Quality Improvement Basics
- "Plan-Do-Study-Act" (or PDSA)
- Capture Missed Opportunities for Well-Child Visits
- Capture Missed Opportunities for Immunizations
- Turn "Sports Physicals" into Adolescent Well Child Visits
- Utilize Pre-Visit Forms
- Institute a Referral Tracking System
Using the basic quality improvement cycle "Plan-Do-Study-Act" (or PDSA), you can try focused changes that will strengthen your medical home.
Always start with a plan. You need to ask yourself: What goal do we want to accomplish? How will we know if we have accomplished our goal? What change can we make to accomplish our goal?
Just do it! Once you've named your goal and decided what you can do to accomplish that goal, just do it! The PDSA cycles are designed to be done rapidly, so pick an idea and try it. If it doesn't work (see the "study" and "act" sections below), you can try another idea!
After you have initiated the change that you outlined in your "Plan" phase, you're ready to see whether that change made a difference. In the study phase, you will ask yourself whether the change you made helped you to accomplish your goal.
Now that you've initiated your change and studied the effect, you are ready to act on what you've found. Were you successful? Great! You can refine your change activity and repeat the cycle. Things didn't go as well as planned? No problem! You can refine your change activity and repeat the cycle. Sound familiar?
Done in rapid succession, these PDSA cycles allow you to implement small, but powerful changes in your practice to strengthen the medical home system for your patients. The beauty of these small cycles is that your initial investment is very little-all you have to do is to make a small change and see if it works. You can try it for an hour, for your first 10 patients or for one day. At the end of that time, you can stop to study your efforts and then decide where to go next. Your change may have worked well, in which case you can refine it and move ahead to make even more improvement. Or you might need to tweak your plan and try again. Since you've invested very little upfront, your loss is minimal, so edit your plan and implement your change in another small increment. Keep doing this until you get things very fine-tuned!
Pick one of the "starters" below and try it in your practice today!
When a patient checks in, have the front office staff look through the chart and flag the date of the last well-child visit. If the patient is due for a checkup, have the staff flag the chart so that the primary care provider can consider doing a well-child checkup that day (if time permits) or at least remind the parent that a well-child checkup is overdue and that one should be scheduled as the parent is leaving.
Bright Futures Periodicity Schedule
- Mechanism for flagging chart
- (for paper charts: try a post-it-note or paper-clip a brightly colored piece of paper to the chart)
- Reminder card for parent to schedule a well-child checkup
Regardless of the reason for the patient's visit, check the immunization record to find out if he/she is up-to-date. If not, and if vaccines are not contraindicated at that visit, order the missing vaccines. If the patient or parent chooses not to receive the vaccines today, suggest that they make an appointment for a nurse visit in the near future, and write an order so that when the patient comes in, the needed shots can be given. Alternatively, you could generate standing orders for your practice (see IAC tool below) so that any time a patient presents, one of your nursing staff could identify the need for vaccination and administer the vaccine.
- CDC/ACIP Immunization Schedule
- Pre-printed vaccine order sheet
- (so that you can check the needed vaccines and use this as an order for today's visit or for a future visit)
- Reminder card for parent to schedule a nurse's visit for vaccines
- (try pre-printed "prescription" for a immunization catch-up visit)
- Immunization Action Coalition Standing Orders for Vaccines
Many adolescents (and their parents!) believe that a sports physical is equivalent to the annual preventive visit, but this is not true! The sports physical is designed to clear an athlete for participation in sports. The preventive visit encompasses much more-including a full physical exam, developmental and behavioral screening, immunizations and lab tests, hearing and vision screening, and anticipatory guidance.
When an adolescent presents for a "sports physical," check the chart to see if he/she has had a preventive visit in the last year. If not, take the opportunity to perform the entire preventive visit. You can incorporate the sports clearance questions and physical exam components into your preventive visit, and the adolescent will have had a more complete exam.
- TNAAP 11-14 year old well child visit form with sports physical clearance components
- TNAAP 15-20 year old well child visit form with sports physical clearance components
- TNAAP Pre-Participation History Questionnaire
TSSAA Athlete Clearance Form
Things always go more smoothly when everyone is prepared, and the same is true for office visits! Parents can take the opportunity to prepare for the visit by reviewing the child's symptoms, outlining a list of questions for the provider and stating goals for a given visit. Providers can prepare for the visit by pulling the child's pertinent medical records, noting the need for longer appointment slots and identifying any opportunities for delivering preventive care that is due.
Ask parents to complete a pre-visit questionnaire before seeing the provider - they can do this while in the waiting room or even at home if you make the forms available on your practice website. On the provider end, fill out a brief pre-visit inventory (especially for children and youth with special healthcare needs). This will help you focus your plan for the visit and help identify any information that may be needed to maximize the effectiveness of the visit (such as records from a recent hospitalization or referral).
In a busy practice and despite the best of intentions, it can be easy for a referral to slip through the cracks. Perhaps an appointment was never made. Maybe your records never made it to the consultant. Perhaps the consultant's findings never made it back to you. Any or all of these can contribute to inefficiencies in the referral process, and ultimately have the potential to lead to delays in a patient or family getting needed services.
Use a referral tracking tool to document all the referrals in your practice. When a referral appointment is made, instruct your staff to flag the calendar. After the appointment should have been completed, follow up with the consultant (or at least be on the lookout for a note describing their findings).
- Referral Tracking Tool
Referral Fax-Back Form