VCH PHCTF EVALUATION CORE INDICATORS, DATA COLLECTION PROCESSES, TOOLS & TARGETS

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1 OVERVIEW In alignment with VCH PHCTF deliverables, there is general agreement that our teams use the following core evaluation indicators and evaluation processes to move closer to the proposed targets or stretch goals. We will be working in partnership with your team and the UBC Family Practice Informatics, Clinical Decision Support System development team, (BC-CDSS). The BC-CDSS together with our VCH evaluation, IT and CDM experts will provide support for your professional practice to integrate and utilize these tools in your daily practice. Our objective is to ensure that over time, they are built into practice to support improvements that ultimately benefit all of your patients. The overall aim and purpose of the evaluation effort is to use this information for positive change and effective office practice redesign. The Model for Improvement developed by the IHI* is the framework being adopted as current best practice for change management. Key questions your project teams are asked to address include: 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in improvement? * Refer to the Institute for Health Improvement at for more information on the Model for Improvement. Chronic Disease Management indicators, processes and targets parallel those used in B.C. CDM Collaboratives Type of Indicators & Definitions Information o Third available appointment. Date of Birth Sex First 3 digits of postal code The third occurrence in a schedule when a certain type of appointment is available. PATIENT DEMOGRAPHICS Entered from chart into PATIENT ACCESS Weekly, MOA counts & records the days until the next routine appointment for each physician / nurse in the practice. Chart / new patient questionnaire for schedule Excel spreadsheet to record weekly counts Spreadsheet (template to be provided by VCH) All patients registered in Appointment for a routine physical within 6 days All others same day access March 2004 Evaluation Core Indicators and Guidelines for Vancouver Coastal Health PHCTF project teams 1

2 CHRONIC DISEASE MANAGEMENT Type of Indicators & Definitions CHRONIC DISEASE MANAGEMENT DIABETES Population o Glycemic Control o Hypertension o Lipids o Eyes o Renal For Diabetes and CHF Patient Registered Patients with diabetes will be retrospectively and prospectively identified HbA1C Results and % of patients with lab test done every 3 months BP % of patients with BP <=130/80 determined by clinical asst. every 3-6 months LDL % of patients with lab test done at least annually (or as indicated) Dilated eye exam % of patients with referral made to Ophthalmologist/Optometrist at least annually (or as indicated) ACR % of patients with lab test ordered at least annually (or as indicated) For CDM, the data is recorded on the flow sheet on the Establish registry from billing code info, MOH secure website info, chart audit and clinical reassessment The Billing system, MOH secure website, registry stored on and transferred from the Registry developed on the and data sent to CDM to CDM Record on to CDM Record on when referral made to CDM to CDM to CDM Taken from CHF and DM Collaboratives based upon Best Practice Guidelines 95% <7.0 % in >90% <=130/80 in >40% <2.5 in Referral made at least annually in Result <2.0 M, <2.8 F In >50% March 2004 Evaluation Core Indicators and Guidelines for Vancouver Coastal Health PHCTF project teams 2

3 Type of Indicators & Definitions DIABETES continued o Neuropathy Lower extremity exam % of patients, at least annually (or as indicated) o Selfmanagement Set and/or review self-management goals with patient annually Record on Record on to CDM to CDM Tested at least annually in >90% CONGESTIVE HEART FAILURE Patient Registered: Population Patients with CHF will be retrospectively and prospectively identified; % of patients LV Ejection Fraction Drug Use in Patients with Systolic HF Drug Use in Patients with Systolic HF o Selfmanagement LV Ejection Fraction as determined by ECHO or RNV will be done; % of patients ACE Inhibitors (or ARB if ACE-I Intolerant); % of patients with documented systolic HF who are on ACE-I (or ARB) B-Blockers; % of patients with documented systolic HF who are on B-Blockers Set and/or review self-management goals with patient annually Establish registry from billing code info, MOH secure website info, chart audit and clinical reassessment Record method used, % Ejection Fraction and whether systolic or diastolic HF on Record drug use on Record drug use on Record on Billing system, MOH secure website, registry stored on and transferred from the to CDM to CDM to CDM to CDM 95% recorded in >85% >85% with systolic CHF will be on ACE- I or ARB >85% with systolic CHF will be on B- Blockers March 2004 Evaluation Core Indicators and Guidelines for Vancouver Coastal Health PHCTF project teams 3

4 Type of Indicators & Definitions PRACTICE SIZE Fee for service sites Quarterly count of current patients listed in Rostered sites - Roster size - Outflows INFLUENZA Dated records of occurrence of tests &/or results Occurrence of vaccination PRACTICE SIZE Query of >1500 active patient records for patients/physician totals over the last >7100 services/physician 18 months Report from MOH >1500 active patients/physician >4000 service/nurse? PREVENTION review & post run charts >80% of these patients will meet patient goals in each category >90% of patients over 65 years of age >90% of diabetics and CHF patients any age SMOKING o Baseline Status Smoking Status Record All patients over 8 years o Self-management This indicator to be reviewed for use next year, not used in Fall 04 report Assess & discuss self-management challenges Offer smoking/risk management Record if ready to quit and when Record date(s) of smoking cessation See for smoking status data collection tool >90% smoking status recorded & documented selfmanagement goals each visit. > X% patients quit 2 weeks to 1 year. X% > 1 year. MAMMOGRAPHY PAP TESTS reduction education Occurrence of mammogram and result Occurrence of Pap test and result within the past 2 years of discussion held for those 50+ if female years and no hysterectomy >90% of women are screened in the last year 1st 3 normal Pap smears at one-year intervals, >90% compliance >90% every year if abnormal >90% every 2 nd year if normal March 2004 Evaluation Core Indicators and Guidelines for Vancouver Coastal Health PHCTF project teams 4

5 Type of o Internal Survey (under review to shorten, review otheralternative tools and send for plain language review) o Internal Survey ( to be discussed at site visits) o PHCTF Project Group Survey (Suggest to be used with physicians only) Indicators & Definitions SATISFACTION SURVEYS PATIENT SATISFACTION SCORES On one randomly Patient selected day each questionnaire month, MOAs distribute a questionnaire to all patients as they check in and collect them in a drop box as patients leave. STAFF SATISFACTION SCORES All staff in the Staff practice will be questionnaire(s) given an anonymous questionnaire every 6 months or more frequently at the discretion of the practice All physicians in the practice will be given an anonymous questionnaire in March 2004, 2005, and March 2006 and a stamped envelope return to VCH evaluation staff. Satisfaction questionnaire MS Access or EXCEL database (to be provided by VCH) MS Access or EXCEL database (to be provided by VCH) VCH staff will send a summary report back to each practice Run Charts posted in clinic and reviewed by team for action Run Charts posted in clinic and reviewed by team for action. March 2004 Evaluation Core Indicators and Guidelines for Vancouver Coastal Health PHCTF project teams 5

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