PCSP 6C- Factors 1, 5,6,7,8

Quality Measurement and Improvement Worksheet

Measure
PCSP 6 C
(Factor 1) / Opportunity Identified / Initial Performance/
Measurement Period
PCSP 6 C
(Factor 5) / Performance Goal
PCSP 6 Element C
(Factor 1) / Action Taken/Date of Implementation
PCSP Element C
(Factor 6) / Performance at Re-measurement
PCSP 6 Element C / Demonstrated Improvement
PCSP6 Element C
(Factors 7-8)
CLINICAL
Use of Effective
Contraceptive
[PCSP 6C: Factor 1, Measure #1] / During 1/1/12 - 11/30/12 - about half of our patients left with a birth control method that is classified as not being highly effective.
This includes any method that is not sterilization, hormonal, IUDs, or implants. / % of patients leaving on an effective method during the time period 1/1/13 through 11/30/13.
1/2013 – 46%
3/2013 – 44%
6/2013 – 55%
9/2013 – 68%
11/2013–71% / 70% of patients will leave with an effective method. / In January 2013 we hired a consultant to assist in the implementation of a plan to improve the use of effective contraception for all patients not seeking pregnancy.
The Plan Do Study Act (PDSA) process was started in March 2013 / % of patients leaving on an effective method during the time period 1/1/14 through 11/30/14,
1/2014 – 56%
3/2014 – 68%
6/2014 – 67%
9/2014 – 70%
11/2014–69% / During the 1 year measurement and quality improvement period, we saw improvement in patients leaving on an effective method (e.g. Starting at 46% and improving to 69% which is very close to the goal of 70%.
Hypertension
[PCSP 6C: Factor 1, Measure #2] / During 1/1/14-3/31/14 -19 hypertensive patients who required follow-up were identified. / % of patients with hypertension who received f/u counseling (as documented in their medical record)
1/1/14 - 3/31/14 – 47% / 75% of patients with hypertension will receive follow-up counseling. / Developed Hypertension Report that pulls data from the EHR to identify patients in need of f/u counseling.
Staff and providers reminded to provide counseling and education to patients as well as to encourage patients to follow-up with their PCP.
Both implemented in April 2014. / % of patients with hypertension who received f/u counseling (as documented in their medical record)
4/1/14 – 6/30/14 – 53%
(PCSP 6C FACTOR 7) / During the 6 month measurement period, the Hypertension Report was developed and used to review and discuss the measure at the Quality Assurance (QA) meetings with all staff. Since the implementation of the report and regular discussions at the QA meetings about the need for counseling of hypertensive patients and the importance of accurate documentation in the record, there has been improvement in the documented f/u counseling of patients with hypertension from 47% in Q1 of 2014 to 53% in Q2 2014. This process will continue to be reviewed as we work toward the goal of 75%.
Smoking / During 5/1/2014-8/31/2014 -87 patients were identified as smokers that should have received smoking cessation counseling. / % of patients who smoke who require f/u and received counseling (as documented in their medical record)
5/1/14 - 8/31/14 – 28% / 90% of current smokers will receive counseling that is documented in their medial record / Developed Smoking Cessation report that pulls data from the EHR and used to identify patients in need of f/u counseling
Staff and providers reminded to provide counseling and education to patients, as well as to encourage referrals for patients that want to quit, and counseling for patients that continue to smoke.
Both implemented in April 2014. / % of patients who smoke who require f/u and received counseling (as documented in their medical record)
9/1/14 – 12/31/14 – 37% / During the 6 month measurement period, the Smoking Cessation Report was developed and used to review and discuss the measure at the Quality Assurance meetings with all staff. Since discussion about the need for counseling of patients who smoke and the importance of accurate documentation in the record, there has been some improvement. We will continue to work toward the goal.
BMI
[PCSP 6C: Factor 1, Measure #3] / During 4/1/2014-6/30/2014 -269 patients were identified as overweight or obese and required counseling. / % of patients that were overweight or obese and received f/u counseling (as documented in their medical record).
4/1/14 - 6/30/14 – 67% / 90% of overweight/obese patients will receive counseling that is documented in their medical record / Developed BMI Report that pulls data from the EHR and used to identify patients in need of f/u counseling
Staff and providers reminded to provide education and document the plan to address patients with high BMI.
Both implemented in April 2014. / % of patients that were overweight or obese and received f/u counseling (as documented in their medical record).
7/1/14 – 9/30/14 - 76%
(PCSP 6C FACTOR 8) / During the 6 month measurement period, the BMI Report was developed and used to review and discuss the measure at the Quality Assurance meetings with all staff. Since discussion about the need for counseling of overweight/obese patients and the importance of accurate documentation in the record, there has been improvement in the documented f/u counseling from 67% to 76%.