Prenatal - First Trimester Care Access

Part 1: Introduction

Part 2: Characteristics for Success: Prenatal - First Trimester Care

Part 3: Implementation of Clinical Quality Measure: Prenatal - First Trimester Care Access

Part 4: Improvement Strategies: Prenatal - First Trimester Care Access

Part 5: Holding the Gains and Spreading Improvement

Part 6: Supporting Information

Part 3: Implementation of Clinical Quality Measure: Prenatal - First Trimester Care Access

Before following the steps in Part 3, an organization should first make a commitment to improve access to first trimester prenatal care and complete the initial steps outlined in the previous section that include:

• Developing an aim statement
• Creating an infrastructure for improvement
• Gaining commitments from leadership

Performance on this measure indicates how effectively all the steps of the processes used to deliver care work together so that prenatal patients access care within the first 13 weeks of pregnancy. Because there are so many factors that can have an impact on the timing of the first prenatal visit, it helps to visualize how these steps are mapped. The next section defines Critical Pathway and illustrates the application of this concept to implement the early initiation of prenatal care.

The case study continued...

Case Study: The Approach

A critical pathway, also known as a clinical pathway, is a visual depiction of the process steps that result in a particular service or care. The sequence and relationship among the steps are displayed, which reveals a map of the care process. Additional information, including tools and resources regarding the mapping of care processes, can be found in the Redesigning a System of Care to Promote QI module. In an ideal world, the care process is reflective of evidence-based medical guidelines. Evidence-based medicine aims to apply the best available evidence gained from the scientific method for medical decision making. ⁽²⁶⁾ A map of the care process steps, that incorporates all of the known evidence and follows respected evidence-based medical guidelines, can be considered the idealized critical pathway.

While the needs of individual patients should always be considered, clinical guidelines synthesize the best evidence into a pragmatic set of action steps that strive to provide the optimum health care delivery system. It is important to emphasize that clinical evidence and guidelines could possibly evolve as knowledge progresses; therefore, the idealized critical pathway may evolve over time and not meet the needs of every individual.

In Figure 3.1, the schematic for Critical Pathway for Prenatal - First Trimester Care Access incorporates available evidence and represents an idealized critical pathway for first trimester early prenatal care. The boxes represent typical steps in care delivery. If these steps happen reliably and well, effective care is delivered and women initiate care in their first trimester of pregnancy.

Walkthrough of the Idealized Critical Pathway

This critical pathway exists both inside the clinic and beyond the clinic walls. In order to begin prenatal care during the first trimester, women must be aware of its importance and how to promptly access it. Since pregnancy begins outside the clinic, timely initiation of care depends largely on each patient's commitment to present early for care. Personal, cultural, and societal beliefs influence these decisions, but the health care system should educate, support, and remove barriers so patients choose to seek care early. Successful practices, with high rates of early entry into prenatal care, indicate that several steps contribute to First Trimester Care Access:

1. The established care processes must help to prepare a woman for timely entry into prenatal care before pregnancy. Preventive care begins with the woman's initial contact with the clinic, regardless of the reason for her visit.
2. By assessing the woman's preventive health needs and pregnancy plans, the patient is more likely to have a planned pregnancy, and establish access to and a rapport with a care provider.
3. If prenatal care is provided in addition to other primary care services, the patient should be educated about the scope of services available. Women should be aware of the importance of early prenatal care to proactively prepare for pregnancy and seek care early. Additionally, women should be educated that early prenatal care is an important and routine aspect of preconception care. Women also benefit from understanding the signs of pregnancy, and where to access affordable diagnostic testing to confirm pregnancy early in the gestation.
4. When a woman presents for a pregnancy test and pregnancy is confirmed, counseling about her options for care is provided.
5. A high priority is placed on scheduling the newly-diagnosed pregnant woman for care. There must be an understanding on the part of the scheduling staff to expedite the initial visit.
6. Prenatal care does not begin until the woman is seen by the provider. If she does not keep her appointment, prompt follow up must take place.

A few important notes:

• The idealized critical pathway for the first trimester is the initiation of care and begins well before pregnancy. A proactive approach reflects the evidence that describes the importance of women receiving preconception care, understanding the signs of pregnancy, and having ready access to pregnancy diagnosis and care.
• An organization may adopt additional prenatal guidelines that include important care parameters beyond early access. The Institute for Clinical Systems Improvement, by the National Guidelines Clearinghouse, describes guidelines for comprehensive prenatal care in Routine Prenatal Care, including recommendations for care beginning with preconception care.(27)
• A critical pathway can also be constructed to illustrate how care is currently provided within an organization (the existing pathway). Understanding the gap between an organization's existing critical pathway (how you provide care now), and the idealized critical pathway (how to provide reliable, evidence-based care aligned with current guidelines), form the basis for improvement efforts.

The schematic in Figure 3.2 reflects a common scenario, as represented in Hill Center Health Services, where preconception information and counseling may exist, but is not systematically and reliably delivered. One of the first considerations to improve the rate of early initiation of prenatal care is to increase the awareness of its importance and standardize its processes to ensure women of child-bearing age are offered preconception care and pregnancy planning as part of their routine wellness care. By comparing what is currently being done with the evidence-based medical guidelines, opportunities for improvement sometimes become apparent.

In addition to understanding the steps for providing timely prenatal care, factors that interfere with optimal care should be understood. As there may be several of these factors, a QI team may find it helpful to focus its attention on factors that interfere with ideal outcomes. This becomes especially useful as plans are developed to mitigate these factors.

Factors that have an impact on Prenatal - First Trimester Care Access can be organized into those that are patient-related, relative to the care team, and a result of the health system. Overlaps exist in these categorizations, but it is useful to consider factors that have an impact on care processes from each perspective to avoid overlooking important ones.

Patient factors are characteristics that patients possess, or have control over, that have an impact on care. Examples of patient factors are age, race, diet, and lifestyle choices. Common patient factors may need to be addressed more systematically, such as, a targeted approach to address a high teen-pregnancy rate, or a systematic approach to educate staff on the cultural norms of a new refugee population. Examples of how patient factors may influence an early entry into prenatal care include:

• Age - Teenagers are more likely to have unplanned or unwanted pregnancies and be less aware of the importance of beginning prenatal care, which may cause their delay in seeking care.
• Cultural differences - Immigrant women may have practices or beliefs in their native countries that do not view early prenatal care as a priority.
• Health literacy - Women unaware of the importance of positive health behaviors are less likely to enroll in early prenatal care. Literacy and language may be barriers to understanding health information.
• Work status - Women working in marginalized employment, with no flexibility for time off, may not make prenatal care a priority.
• Comorbid diagnosis - Homelessness, drug use, or mental health disease may negatively have an impact on the timing of entry into care.
• Socioeconomic status - Limited financial resources may be a barrier to accessing care.

Care team factors are controlled by the care team. These types of factors may include care processes, workflows, how staff follows procedures, and how effectively the team works together. Care team factors that may influence early entry into prenatal care include the processes and procedures that:

• Staff use to handle "no-show" appointments and reschedule those appointments
• Provide culturally competent care to address the patient's cultural norms
• Provide planned care for women of child-bearing age, including attention to preconception care and preventive care

Health system factors are controlled at the high level of an organization and often involve finance and operational issues. Health system factors that may influence early entry into prenatal care include:

• Cost - uninsured or underinsured women may have difficulty finding a provider willing to provide care
• Scheduling systems - availability of evening and weekend appointments and wait time may have an impact on access
• Location - no transportation or an unsafe location may present barriers

These factors, when added to the critical pathway, create another dimension to the map as shown in Figure 3.3:

Example 3.1: A Team's Brainstorming Session

The team brainstorms on factors that have an impact on the arrow (or opportunity) between Steps 1 and 2 [link] of the Critical Pathway for First Trimester Prenatal Care (from Figure 3.3).

Example 3.1: A Team's Brainstorming Session

Factor Category	Factors Pertinent to our Organization - Steps 1 and 2
Patient	Hispanic population - cultural norms impede understanding need for early prenatal care; large teen population presents challenges to engage patients in planning
Care Team	No staff, workflows, or prompts dedicated to assessment of family planning needs; available educational materials are not culturally appropriate for the population
Health System	Additional co-pay for preconception visit and appointments for routine gynecological care are backed up eight weeks

The team continues to look at different parts of the pathway to identify relevant impacts for each part. Once it is able to evaluate where there are potential opportunities for improvement, it can use this information to target its efforts. Additional examples of strategies to improve care for the measure, Prenatal - First Trimester Care Access, are described in the Improvement Strategies section of this module.

Once the team visualizes the pathway and identifies opportunities for improved care, the next step is to collect and track data to test and document them. First, a QI team needs to determine how to collect data to support its improvement work. This step is essential for understanding the performance of its current care processes, before improvements are applied, and then monitoring its performance over time.

There are three major purposes for maintaining a data infrastructure for quality improvement work:

• To know the starting baseline
• To track and monitor performance as changes are implemented
• To perform systematic analysis and interpretation of data in preparation for action

The first step to creating a data infrastructure for monitoring the performance measure is to determine the baseline. A baseline is the calculation of a measure before a quality improvement project is initiated. It is later used as the basis for comparison as changes are made throughout the improvement process. For the Prenatal - First Trimester Care Access measure, an organization can determine the percentage of prenatal patients that access care within the first trimester as a result of established systems of care. Systems of care reflect the current organizational infrastructure and the patient's interactions with existing care processes and the care team.

Baseline data is compared to subsequent data calculated similarly to monitor the impact of quality improvement efforts. The details of how to calculate the data must be determined to ensure that the calculation is accurate and reproducible. The difference between how an organization provides care now (baseline) and how it wants to provide care (aim) is the gap that must be closed by the improvement work.

The next step of data infrastructure development involves a process in place to calculate the measure over time as improvements are tested. A QI team's work is to make changes, and it is prudent to monitor that those changes result in achieving the stated aim. This involves deciding how often to calculate the measure and adhering to the calculation methodology.

Finally, an organization's data infrastructure must include systematic processes that allow analysis, interpretation, and action on the data collected. An organization that knows its performance is insufficient for improvement. It is important for an organization to understand why performance is measured and to predict which changes will improve Prenatal - First Trimester Care Access based on an organization's specific situation. Collecting data related to specific changes and overall progress related to achieving an organization's specified aim are important to improvement work. The next section describes in more detail how to develop a data infrastructure to support improvement.

This section explores each step to create the data infrastructure used to improve performance on the measure, Prenatal - First Trimester Care Access.

1. Step 1 - Determine and Evaluate the Baseline

   As discussed above, a baseline for improvement is a calculation that provides a snapshot of the performance of the systems of care for a measure before improvements are applied. The baseline is determined by calculating the measure and collecting the information for the numerator and denominator.

   The following figure depicts a decision algorithm for the measure, Prenatal - First Trimester Access. The algorithm outlines the steps that an organization follows to determine its baseline and monitor improvements for Prenatal - First Trimester Care Access.
   

   Figure 3.4: Prenatal First Trimester Decision Algorithm
   

   Detailed specifications, including instructions to identify the denominator and numerator for the measure, Prenatal - First Trimester Care Access, can be accessed on the HRSA Clinical Quality Performance Measures Web site.

   Evaluate the baseline. Initially, a team compares its baseline to the performance it hopes to achieve. It is important to remember this gap in performance is defined as the difference between how the care processes work now (baseline) and how an organization wants them to work (aim). An organization may often modify its aim or timeline after analyzing its baseline measurement and considering the patient population and organizational constraints.

   As an organization moves forward, the baseline is used to monitor and compare improvements in care over time. While it is important for an organization to stay focused on its aim, it is equally significant to periodically celebrate the interim successes.

2. Step 2: Create a reliable way to monitor performance over time as improvements are tested. An organization should:
   1. Standardize its processes and workflows to ensure the team collects and calculates performance data the same way over time. An organization should document exactly how the data is captured so staff turnover does not interfere with the methodology.
   2. Determine the frequency that performance will be calculated. Frequent data collection is often associated with higher levels of improvement. Monthly measurement is recommended if feasible, as it is associated with a higher level of team engagement and success. If it is infeasible, quarterly measurements may be obtained. Less frequent performance measurements are adequate for reporting purposes, but do not adequately support improvement efforts. An advanced discussion can be found in the Managing Data for Performance Improvement module.
   3. Chart and display results. A simple chart audit form [PDF | 37KB] is appropriate for manual audits and can be repeated frequently as desired. Results of multiple audits can be presented in a graphic format to demonstrate trends. Refer to Managing Data for Performance Improvement module for more information and examples of data displays that have been used to communicate information about improvement efforts to a variety of stakeholders.

   Note: The frequency of team meetings is not necessarily prescribed for success. Many successful teams meet once a week while others may meet bi-weekly when focusing their improvement efforts on any given measure. Success of these meetings is rather the output of the team members' active engagement in the meeting and being prepared to report on recent improvement findings. More information, including resources and tools supporting developing and implementing effective team meetings, can be found in the Improvement Teams module.

3. Step 3: Create systematic processes that allow organizations to analyze, interpret, and act on the data collected.

   Having the data is not enough. Improvement work involves thinking about the data and deciding what to do based on that analysis. A QI team needs to put processes in place - team meetings, scheduled reports, and periodic meetings with senior leaders, to use the data tracked. This section describes how a QI team may accomplish the work of creating actionable plans based on the data collected. In Example 3.2: QI at Team Excelsior Health, the hypothetical scenario illustrates how a team may use these concepts to act on its data.

   1. Analyze: What are the data trends? Tracking performance over time for the measure, Prenatal - First Trimester Care Access, is critical to successful improvement, but calculation of performance is not enough. It is important for a team to meet to analyze the data on a regular basis. QI teams that are experienced in looking at data recognize these common patterns:
      • Performance is improving
      • Performance is decreasing
      • Performance is flat
      • Performance has no recognizable pattern
      Additional examples of common data patterns are provided with further explanation in the Managing Data for Performance Improvement module. It is typical for a team to see little movement in its data over the first several months. If a team has chosen to monitor an associated process measure, such as, the percent of no-show prenatal patients who are rescheduled, performance improvement may be evident more quickly. Regardless, it is important that a QI team review performance progress regularly. A QI team that meets regularly and calculates performance monthly should spend part of one meeting each month reviewing its progress to date.
   2. Interpret: What do these data trends mean? A QI team needs to then interpret what these data trends mean within the context of its own organization. If performance is increasing, but has not yet reached the numerical aim, perhaps the changes in place are having the desired effect and the aim will be reached over time. If performance is decreasing, what has changed? Are there new care process changes, a failure of registry data input, or a large increase in those patients included in the registry? If performance is flat, did the organization maximize the benefits from changes implemented or was there some regression to the former way of doing things? Improvement trends that have reached a plateau may indicate that an organization needs to think differently about future changes. A few suggestions that an organization may consider when experiencing a plateau in improving Prenatal - First Trimester Care Access are listed below:
      1. Consider looking at outliers that may create barriers to patients accessing timely prenatal care, for example, lack of insurance, transportation, or language and cultural differences.
      2. Consider changes in a different part of the framework to get improvement back on track. If using a critical pathway approach, an organization may look at the steps prior to where the problem seems to be. If an Care Model approach is used and the team worked hard on delivery system design issues, opportunities to better leverage the clinical information systems or engage the community may be considered.
      Interpretation of data over time is critical in determining where a team will target its efforts. Additional tools that can assist a team in understanding underlying causes for data trends are beyond the scope of this manual but are discussed in detail in a monograph that was published by the NQC, A Modern Paradigm for Improving Healthcare Quality [PDF | 849KB].
   3. Act: Make decisions based on data. Once a QI team has a better understanding of what the data means, efforts should be targeted to further advance the performance toward the aim. Often the decisions are made at the team level about what to tackle first. Then small tests of change can be accomplished to determine what improvements could be implemented to enhance performance. The practice of using small tests of change actually allows multiple changes to be tested simultaneously.
      
      Note: An advanced discussion on how to use the data collected to advance an organization's improvement, including resources and tools to support improvement, can be found in the Managing Data for Performance Improvement module.

   Example 3.2: QI Team at Excelsior Health

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   The Quality Improvement (QI) Team at Excelsior Health worked diligently to improve access for prenatal patients increasing their first trimester enrollment from 50 to 75 percent over the last several months. They focused on staff education and scheduling issues and had streamlined those processes. But during the last three months, the performance remained the same, which was below their aim of 90 percent.

   Analysis: The team noted improvement initially. Registry input, care processes and patient volumes seemed to be stable but performance was flat for the last four months.

   The team leader asked for a list of those patients who initiated prenatal care after their first trimester-outliers for the measure. Further study of these specific cases found that, 90 percent of the time, patients who presented for care after the first trimester were diagnosed as pregnant during their second trimester.

   Interpretation: Because there was initial improvement followed by several months of flat performance, the team leader looked for obvious changes in processes that would have an impact on performance, but found none. The team leader interpreted the data to mean that initial changes provided some improvement, but not enough to achieve their aim and have a positive impact. More work was needed. The team leader employed a common strategy to find additional opportunities; i.e., looked at the population not in compliance (the outliers) for a common cause to be addressed. In this case, a common thread was that patients, who were coming in late for care, were not diagnosed as pregnant until the second trimester.

   This information allowed the team to consider ways to encourage patients to present earlier for pregnancy diagnosis. It looked at Changes that Worked for ideas and then added suggestions based on its own patient population. The team decided to increase focus on patient outreach, education about early signs of pregnancy, and ways to improve access to pregnancy testing. To accelerate these improvements, some members of the improvement team led an ad-hoc group to develop outreach materials, promoting the importance of early prenatal care, to be distributed at community venues. Another small group employed the Plan-Do-Study-Act (PDSA) cycle by working with the front desk staff and a few willing patient volunteers to make pregnancy testing more accessible. The improvement team will continue to monitor its performance to determine if these changes are effective for achieving its aim statement goals.

   Act: The information gathered from the analysis and interpretation of the data allowed the team to focus their next efforts. Since patients were not diagnosed until the second trimester, they targeted their efforts on supporting patients to recognize signs and symptoms of early pregnancy and assuring clinic systems did not have barriers to pregnancy testing. This enabled the team to focus on PDSAs to test changes specific to these areas and monitor their progress.

   
   A QI team leader needs to monitor the pace of the progress over time. If there is insufficient progress to meet the specified aim, reasons should be analyzed and addressed. One organization may choose to accelerate its improvement efforts; another may decide to extend its initial allotment of time to achieve its aim and consider other constraints within the organization.