Increasing Chlamydia Screening at Sugarhouse Clinic through Workflow Redesign

The AAFP, USPSTF, ACOG, AAP, and CDC recommend annual Chlamydia screening of asymptomatic sexually active women ages 14-24. National Chlamydia (CT) screening rates average at 45% for commercial insurance and 57% for Medicaid. The institutional goal for the University of Utah (U of U) community clinics is 50.4%. The rate of annual Chlamydia screening at Sugarhouse clinic (SHC) was 51.5% in women 16-24 at the start of the fiscal year when all patients assigned a PCP at SHC were counted. This clinic quality improvement project illustrates a very valuable concept that is commonly encountered in CQI projects: the need to redesign work flows versus adapt health care systems to work within current work flows to improve quality. Constant workflow redesign can result in "innovation fatigue", especially if each new workflow redesign adds new steps to the current processes in place to care for patients. One solution to avoid innovation fatigue amongst providers without compromising quality would be to redesign systems, not work flows, to work within work flows that already exist. The HM item solution to message patients directly about their overdue screening tests seems like a good one, but it should be noted that providers are unlikely to participate in population health (PH) management efforts like these unless they are provided with compensated time to perform them. Better yet, automate these PH management efforts entirely.

Increasing Chlamydia Screening at Sugarhouse Clinic through Workflow Redesign Evans, Matt MD; See, Melissa MD; Stoesser, Kirsten MD; Van Hala, Sonja MD; Knox, Jordan MD; Corcoran, Blake MD Family Medicine Division, Department of Family and Preventive Medicine, University of Utah Salt Lake City, UT, USA Background ​The AAFP, USPSTF, ACOG, AAP, and CDC recommend annual Chlamydia screening of asymptomatic sexually active women ages 14-24.​ National Chlamydia (CT) screening rates average at 45% for commercial insurance and 57% for Medicaid1. The institutional goal for the University of Utah (U of U) community clinics is 50.4%. The rate of annual Chlamydia screening at Sugarhouse clinic (SHC) was 51.5% in women 16-24 at the start of the fiscal year when all patients assigned a PCP at SHC were counted. Results: Quality Indicators ​The aim of our study was to increase annual screening rates in sexually active women, ages 16-24, from a baseline of 51.5% to 57% from December 14, 2015 March 31, 2016. At a CQI meeting in January many providers stated that they either did not like the placard/highlighters (too obvious and bright), they did not feel like the intervention was helping them to remember to screen for CT, or they just didn't like an extra step in the work flow. We considered a secondary intervention that would take advantage of sending reminder messages to patients through a registry, but unfortunately a registry to identify patients eligible for Chlamydia screening did not exist and there was no IT infrastructure to efficiently send patients who are deficient for Chlamydia screening reminders. Also, sending patients aged 14-17 messages would entail some legal gymnastics that we had not prepared for; so, we decided to change the system: Although our CQI intervention was not able to reach our goal of 57% Chlamydia screening amongst sexually active females ages 16-24, our CQI intervention was able to consistently remain above the University of Utah institutional annual Chlamydia screening goal of 50.4%. Additionally, Chlamydia screening rates at Sugar House Health Center in March of 2015 was 43.8%, whereas our CQI project intervention was able to increase screening rates to 52.5% by the end of March 2016. ​ When our data is compared to what is known nationally and locally about Chlamydia screening, SHC can be proud of our accomplishments: We decided that instead of using our time to work with a system that wasn't working for us, we would contact the clinical decision support (CDS) team to ask what it would take to get Chlamydia screening to be a best practice alert (BPA) or health maintenance (HM) item. BPAs and HM items are Epic EMR functions that either alert a provider when they should order a screening test for a patient, or list the screening test as a deficiency in the Health Maintenance tab in Epic. Methods After brainstorming ideas to improve Chlamydia screening, the Chlamydia Clinic Quality Improvement (CQI) team at Sugarhouse eventually identified the target of the intervention to be providers often forgetting to screen sexually active females aged 16-24. To help aid providers in remembering to screen for Chlamydia, the following clinic workflow redesign was performed: • A green HIGHLIGHTER will be placed in every clinic provider's BOX. • MA and Provider to HUDDLE at the beginning of session and HIGHLIGHT patients to be screened on provider's printed schedule. • MA will check-in previously identified screening eligible patients and PEND order. • MA will PLACE green placard on the basket on the door outside of the clinic room to serve as reminder to provider (green placards will be available on each side of the clinic, housed along with the X-Ray signs). • Provider will DETERMINE clinical appropriateness of screening and will SIGN order.​ The intervention started on December 14, 2015 and ended on March 31, 2016. Data was gathered monthly to determine our rate of Chlamydia screening. The definition of sexually active included sexually active history obtained, prescribed birth control, or previously tested for Chlamydia or pregnancy. Results: Participant Evaluations Results: Team Development Conclusions This clinic quality improvement project illustrates a very valuable concept that is commonly encountered in CQI projects: the need to redesign work flows versus adapt health care systems to work within current work flows to improve quality. Constant workflow redesign can result in "innovation fatigue", especially if each new workflow redesign adds new steps to the current processes in place to care for patients. One solution to avoid innovation fatigue amongst providers without compromising quality would be to redesign systems, not work flows, to work within work flows that already exist. The HM item solution to message patients directly about their overdue screening tests seems like a good one, but it should be noted that providers are unlikely to participate in population health (PH) management efforts like these unless they are provided with compensated time to perform them. Better yet, automate these PH management efforts entirely! The U of U CDS team was not excited about BPAs since they have been found to slow down patient care, frustrate specialists who don't need to see them, and are often just ignored entirely. However, the CDS team was excited to add Chlamydia screening as a HM item. Not only will this let SHC providers review which patients are candidates for screening, but also it will now be possible to send patients messages through our MyChart system as a "batch message". There are other functionality benefits that are available as well. References and Acknowledgements 1.Commercial Screening Percentages Reported by Commercial and Medicaid Plans. CDC website: http://www.cdc.gov/std/chlamydia/chlamydia-screening-2014.htm I would like to thank the authors and the following PA, RNs, and MAs for their contributions to this project: Malea Satterwhite, PA-C; Marci Thayne, RN; Tracy McDonald, OSS; Jamie Guzik, MA; Dee Valdovinos, MA; Christi Stoll, MA; Sheryl Nelson, MA; Jessica Mella, MA; Rusty Hendrycks, MA a