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2014 Model Practices
Application Name: 2014 Model Practices : Florida Department of Health in Osceola County : Early Access Prenatal
Applicant Name: Ms. Susan Crawford
Florida Department of Health in Osceola County
1875 Boggy Creek Road
Submitting LHD/Agency/Organization/Practice website:
Practice Contact Job Title:
Quality Management Consultant
Head of LHD/Agency/Organization:
Provide a brief summary of the practice in this section. Your summary must address all the questions below.
Size of LHD jurisdiction (select one):
In the boxes provided below, please answer the following:
1)Where is LHD located? 2)Describe public health issue 3)Goals and objectives of proposed practice 4)How was practice implemented / activities 5)Results/ Outcomes (list process milestones and intended/actual outcomes and impacts. 6)Were all of the objectives met? 7)What specific factors led to the success of this practice? 8) What is the Public Health impact of the practice?
1) The Florida Department of Health in Osceola County is located in east central Florida, part of the Orlando-Kissimmee metropolitan statistical area.
2) Osceola County’s prenatal and fetal/infant population-based health status indicators are worse than state and national benchmark comparisons and Healthy People 2020 goals. Low first trimester prenatal care rates and high rates of low birth weight, prematurity, and infant mortality are particularly evident in Osceola’s combined population groups (46% Hispanic and 11% Black) that form the majority population. Statistically, these groups are considered to suffer greater health disparities. The 2012 County Health Rankings shows Osceola ranks poorly in comparison to Florida’s 67 counties, 43rd for morbidity factors including low birth weight and 54th for lack of access to healthcare.
3) Maternal and child health indicators are important public health goals. OCHD’s quality improvement (QI) initiative focused on reducing the risk of maternal and infant mortality and pregnancy-related complications by increasing early access to quality health care. OCHD is the single largest prenatal services provider in the county, having served 43% of all prenatal patients in 2011. By improving OCHD’s first trimester prenatal care rate, we could positively impact the county-wide rate. Our in-process indicator was to improve timely access to OCHD’s prenatal services. Our “if-then” improvement theory prediction was that “if...we reduce barriers to accessing care, then...we will have a positive effect on women obtaining earlier prenatal care, which could improve birth outcomes.” Our one-year Aim Statement became: “By December 2012, we will improve access to prenatal care services by increasing the percentage of pregnant women receiving their initial prenatal medical exam within two weeks of a positive pregnancy test, from a baseline of 4% to 75%.”
4) Using a 9-Step Process Management Model with Plan-Do-Check-Act (PDCA), we determined that to improve the rate of pregnant women accessing care during the first trimester of pregnancy, we would have to improve the access process from the point of pregnancy testing to initiation of prenatal medical care. During the Plan phase of the PDCA cycle, we utilized QI tools to determine the root-cause of delayed access was artificially imposed barriers resulting in too many separate, specialized visits in the prenatal admission process.
QI tools included Input/Output Diagram to define the process of prenatal access; Process flow charting to show the steps in the process; Fishbone Diagram to categorize potential causes of process problems and further refine the root-cause. In the next “DO” PDCA phase, we revised the Process Flow, eliminating the separate nurse-only appointment, combining the activities into the provider visit. In the “Check” phase we monitored the rate of first prenatal exams within two weeks of pregnancy testing. We presented monthly data to senior management and staff. We used staff input to implement continuous improvement interventions, after which we went into another “Check” cycle to monitor performance for the next month.
5) Data showed an improvement from our 4% baseline in December 2011 to 39% by December 2012. We saw monthly data fluctuations in response to PDCA interventions. Although we did not reach our goal of 75% in the first year, we made a 35% overall improvement of pregnant women having their first medical visit within two weeks of their pregnancy test. Based onimprovement momentum, we continued testing PDCA cycles. By April 2013, we reached another milestone of 70%.
6) Although our target goal of 75% was not met during the 16-month project period, we did achieve 70%. This represents a 66% improvement over baseline.
7) Our success is attributable to using QI tools such as our 9-Step Process Management Model/PDCA as a detailed, systematic methodology to develop, implement, and manage processes. This approach was a roadmap that enabled us to analyze performance; identify strengths and opportunities for improvement; and address performance gaps so that we were better able to manage improvement efforts and have a positive impact on better health outcomes and health disparities.
8)Managing our efforts to improve health care access is a leading performance indicator in helping achieve lagging indicators such as better health outcomes. The majority of patients OCHD serves are those in population subsets that have a tendency to suffer greater health disparities; i.e. 98% below 200% of the federal poverty level; 83% racial/ethnic minorities; and 27% better served in a language other than English. By improving our processes to get more pregnant women into prenatal care during their first trimester, we are having a positive impact on public health status outcomes such as low birth weight, prematurity, and fetal/infant mortality/morbidity.
You may provide no more than two supplement materials to support your application. These may include but are not limited to graphs, images, photos, newspaper articles etc. (Please use one of the following: pdf; txt; doc; docx; xls; xlsx; html; htm)
Model Practice(s) must be responsive to a particular local public health problem or concern. An innovative practice must be 1. new to the field of public health (and not just new to your health department) OR 2. a creative use of an existing tool or practice, including but not limited to use of an Advanced Practice Centers (APC) development tool, The Guide to Community Preventive Services, Healthy People 2020 (HP 2020), Mobilizing for Action through Planning and Partnerships (MAPP), Protocol for Assessing Community Excellence in Environmental Health (PACE EH). Examples of an inventive use of an existing tool or practice are: tailoring to meet the needs of a specific population, adapting from a different discipline, or improving the content.
In the boxes provided below, please answer the following:
1)Brief description of LHD – location, jurisdiction size, type of population served 2)Statement of the problem/public health issue 3)What target population is affected by problem (please include relevant demographics) 3a)What is target population size? 3b)What percentage did you reach? 4)What has been done in the past to address the problem?5)Why is current/proposed practice better? 6)Is current practice innovative? How so/explain? 6a)New to the field of public health OR 6b)Creative use of existing tool or practice 6b.1)What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO’s Toolbox etc.) 7)Is current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.)
1) OCHD is part of the Florida Department of Health’s statewide integrated public health agency, which is authorized by law to provide services. The agency is led by the State Surgeon General and Secretary of Health, who is appointed by the Governor. The County Health Department Directors/Administrators are state employees who are appointed by the State Surgeon General, approved by the Board of County Commissioners, and report to the Deputy Secretary of Statewide Services.
OCHD is unique in that we are one of eight of Florida's 67 county health departments that also are designated by the Health Resources and Services Administration’s Bureau of Primary Health Care as a federally qualified health center. Osceola County is a federally designated whole county Medically Underserved Area/Population (MUA/MUP); a Primary Medical, Dental, and Mental Health Professional Shortage Area; and has a 50.4 Index of Medical Underservice. Osceola’s ratio of population to each primary care physician is 2229:1, compared to Florida at 1438:1, and the national benchmark of 631:1 (2013 County Health Rankings).
"Access to health care services" was identified in Osceola’s three iterations of the Mobilizing for Action through Planning and Partnerships (MAPP) process as an issue of critical need, particularly for health disparate populations. Given Osceola’s lack of access and in response to The Ten Essentials of Public Health to "link people to needed personal health services and assure the provision of health care when otherwise unavailable," OCHD is the single largest primary care provider in the county. In addition to public health services, OCHD has five health centers that provide primary healthcare for our most vulnerable citizens.
Osceola County, located in east Central Florida, is the sixth largest county in land mass in the state. While much of the county is a vast, sparsely populated rural expanse, the majority of the population is in the urban/suburban areas in the northwest quadrant of the county which includes Kissimmee, St. Cloud, and Poinciana. Osceola County experienced a 61% growth in population from 2000 to 2011; the estimated 2011 population was 276,163. Due to our proximity to Walt Disney World(located across both Osceola and neighboring Orange County), there is a daily average of 100,000 overnight visitors. This represents a 37% increase to our resident population. There is an ever-present potential these world-wide tourists could have a tremendous impact on Osceola’s public health system with an increase in the number of people that require epidemiological, environmental, and public health preparedness services.
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Socio-economic demographics include a population of 40% White; 13% Black/African American; and 46% Hispanic ethnicity. The combined Hispanic and Black/African American populations represent a 59% majority, which is of significance as these population subsets are considered at greater risk of health disparities. Forty-four percent of residents older than five years of age speak a language other than English at home and 11% indicate language barriers or cultural differences make it difficult for them to get medical care. Twenty-seven percent of residents have no health insurance and 41% live below 200% of the federal poverty level. For patients served in OCHD's health centers, 98% are below 200% federal poverty level; 83% are racial/ethnic minorities; 27% are better served in a language other than English; and 42% are uninsured.
2) Osceola County has several maternal, infant, and child health population-based health outcome indicators that are worse than national Healthy People 2020 targets and show a critical need for improvement. Included are:
a) The Healthy People (HP) 2020 national health target is to increase the proportion of pregnant women who receive prenatal care in the first trimester to 77.9%. The rate for pregnant women who are patients at OCHD is 52%.
b) Osceola County’s fetal death rate per 1,000 deliveries is 6.5 (HP 2020 target is 5.6). The rate for Blacks is worse at 8.4.
c) Osceola’s neonatal death rate is 4.5 per 1,000 live births (HP 2020 target is 4.1). The rate for Blacks is worse at 8.5.
d) Osceola’s infant death rate is 6.3 per 1,000 live births (HP 2020 target is 6.0). The rate for Blacks is worse at 15.3.
e) Osceola’s rate of 13.6% preterm births is worse than HP 2020 target (11.4%).
f) Osceola’s low birth weight rate of 8.3% is worse than the HP 2020 target (7.8%).
g) The University of Wisconsin’s 2012 County Health Rankings shows Osceola ranks poorly in comparison to Florida’s 67 counties; for example, 43rd for morbidity factors such as the percent of low birth weight and 54th for clinical care measures such as lack of access to health care.
h) To address population-based health indicators, OCHD formed the Fetal/Infant Mortality/Morbidity Review (FIMR) committee, consisting of multiple community partners, to study poor birth outcome indicators. Results showed that 13% of mothers with poor birth outcomes had no prenatal care. Also, the highest fetal and infant deaths were in two Osceola zip codes that had a 66% minority, health disparate population (55% Hispanic and 11% Black).
3a) Osceola’s population subsets (46% Hispanic and 13% Black) are those typically considered at greater risk for health disparities. When combined, these groups form a 59% majority population for the county overall. For patients served at OCHD health centers, 83% are racial/ethnic minorities.
3b)Our project target population was estimated on the basis of Osceola County’s 3,781 births in 2012. During the same year, there were 1,429 births for prenatal patients served by OCHD; which is 43%. This is an estimate since various factors may have skewed the total, such as births to mothers not residing in Osceola County and county residents that delivered out-of-county.
3c) Our Early Access Prenatal project reached 867 prenatal patients during the 2012 initial project 12-month period, representing 61% of target population. During project continuation through April 2013, an additional 287 were seen.
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4)We had not adequately focused on addressing the problem in the past. We had internal processes in place for prenatal admissions that were based on what we had done for years and were not focused on reducing artificially created barriers to timely access.
5) Our current practice has enabled us to use a systematic process management approach to improve timely access to prenatal care. We reduced artificially imposed barriers in the patient admission process that made the system work for us and not necessarily for our patients. By managing our processes we were able to reduce the number of separate, specialized visits the prenatal patient had to go through from the time of her pregnancy test to the first medical visit. Of the original four separate visits in that process, we used process mapping to redesign the work flow and eliminate one step (the nurse work-up visit) by incorporating those activities into the first medical visit. This PCDA process improvement intervention had a positive impact on timely access. Additional PDCA cycle improvement interventions included redesigning our appointment system; streamlining our eligibility process; training staff; and setting up a new clinic schedule so that several 4-hour appointment blocks during the week were reserved for prenatal patient initial visits only, which improved efficiency and timely access for provider visits. These improvement interventions had a positive effect on our in-process indicator of patients receiving their first medical visit within two weeks of their pregnancy test from a baseline of 4% at the beginning of the project in December 2011 to 70% in April 2013.
6b) Our project creatively used and built upon existing quality improvement tools to combine into our internally developed 9-Step Process Management Model with PDCA (included in the Supplemental Materials section of this application). The Plan-Do-Check-Act is a widely accepted QI tool used for continuous improvement cycles. We included in our model the three questions from the Model for Improvement (“What are we trying to accomplish?” “How will we know a change is an improvement?” and “What change can we make that will result in an improvement?”) The Model for Improvement was developed by Associates in Process Improvement and used, among others, by the Institute for Healthcare Improvement and the HRSA Bureau of Primary Health Care’s national Chronic Disease Collaboratives. One of the most effective elements we included in our process management model was a detailed description of what to do in each of the PDCA steps along with recommendations on which QI tools are appropriate for each step. Our 9-Step Process Management Model with PDCA became our roadmap to guide our QI team through improvement cycles. Our model can be used for our ongoing QI efforts, as it is a concise roadmap/QI tool that will enable us to replicate our successful process management methodology.
7) We used Healthy People 2020 and the University of Wisconsin's County Health Rankings as evidence-based guidelines.
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The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broad-based involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
In the boxes provided below, please answer the following:
1)Goal(s) and objectives of practice 2)What did you do to achieve the goals and objectives? 2a)Steps taken to implement the program 3)Any criteria for who was selected to receive the practice (if applicable)? 4)What was the timeframe for the practice 5)Were other stakeholders involved? What was their role in the planning and implementation process? 5a)What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s) 6)Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Else, provide an estimate of start-up costs/ budget breakdown.
1) The QI team used an internally developed 9-Step Process Management Model with Plan-Do-Check-Act (PDCA) as a systematic approach to develop, implement, and manage the timeliness and efficiency of our prenatal healthcare access process. The QI team determined we could more effectively improve the rate of admission to prenatal care during the 1st trimester of pregnancy, a lagging/outcome indicator, by addressing in-process/leading indicators that ultimately affect
the outcome. We determined our in-process indicator would be the rate of pregnant women who have their initial prenatal visit within two weeks of their positive pregnancy test. Our project goal was to improve this rate from a baseline of 4% to 75% during 2012.
2) We used various QI tools along with our 9-Step Process Management Model with PDCA to implement our program, including:
a)Input/Output Diagram – The QI Team used this tool to define the process of prenatal care access. This included: Inputs (pregnant women needing prenatal care); In-Process Activities (pregnancy test, eligibility appointment, eligibility determination, and prenatal provider appointment); Outputs (pregnant woman gets prenatal care); and Outcome (improved opportunity for a healthy pregnancy and healthy baby).
b.)Process flow charting – Once the QI Team had the prenatal access process defined with the Input/Output Diagram, we used that information to develop a process flow chart. The process flow chart, which is a visual depiction, clearly showed the number of steps the patient had to go through from the time of the positive pregnancy test until her first prenatal provider examination. The process flow chart also showed what steps the staff had to perform at each of the patient visits. The QI Team was able to clearly see a prolonged access to care for the patient and inefficient use of staff time and scheduling.
c.)Brainstorming and Fishbone Diagram – The QI Team used the process flow charting information to brainstorm various issues involved in the prenatal access process. The issues were captured in a Fishbone Diagram (cause and effect diagram), which served as a visualization tool for categorizing the potential causes of process problems so that we could further refine it to identify the root-cause.
d.)5-Whys and Root-Cause Analysis - As the QI Team was trying to dig deeper for the real root-cause from the various categories on the Fishbone Diagram, we used the 5-Whys tool to keep asking “why” until we felt we had reached the real root-cause. The QI Team also brainstormed ideas regarding which of the identified issues that we felt we could control or influence and then selected by consensus the most plausible root-cause. Using our 9-Step Process Management Model with PDCA, we continued through the steps that would test, by data analysis, whether our initial root-cause held up as the real root-cause. The QI Team concluded the root-cause to be “artificially imposed barriers to make system work for the agency and not necessarily for the patient, i.e. there were too many separate, specialized visits.” We needed to improve access by eliminating and/or combining certain of the visits/steps from pregnancy testing to initial provider visit.
e.)Revised Process Flow – After completing the steps above, the QI Team developed a revised or improved process flow chart that we implemented. The improved process flow eliminated one of the four steps in the process, i.e. the “separate, specialized” prenatal work-up nurse visit. We combined the activities from this step into the provider visit step.
In the five steps above, the QI Team had followed the “Plan” and “Do” phases of our 9-Step Process Management Model with PDCA. We were now at the “Check” phase in which the QI team monitored on a monthly basis the rate of first prenatal exams within two weeks of pregnancy testing. We collected, analyzed, and displayed the data using a line graph. We presented the line graph each month to senior management, eligibility staff, and prenatal clinic staff; discussing with them what the data were indicating.
At this point the QI Team started the “Act” phase of the PDCA cycle by identifying opportunities for improvement through revised process flow and testing, and taking action to fix obvious problems or identifying root-causes of difficult problems. Based on the data we then brainstormed with staff the potential causes of why we were not progressing as planned. We used input from the staff to determine root-causes and what they thought, based on their experience, we could put into place as an intervention for improvement. Interventions generally were specific and focused on the staff’s experience of what had happened that month to cause a delay in progress. Their suggestions for an improvement intervention were based on what had occurred. The planned interventions for improvement were then set into place and the QI Team went into another “Check” cycle to monitor performance for the next month.
Monthly in-process data showed an improvement from our baseline of 4% in December 2011 to 39% by December 2012. There were monthly fluctuations in the data that responded to the PDCA cycle of improvement interventions we put into place. Although we did not reach our Aim Statement goal of 75% in the first year of the practice, we made an overall improvement of 35% of pregnant women having their first medical visit within two weeks of their pregnancy test. Based on the impact of our improvement momentum, our QI team decided we to continue testing PDCA cycles until we achieved our desired level of improvement. We used additional PDCA cycles to refine improvement interventions. By April 2013, we reached another milestone of 70%.
Examples of our improvement interventions include:
a.) Eliminating the nurse work-up visit which was being held on a separate day from the medical exam. This resulted in a 13% improvement in prenatal patient getting their initial provider visit within two weeks of pregnancy testing.
b.) Data monitoring showed an increase one month in the average number of days from the eligibility appointment to the first prenatal provider visit. We used the 5-Whys QI Tool to help us weed through the low hanging fruit (or symptoms) to identify the root-cause. In going through the 5-Whys technique (symptoms, visible problem, first level cause, higher level cause, and then the highest level / root cause) the QI Team determined that staff had begun utilizing prenatal visit slots in the appointment schedule to fill with well-women gynecology exams that were in higher demand that month. This substantially decreased the appointment slots available for the prenatal exams. The QI Team then went into the “Act” phase to take action to fix the obvious problem. The action taken was to re-train staff in the importance of appropriate scheduling, i.e., not using initial prenatal visit slots for well-women gynecology exams. This intervention resulted in a 23% improvement with the next monthly data analysis.
c.) The data during September 2012 showed a decline of 19% from the previous month in the initial prenatal visit within two weeks of pregnancy test. The QI Team went into the “Act” phase and used the 5-Whys tool. We identified the root-cause to be that the prenatal providers were covering for the absence of another provider who was on extended leave, causing a delay in available appointments for the first prenatal exam. This situation continued during October, then improved 17% in November when the provider returned. The QI Team became aware that this prenatal provider would be on leave intermittently during the coming months.
NOTE: A significant accomplishment that resulted from our QI initiative was that based on our prenatal access data that showed inconsistent provider staffing was impacting timely prenatal access, the QI Team was able to demonstrate to senior management the need for an additional obstetric provider. As a direct result, senior management initiated a recruitment process to hire another obstetric provider to help ensure timely access to early prenatal care.
3) Those selected to receive the practice was determined to be the pregnant women seeking prenatal healthcare services at OCHD.
4) The initial project timeframe was December 2011 to December 2012. Due to the momentum gained in improvement processes and in-process indicator results, we have continued to monitor the practice as we seek to standardize it. We have included this in-process indicator as one of our routinely monitored clinical performance indicators on our Clinical Performance Scorecard.
5)The Early Access Prenatal project has been an OCHD internal process. There is six OCHD interdisciplinary staff members actively involved on the QI Team. Other staff members involved in implementation include six prenatal eligibility determination staff; four obstetric providers; and approximately 10 clinical staff (nursing, medical assistants, and clerical) were involved in providing direct prenatal clinical services. OCHD’s Administrator has discussed the project findings during the Osceola Health Leadership Council, which includes members from various Osceola County community partners and stakeholders. The maternal and child health status indicators and the results our project has achieved thus far have been presented to various community partner workgroups, including the 2013 Osceola Health Summit – The Business of Health (a gathering of over 100 community stakeholders from business, healthcare, government, social services, school system, neighboring county public health department staff, faith-based, grass-roots, law enforcement, elected officials, concerned citizens, and other stakeholders). The Summit was held as part of Osceola County’s development of the 2012 Community Health Assessment (CHA) and the resulting 2013-2016 Community Health Improvement Plan (CHIP). "Improvement in low birth weight rates" was selected by the community partners during the CHA process as one of the Osceola CHIP’s strategic priorities. The multi-community agencies Fetal and Infant Mortality/Morbidity (FIMR) committee is the CHIP Process Owner responsible for developing action plans with measurable objectives to address the health status indicator of low birthweight and poor birth outcomes. The FIMR committee, chaired by an OCHD staff member, currently is in the process of developing their CHIP SMART measures. Progress will be monitored monthly by the Health Leadership Council. FIMR’s objectives will center on early prenatal access and developing health education campaigns regarding obesity at the time of conception and during pregnancy as a risk factor for poor birth outcomes. The education campaigns, while presented county-wide, will also specifically target Osceola’s census tracks with the highest rates of fetal/infant mortality/morbidity. These are the census tracks with a majority population considered to be at risk for suffering health disparities. OCHD’s work internally on early access prenatal care improvement and the work with community partners to develop pregnancy health education campaigns have the potential to positively impact the population-based health status indicator of low birth weight rates.
6) Since the Early Access Prenatal QI project was part of OCHD’s continuous performance improvement processes, we did not incur any dedicated start-up or in-kind costs. The following information provides an estimate of associated costs:
Total number of staff on QI team: 6
Total number of full-time equivalents (FTEs) on QI team: 0.85 FTE
Characteristics of QI Initiative team with their OCHD position and percentage FTE dedicated to project include:
a. Project Manager - QI Consultant, FTE 0.2
b. Project Champion - Administrator/Public Health Officer, FTE 0.05
c. Clinical Lead - Nursing Director, FTE 0.2
d. Eligibility Process Owner - Eligibility Department Manager, FTE 0.1
e. Eligibility Process Lead - Eligibility Supervisor, FTE 0.2
f. Data Analysis – Quality Management Data Analyst, FTE 0.1
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.
Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
In the boxes provided below, please answer the following:
1)What did you find out? To what extent were your objectives achieved? Please re-state your objectives from the methodology section. 2)Did you evaluate your practice? 2a)List any primary data sources, who collected the data, and how (if applicable) 2b)List any secondary data sources used (if applicable) 2c)List performance measures used. Include process and outcome measures as appropriate. 2d)Describe how results were analyzed 2e)Were any modifications made to the practice as a result of the data findings?
1) The QI team determined we could more effectively improve the rate of admission to prenatal care during the 1st trimester of pregnancy, a lagging/outcome indicator, by addressing in-process/leading indicators that ultimately affect the outcome. We determined our in-process indicator would be the rate of pregnant women who have their initial prenatal visit within two weeks of their positive pregnancy test. Our project goal was to improve this rate from a baseline of 4% to 75% during the 2012 project period.
2) The QI team used an internally developed 9-Step Process Management Model with PDCA as a systematic approach to develop, implement, and manage the timeliness and efficiency of our prenatal healthcare access process. Step 7 in the “Check” phase of the PDCA cycle is to monitor performance. This phase established the basis for evaluating the impact of the QI initiative.
The QI team determined we could more effectively improve the rate of admission to prenatal care during the 1st trimester of pregnancy, our lagging/outcome indicator, by addressing in-process/leading indicators that ultimately affect the outcome. We determined our in-process indicator would be “the rate of pregnant women who have their initial prenatal visit within two weeks of their positive pregnancy test.” If we could improve this in-process indicator by eliminating barriers, there would be a corresponding positive impact on earlier access to prenatal care, as well as an improved opportunity for a healthier pregnancy and healthy baby. Our project goal was to improve our in-process indicator from a baseline of 4% in December 2011 to 75% at the end of the QI initiative project period.
The data source used to capture information about our in-process measure was our eligibility tracking log that was already in place to document the date of the pregnancy test and the date of eligibility determination and payer source. The Eligibility Department Manager, a member of the QI Team, suggested that by adding an additional data point to the eligibility tracking log we could capture the date of the patient’s initial provider visit. This small process improvement enabled us to capture on the one log all the data we needed to evaluate performance.
The data the QI Team used to monitor our in-process indicator, i.e. the percent of first prenatal exams within two weeks of a positive pregnancy test, show monthly fluctuations during the first year of the project period. The monthly data along with PDCA-identified improvement interventions, that were modifications of the practice due to the data findings, include:
December 2011: 4% - Baseline established. Process flow redesign eliminated nurse work-up visit step.
January 2012: 17%
February 2012: 15%
March 2012: 13% - Added 1 FTE eligibility staff
April 2012: 11% - Revised eligibility appointment schedules to open more prenatal slots
May 2012: 22% - Started Early Access Prenatal Clinic where only new prenatal patients are scheduled
June 2012: 25% - Staff re-trained not to use prenatal slots for well-woman gynecology visits
July 2012: 32%
August 2012: 45%
September 2012: 26% - Note: 1 OB provider on extended leave during Sept-Oct
October 2012: 22%
November 2012: 39% - We had full OB provider staffing; 1 provider again will be on extended leave after this month – Decision by senior management to hire additional OB provider.
December 2012: 31% - Even though we had not achieved the project goal of 75% during the initial project year, the improvement momentum we gained led the QI Team to determine the value of continuing the project PDCA cycles and associated monitoring as we worked to standardize the process.
April 2013: 70% - The staff celebrated the highest percentage achieved as we continued improvement efforts.
Although we had not yet reached our Aim Statement goal of 75% as of April 2013, we have made an overall improvement of 66% over the baseline.
Additional in-process data we monitored showed a significant reduction (improvement) in the average number of days in the process from pregnancy test to the eligibility determination appointment, i.e. from a baseline of 23 days in December 2011 to 6 days in April 2013. We were able to achieve this significant improvement by revising eligibility appointment schedules to increase the number of slots available for prenatal patients and revising individual eligibility staff assignments so that some could specialize in prenatal eligibility, which resulted in faster processing through this step. The average number of days in the prenatal access process from the eligibility determination until the first prenatal provider exam has also shown a significant reduction (improvement); from a baseline of 16 days in December 2011 to 7 days in April 2013. Improvements in the process resulted in an average of 13 days from pregnancy testing to the first prenatal provider examination. This represents a significant accomplishment in our quality improvement effort aimed at the outcome goal of improving Osceola’s population-based health status indicator of first trimester admission to prenatal care.
A significant outcome that resulted from our project was that, based on our prenatal access data that showed inconsistent availability of provider staffing was impacting timely prenatal access, the QI Team was able to demonstrate to senior management the need for an additional obstetric provider. As a direct result, senior management initiated a recruitment process to hire another obstetric provider to help ensure timely access to early prenatal care.
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that stakeholders are invested in its maintenance and to ensure it is sustained after initial development. (NACCHO acknowledges fiscal crisis may limit the feasibility of a practice’s continuation.)
In the boxes provided below, please answer the following:
1)Lessons learned in relation to practice 2)Lessons learned in relation to partner collaboration (if applicable) 3)Is this practice better than what has been done before? 4)Did you do a cost/benefit analysis? If so, describe 5)Sustainability – is there sufficient stakeholder commitment to sustain the practice? 5a)Describe sustainability plans
1 and 3) Although as of April 2013 we had not yet reached our target goal of 75% of pregnant women receiving their first prenatal exam within two weeks of pregnancy test, we did reach a project milestone of 70%. This represents a 66% improvement over the baseline as we implemented improvement interventions based on our PDCA cycles and data analysis.
Barriers the team faced included the lack of consistent prenatal provider availability due to extended leave time of one of
the providers. When provider schedules were available and consistent, our process controls worked well. We were able to utilize the data to show the need for provider appointment availability so that we could ensure early access to prenatal care, which has resulted in the decision by senior management to hire an additional provider. The QI team will continue to monitor the early access data to ensure improvements continue toward our target goal and as we standardize our prenatal admissions process.
A challenge has been in determining whether our in-process indicator (first prenatal visit within two weeks of pregnancy test)is the best measure of process improvement. We selected this indicator initially since the QI Team determined it was a valid predictive indicator that could be measured “in-process;” could be collected at regular and frequent intervals; and would be predictive of our outcome indicator (percent of women obtaining prenatal care during their first trimester of pregnancy). The in-process measure was also SMART (Simple, Measurable, Achievable, Reportable, Time-bound). Additionally, the indicator was aligned with OCHD’s organizational goals included in our formal Strategic Plan.
As we proceeded in our process management, the QI team realized that our in-process indicator did not account for patient-imposed variables such as no-show rates or whether the patient selected a later appointment date (for her convenience) than what was actually available. We are in the PDCA cycle process of revisiting our in-process performance indicator to determine whether we should change it, for instance, to measure the next available appointment in order to negate patient-imposed variables. The QI Team also is considering keeping our current in-process indicator, while adding other measures
that might further clarify performance variations, such as the next available appointment and no show rates.
3) Included in 1.) above.
5) Sustainability of our momentum will be achieved through several avenues, including linkage to OCHD’s formal Strategic Plan; Osceola County’s 2013-2016 Community Health Improvement Plan (CHIP), which will be monitored by the Osceola Health Leadership Council consisting of a variety of collaborative community partners; and inclusion in our OCHD internal Scorecard of Clinical Performance Indicators. Our Scorecard is a QI tool that reports baseline and actual performance against the established target for each of OCHD’s Clinical Performance Indicators. The data are presented quarterly in a dashboard format using red/yellow/green color coding to visually depict the progress of each measure against its target. The Scorecard is presented to senior management, the Board of Directors, and shared with staff. It is also included in our annual progress reports to HRSA’s Bureau of Primary Health Care as part of our federally qualified health center quality improvement efforts.
5a.) The last phase of our 9-Step Process Management Mode with PDCA is the “Act” cycle where action is taken to make further improvements and/or maintain the improvements achieved. As we continue working to achieve our established performance indicator target (75% of pregnant women receive their initial prenatal medical exam within two weeks of a positive pregnancy test), we are updating our process documentation and training staff as we standardize the improved prenatal admissions process.
OCHD’s mission is to “protect and improve the health of all residents.” Additionally, three objectives in OCHD’s Strategic Plan link directly to this Early Access Prenatal QI initiative: 1) monitoring/improving health status indicators; 2) improving access to health care services; and 3) integrating a culture of performance excellence/quality improvement throughout the organization. This linkage further enhances our ability to continue this QI initiative and make it part of our Scorecard of Clinical Performance Indicators.
Please identify the topic area(s) the practice addresses. You may choose up to three public health areas:
Practice Category One:
Access to and/or Equality of Care
Maternal and Child Health
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