resources and tools can be found in the Improvement Teams module.

  Organizing Improvements

  Successful organizations learned that planning an approach to change is essential. Change is, by nature, unsettling for some and presenting a clear direction and methodology can be reassuring and can engender support from staff. Most organizations with quality improvement experience adopted methodologies that help them organize their improvements.

  As a QI team approaches improvement of HIV screening for pregnant women, it should use quality models already embraced by its organization. For example, many organizations adopted the Care Model to organize their approaches to implementing quality improvement changes. Others successfully embraced the FOCUS PDSA approach; both of these models provide a framework for a health care organization to plan and move toward implementing its improvement efforts. There is no single model that is considered correct. Organizational alignment of methodology makes sense from the perspective of efficient training. A consistent quality improvement approach and the sharing of improvement ideas among members of a quality team can facilitate the replication of QI activities across an organization and maximize the impact of the overall QI program.

  Just as organizations that are experienced in quality improvement activities adopted quality models that guide their work, many embraced a change methodology. A change methodology guides the actual change process, which involves managing how changes are made as opposed to what changes are made.

  For some organizations, all changes are approved by a decision leader and then implemented. Others use a committee structure to evaluate and implement changes. Again, there is no right or wrong methodology, but one change methodology that is helpful in quality improvement is the Model for Improvement. The Model for Improvement, developed by Associates in Process Improvement, is a simple, yet powerful, tool for accelerating improvement. The model is not meant to replace a change model that an organization may already be using, but rather to accelerate improvement by making it systematic and stepwise in approach. This model has been used successfully by health care organizations to improve many different health care processes and outcomes.

  The Model for Improvement encourages small, rapid-cycle tests of changes. In improvement, this has a distinct advantage in decreasing the time it takes for changes resulting in improvement to be implemented. This methodology also directly involves the individuals who do the work, as they provide additional practical insights into how to rapidly improve care processes. Advance discussions can be found in the Testing for Improvement module

  Building on the Efforts of Others by Using Changes that Worked

  One hallmark that successful organizations found beneficial in advancing their quality improvement programs is that everyone across the organization uses the same tools and language to make continuous improvements. A motto of many QI training leaders is "steal shamelessly." This is not the unethical, criminal intent, but instead the sense of "Why reinvent the wheel?" What does it mean to "steal shamelessly"? It means "stealing" or using what has worked in other organizations and "shamelessly" testing and implementing it to create rapid change in one's own organization.

  Specific change ideas that worked for others to successfully improve prenatal care are detailed later in this module in the Changes that Work section. Additionally, an organization that has improvement experience in another measurement area, such as, diabetes, cancer screening, or immunizations, is often able to adapt the successful tools to use with a new measure.

3. Commitment from Leadership 

For quality improvement efforts to be effective and sustained, leaders must show commitment to them. Typically, leaders may make a commitment to specific target areas for improvement once they consider the overall needs of the organization, requirements of funders, and how the proposed efforts align with the organization's vision, mission and strategic plan. Leaders that consider quality improvement efforts as an "add-on" may be unable to maintain QI as a priority as other realities compete for the organization's attention and resources. Successful leaders in quality improvement integrate and align QI activities as part of their daily business operations and are able to message that concept to the rest of the organization.

A quality improvement team needs to have leadership commitment expressed in a tangible way. Often, it is an explicit dedication of resources, which may include team meeting time, data support, and specific planned opportunities that communicate actionable improvement suggestions to an organization's leadership. The authority of the improvement team and any constraining parameters should be clear. Detailed information highlighting the important role of leadership in a QI project can be found in the Quality Improvement module.

Below is a hypothetical case study that is followed throughout the module and depicts the effort of a fictional QI team as it focuses on improving the number of prenatal patients in its organization who receive HIV screening. The case study may be read in its entirety by clicking here.

Case Study: The Problem.