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 4: Improvement Strategies: Prenatal - First Trimester Care Access 

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 Prenatal - First Trimester Care Access are the Care Model approach and the Critical Pathway approach

The case study continued...

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 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, Prenatal - First Trimester Care Access and chronic disease conditions. 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; that 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 ⁽²⁷⁾
   

   Figure 4.1: The Care Model
   

   
   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 Support	Delivery System Design	Decision Support	Clinical Information Systems
   Provide resources to assist an organization in continued education on cultural competency	Allocate resources and remove barriers for improving prenatal care and access	Create expectation that patient take responsibility for scheduling and attending prenatal visits	Anticipate and plan the prenatal intake visit to assure timely registration and follow up with clinician	Provide initial and ongoing education for providers and staff regarding importance of timely prenatal care	Use clinical information systems to accurately identify prenatal patients
   Provide access via mobile services to provide prenatal screening and services	Integrate attainment of early prenatal care into business, strategic, and performance improvement plans	Use all staff interactions with patients as opportunities to assist in self-management goal setting and practices		Facilitate provider access to clinical guidelines	Establish a process for obtaining records from other providers
   Increase access to diagnostic screening services, especially for uninsured patients		Create mechanisms for patient peer support and behavior change programs, such as group prenatal visits

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

   Note: Improvement strategies are not "one-size-fits-all." An organization may choose to adapt and refine an existing tool to assist improvement for the measure, Prenatal - First Trimester Care Access. 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 continued…

   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 Prenatal - First Trimester Care Access 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 assure 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, Prenatal - First Trimester Care Access, influences on performance begin prior to the pregnancy, as indicated by the first step in the critical pathway: A woman of reproductive age presents for care.

   An organization should ensure that visits for women of childbearing age include opportunities to discuss all issues relating to pregnancy and childbirth, within the context of overall health care. These issues can be addressed systematically and periodically with appropriate sensitivity to cultural norms, regardless if the woman is planning a pregnancy in the immediate future. Promoting education and open dialogue for preconception and perinatal care as an important part of health care for women, encourages women to seek appropriate care when planning a pregnancy and early in the gestation.

   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.

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

   Note: Improvement strategies are not "one-size-fits-all." An organization may choose to adapt and refine an existing tool to assist improvement for the measure, Prenatal - First Trimester Care Access. Testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent..

   
   Changes That Work

   Table 4.2: SampleChanges That Work Are Linked to the Critical Pathway for Prenatal - First Trimester Care Access 

   Area of Critical Pathway	Patient Changes	Care Team Changes	Health System Changes
   A woman of reproductive age presents for care	Patient educational resources regarding importance of early prenatal care routinely given Create expectation that patient must take responsibility to assure early prenatal care	Care team members knowledgeable about importance of early prenatal care and can reinforce with messaging and materials during well-woman exams	Health system understands importance of early prenatal care
   Preventive care needs are assessed as part of intake family planning, pregnancy plans	Educational materials are available regarding signs of pregnancy Education materials regarding the importance of good health before pregnancy	Care team knowledgeable regarding clinical guidelines for preventive care	Clinical guidelines for preventive care embedded in health system
   Education provided related to contraception, pre-conception, and preventative health service	Education provided regarding contraception, preconception, and preventative care	Care team knowledgeable regarding clinical guidelines and understanding of latest contraceptive methods, including risk assessments for contraception, etc.	Education is provided related to contraception, preconception, and preventative health
   Patient presents for pregnancy test with positive result	Patient educated on signs of pregnancy and the importance of early prenatal care	Care team members knowledgeable about importance of early prenatal care
   Patient is scheduled for initial prenatal visit with provider	Patient understands importance of early prenatal care	Care team members knowledgeable about importance of early prenatal care	Health System understands the need for early prenatal care
   The pregnant woman is seen during her first trimester

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 more discussion about change management, refer to the Testing for Improvement and Redesigning a System of Care to Promote QI module. 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

1. Model for Improvement 

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

   

   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 its patients' first trimester care access benefits from implementing PDSAs to test change processes that have an impact on access to care in the first trimester. 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 Prenatal - First Trimester Care Access are listed below:

   • What is the recall system in place if a prenatal patient no-shows for a first appointment?
   • What is the timeframe until the next available appointment for a first prenatal appointment?
   • A portion of the population may not see pregnancy as a condition needing medical care. Is there an opportunity for education prior to pregnancy confirmation?
   • Is there an opportunity to educate the community on the importance of early prenatal care at a community health fair?
   • 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 the 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 continued…

   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 challenged, 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

2. 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 first trimester access to care for prenatal patients.

   Both of these improvement strategies are illustrated in Example 4.1:

   Example 4.1: Illustrations of Improvement Strategies

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   Improving recall for patients who "no-showed" for their first prenatal visit

   At a small clinic in the Southwest, about 42 percent of prenatal patients in the last year were Hispanic and only 62 percent of them were seen in the first trimester of their pregnancy. Further investigation revealed that at least 40 percent of those patients who delayed entering care were a no show for their first appointments. The improvement team decided to look at the process of how women, newly diagnosed as pregnant, were scheduled and received their first prenatal visits. The current process mapped by the improvement team was:

   1. Pregnancy diagnosed (nurse visit per protocol)
   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 the estimated gestational age (EGA) of the pregnant women in the appointment and follow-up process. An important part of the protocol for pregnancy diagnosis is dating the pregnancy, but that information was not passed to the front desk staff, and they were given no guidance about scheduling first prenatal appointments.

   The QI team called the nurse and front desk personnel together to train them about the importance of early prenatal care and to guide them on the significance of EGA. The goal was for the prenatal patients to be scheduled for their first appointments before 13 weeks EGA or as soon as possible after the pregnancy diagnosis. They brainstormed ideas on how to accomplish this. The first idea was tested the next day; the nurse gave EGA and patient demographic information to the front desk for a woman seen for pregnancy diagnosis. The front desk staff realized that the patient was already 10 weeks along, but the providers' schedules were full for the next three weeks. She consulted her supervisor, and they decided to schedule the patient, but also made a note to speak to operations about a rule to accommodate this new activity into overall scheduling procedures. Over the next few weeks, the nurse and front desk staff worked together to test "handoff" strategies to ensure patients were seen as soon as possible. The scheduling procedure was changed to allow priority for first prenatal care visits. In a similar manner, the team led tests to improve the recall policy, again recognizing the urgency and need to get women into care.

   The team strategy was successful. By choosing an improvement to link the appointment and follow up to EGA, and then "testing" the best ways to make it operational in the clinic, the team improved first trimester entry time to 71 percent. They were also successful in rescheduling patients, who no-showed that first visit prior to 13 weeks EGA, to more than 90 percent of the time.

   
   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.

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 convinced that changes are leading to improvement. 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 and excitement in the overall quality improvement process.

Measures are collected prior to beginning the improvement process and continue on a regularly scheduled basis throughout the improvement program. 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.