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 4: Improvement Strategies: HIV Screening for Pregnant Women 

The actual improvement process is composed of three steps that respond to the following questions:

1. What changes can an organization make?
2. How can an organization make those changes?
3. How can an organization know the changes caused an improvement?

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.

The case study continues….

The Case Study: The Improvement Journey

1. Care Model Approach: Implementing the changes described in the Care Model is a proven method to improve care delivery. The Care Model, shown in Figure 4.1, is an organizational framework for change and is organized into six domains:
   1. Organization of Health Care
   2. Clinical Information Systems
   3. Delivery System Design
   4. Decision Support
   5. Community
   6. Self-Management Support

   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.

   
   Figure 4.1: The Care Model

   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.

   In Table 4.1: Care Model Key Changes, key changes are presented that have been used successfully to improve prenatal care within the Care Model framework:  

   Table 4.1: Care Model Key Changes

   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

   This toolkit is meant as a guide to help organize ideas, but is also designed to allow flexibility for creative planning.

    

   Note: An organization may choose to adapt and refine a tool to assist improvement for the measure, HIV Screening for Pregnant Women. Testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent.

   The case study continues….

   The Case Study: The QI Team

2. 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:

   • Patient changes-efforts to support self-management efforts, patient engagement, and navigation of the care system
   • Care team changes-changes in job duties or work flow that assist to retain patients in care and ensure timely evidence-based prenatal care
   • Health system changes-changes that have an impact on how care is delivered, independent of who does it

   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.

   Changes That Work  

   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.

   Table 4.2: Sample Changes That Work

   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	Health system understands importance of HIV screening Adapt and print copies of patient educational brochure, place in waiting areas, and have available where staff offers testing
   Patient completes initial intake process which includes discussion and order for routine lab testing	Education provided on the prevention of HIV Educational materials provided regarding HIV testing in pregnancy Patient educational resources regarding early treatment to prevent mother-to-child transmission	Team is educated on counseling patients on the importance of HIV testing in early pregnancy Care team is knowledgeable about importance of HIV screening and can reinforce with messaging and materials during well-woman exams Care team is educated on the cultural differences in the acceptance of HIV testing	Clinical guidelines for HIV screening embedded in health system Prepare tool for staff to be used when discussing and offering HIV testing to patients
   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		Care team is knowledgeable to provide patient counseling (pretest) Develop an HIV testing flow sheet If patient declines, develop a process for continued education and encouragement for HIV testing	Build informed consent into organization's general consent for care Prepare a separate written consent if required by State
   HIV test performed on patient	Educational materials provided to explain negative test results: Discuss importance of partner testing and discordance Explain importance of HIV prevention and risk-reduction steps Encourage continuous health care attendance and delivery in health and repeat testing if any risk factors Explain positive test result and provide support: Discuss available MTCT services Discuss importance of partner testing and prevention of sexual transmission Provide information on available treatment, care, nutrition, family planning and support services Encourage health care visits and return visit. Patient presents to appropriate location for testing	Care team is knowledgeable and able to provide post-test counselling to explain negative test results: Discuss importance of partner testing and discordance Explain importance of HIV prevention and risk-reduction steps Encourage continuous health care attendance and delivery in health Explain positive test result and provide support: Discuss available MTCT services Discuss importance of partner testing and prevention of sexual transmission Provide information on available treatment, care, nutrition, family planning, and support services Encourage health care visits and return visit	Opportunities for CEU for care team skills in counseling for HIV test results Community partnerships in place for affordable and convenient lab testing for patients
   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

   This toolkit is meant as a guide to help organize ideas, but is also designed to allow flexibility for creative planning.

    

   While an organization may choose to adapt and refine a tool to assist improvement for the measure, HIV Screening for Pregnant Women, testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent.

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:

1. Small tests of change Model for Improvement and PDSA (Plan-Do-Study-Act)
2. Process mapping

3. Model for Improvement 

   The Model for Improvement ⁽²⁸⁾ identifies aim, measure, and change strategies by asking three questions:

   
   Figure: AIM Measure Change
   
   These questions are followed by the use of learning cycles to plan and test changes in systems and processes. These are referred to as PDSA (Plan-Do-Study-Act) cycles. The PDSA Cycle is a test-and-learning method for discovering effective and efficient ways to change a current process. In Figure 4.3: The PDSA Cycle, the graphic provides a visual of the PDSA process:
   
   Figure 4.3: The PDSA Cycle

   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:

   • What is the recall system in place if a prenatal patient no-shows for a first appointment?
   • What is the process for ordering prenatal testing?
   • What is the appropriate content for education regarding HIV Screening for Pregnant Women?
   • Are there institutional barriers to HIV testing, such as, reporting to a new location, need for insurance coverage, or need for written consent?
   • Are there cultural, linguistic, and literacy barriers that the organization may need to address?

   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.

   The case study continues….

   The Case Study: PDSA Cycles in Action

   Tips for Testing Changes

   • Keep the changes small and continue testing
   • Involve care teams that have a strong interest in improving prenatal care
   • Study the results after each change. All changes are not improvements; do not continue testing something that does not work!
   • If stuck, involve others who do the work even if they are not on the improvement team
   • Make sure that overall aims are improving; changes in one part of a complex system sometimes have an adverse effect in another

• Process Mapping

  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:

  Example 4.1: Illustrations of Improvement Strategies

  
  
  Improving recall for patients who “no-showed” for their first prenatal visit
  
  At a small clinic in the Southwest, about 40 percent of prenatal patients in the last year were Latina and only 20 percent of them transferred into care from another provider. The improvement team felt that this may be a group that was not receiving good continuity of care, including appropriate prenatal testing. They decided to look at the process of how women transferring into care were enrolled. The current process mapped by the improvement team was:

  1. Patient called or presented requesting prenatal appointment
  2. First available appointment given (front desk)
  3. Routine no-show policy followed; patient called and given next available appointment (front desk)

  The improvement team immediately noticed that no attention was paid to securing records of previous prenatal care or to assessing gaps in care during the current pregnancy. These tasks fell to the provider seeing the patient for the first time. The QI team called the prenatal nurse and front desk personnel together to discuss this issue and the impact it might have on the organization's performance rate on the measure of HIV Screening for Pregnant Women. The proposed solution was to schedule all new prenatal patients with the prenatal nurse who would request past records, perform a history, and provide appropriate education. Over the next few weeks, the nurse and front desk staff worked together to ensure patients were seen promptly and appropriately. The nurse's schedule was changed to allow her to accommodate all first prenatal care visits.
  
  The team strategy was successful. By choosing an improvement and then testing the best ways to make it operational in the clinic, the team improved prenatal HIV testing rates an additional eight percent.

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.