The actual improvement process is composed of three steps that respond to the following questions:
It is important to understand that improvement requires change, but not all change results in improvement. Considering all of the possible changes that can be made to health care systems, considerable effort has been dedicated to creating various quality improvement strategies providing a framework that organizes possible changes into logical categories. Frameworks for change in health care quality improvement are known as quality models and have been tested to guide change. In fact, considering that there are limited resources to dedicate to improvement, most organizations adopt one or more quality models to guide their improvement efforts. There is not a right or wrong approach, and there are many areas of overlap in quality models. Experienced quality improvement teams often use multiple strategies to overcome challenges as they progress. Two approaches often used by teams that are working to improve HIV Screening for Pregnant Women are the Care Model approach and the Critical Pathway approach.
Changes within these domains can effectively leverage transformation of a current reactive care system to one that better supports care for preventative health measures, such as, HIV Screening for Pregnant Women and chronic disease conditions.
If an organization does not have general experience with the Care Model, reading about the Care Model before proceeding is recommended. The Care Model recognizes that care for pregnant women is ongoing and requires more proactive care than the health care system often provides. The Care Model is implemented to improve care by working in six domains, defined below, that transform the way care is delivered:
Community-To improve the health of the population, a health care organization reaches out to form powerful alliances and partnerships with State programs, local agencies, schools, faith organizations, businesses, and clubs.
Organization of Health Care-A health care system can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish.
Self Management-Effective self management is very different from telling patients what to do. Patients have a central role in determining their care and one that fosters a sense of responsibility for their own health.
Delivery System Design-Delivery of patient care requires not only to determine what care is needed, but to clarify roles and tasks to ensure the patient receives the care; all of the clinicians who take care of a patient have centralized, up-to-date information about the patient's status, and make follow-up a part of their standard procedures.
Decision Support-Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. A health care organization integrates explicit, proven guidelines into the day-to-day practice of primary care providers in an accessible and easy-to-use manner.
Clinical Information System-A registry, that is, an information system that can track individual patients and populations of patients, is a necessity when managing chronic illness or preventive care.
Definitions above adapted from the Institute for Healthcare Improvement Web site.
|Community||Organization of Health Care||Self Management||Delivery System Design||Decision Support||Clinical Information System|
|Clarify community served by clinical facility and cultural/ language needs||Provide opportunity for perinatal staff to meet regularly and participate in continuing education||Appreciate and consider the culture-provide patient with culturally- and literacy-appropriate educational tools and resources for HIV screening||Anticipate and plan the prenatal intake visit to ensure timely screening and follow-up||Provide initial and ongoing education for providers and staff regarding HIV screening||Use clinical information systems to identify prenatal patients|
|Develop partnerships with community organizations that promote screening and provide HIV/AIDS treatment||Allocate resources and remove barriers for improving HIV screening and access||Provide appropriate pretest counseling||Include HIV test on prenatal lab forms||Facilitate provider access to clinical guidelines||Establish a registry of prenatal patients|
|Increase access to diagnostic screening services, especially for uninsured patients||Integrate prenatal HIV screening and follow-up into performance improvement plans||Create expectation that patient should pursue results and provide feedback to the providers||Design communication and organize follow-up systems to meet patient and provider needs||Develop and implement standing orders for prenatal testing||Generate automatic reminders for screening at initial prenatal intake in EMR|
|Look to community agencies to help reduce barriers to the evaluation of abnormal screens||Regularly update Board, senior leadership, staff, and community on process and progress||Develop incentives for timely prenatal testing||Make notification of results a routine part of care||Make performance feedback available to appropriate staff|
|Maintain a resource/referral database on support services available to people diagnosed with HIV infection||Repeat testing later in pregnancy for women at risk||Develop a process for using and maintaining the prenatal patient registry|
Critical Pathway Approach: As with all critical pathways, good performance relies on many different systems and processes working together efficiently. An organization is encouraged to map its own critical pathway for HIV Screening for Pregnant Women or refer to the schematic in Figure 4.2. Often when a QI team maps its pathways, it readily can see how complex each step is. It is common for different team members to do the same step differently. Workflow inefficiencies become clear when an organization visualizes how each step is completed and the interdependencies among the steps. Some teams are overwhelmed by the possibilities of changes that can be made in their systems; others focus only on a specific group of factors.
One way to organize the factors that have an impact on the systems is to consider that some are controlled by the patient, others are primarily controlled by the care team, and still others are inherent in the system of care delivery. All three sets of changes must be considered to improve systems of care. In general, these categories can be defined as follows:
A team should use the steps along the critical pathway to target improvements. For this measure, HIV Screening for Pregnant Women, influences on performance begin prior to the pregnancy, as indicated by the first step in the critical pathway: Patient presents for prenatal care services.
An organization can think through each part of the critical pathway in turn, teasing out what happens and what could be improved. In Table 4.2, changes that have worked for other QI teams are matched with the part of the system on which they have the most impact. These ideas are not meant to be inclusive, but to start a dialogue of what may improve each part of the critical pathway in an organization, and thus improve it overall.
In Table 4.2: a matrix of sample changes that work are linked to the critical pathway for HIV Screening for Pregnant Women in Figure 3.1.
|Area of Critical Pathway||Patient Changes||Care Team Changes||Health System Changes|
|Patient presents for prenatal care services||Create expectation that patient must take responsibility to ensure good prenatal care||Care team understands importance of prenatal education and care|
|Patient completes initial intake process which includes discussion and order for routine lab testing|
|Provider orders HIV test||Patient understands process for obtaining testing, costs, and appropriate timing||Determine and provide proper referral form to appropriate testing site||Identify State/local partnerships that an organization can partner with for HIV screening|
|Patient consents to (or opts out of) HIV testing|
|HIV test performed on patient|
|HIV test results documented in chart||HIV Results documented in chart||Care team identifies a point person for ensuring labs received and entered into patient medical record||Organized protocols for lab receipt and entry into patient chart|
Earlier in this module, examples are provided of changes (Critical Pathway and Care Model) that have led to improved organizational systems of care and better patient health outcomes. Because every change is not necessarily an improvement, changes must be tested and studied to determine whether the change improves the quality of care. This concept is addressed in detail in the Testing for Improvement module.
It is important that these changes be tested in the context of an organization's staff, current processes, and patients. The goal is that the change results in lasting improvements within an organization.
Organizations commonly use tools to manage change as they work to improve their systems. For a comprehensive discussion of change management, refer to the Testing for Improvement and Redesigning a System of Care to Promote QI modules. Here are a couple of tools that are worth mentioning in the context of this measure:
The Model for Improvement (28) identifies aim, measure, and change strategies by asking three questions:
An organization focusing its improvement efforts on HIV Screening for Pregnant Women benefits from implementing PDSAs to test change processes that have an impact on mother-to-child HIV transmissions. Those organizational processes tested may focus on outreach, operational procedures, or patient education interventions ensuring that patients have timely access to care. A few examples of such processes relating to HIV Screening for Pregnant Women are listed below:
As an organization plans to test a change, it should specify who, what, where, and when so that all staff know their roles clearly. Careful planning results in successful tests of change. Documentation of what happened – the S or study part of the PDSA - is also important. This can help a team to understand the impact of changes to a process as unanticipated consequences may occur.
Tips for Testing Changes
Process mapping is another valuable tool that an organization focused on improvement often uses. A process map provides a visual diagram of a sequence of events that result in a particular outcome. Many organizations use this tool to evaluate a current process and again when restructuring a process. The purpose of process mapping is to use diagramming to understand the current process; i.e., how a process currently works within the organization. By looking at the steps, their sequence, who performs each step, and how efficiently the process works, a team can often visualize opportunities for improvement.
Process mapping can be used before or in conjunction with a PDSA cycle. Often, mapping out the current process uncovers unwanted variation. In other words, different staff may perform the process differently, or the process is changed on certain days or by specific providers. By looking at the process map, a team may be able to identify gaps and variation in the process that have an impact on HIV screening for pregnant women.
Process mapping, when used effectively, can identify opportunities for improvement, supporting the testing of changes in the current system of care. Additional information, including tools and resources to assist an organization in adapting process mapping as an improvement strategy within its organization, can be found in the Redesigning a System of Care to Promote QI module.
Both of these improvement strategies are illustrated in Example 4.1:
Measures and data are necessary to answer this question. Data is needed to assess and understand the impact of changes designed to meet an organization's specified aim. Measurement is essential in order to be verified or document that changes are leading to improvements and that the improvements are in the areas intended. It is also important to look for unintended consequences of changes that have been made and to be aware that they can be positive or negative. Organizations that have experienced successful improvement efforts found that data, when shared with staff and patients outside the core improvement team, led to the spread of improvement strategies, in turn generating interest, excitement and momentum in the overall adoption of a culture of quality and continued energy for the organization's quality improvement program.
Measures are collected prior to beginning the improvement process (the baseline) and continue on a regularly scheduled basis throughout the improvement program (trending over time). Once an organization reaches its specified goal, frequency of data collection may be reduced. Additional information regarding frequency of data collection, tracking, and analyzing data can be found in the Managing Data for Performance Improvement module.
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