A UNHS Hospital Quality Assurance (QA) /Improvement (QI) Self-Assessment Tool

1. A UNHS Hospital Quality Assurance (QA) /Improvement (QI) Self-Assessment Tool Yaoli Li, MD, MS, MA CCC-A Penny Hatcher, RN, MSN, DrPH, PHN EHDI Program Community and Family Health Minnesota Department of Health St. Paul, MN

2. Faculty Disclosure Information In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s)of the product(s) or provider(s) of the service(s) that will be discussed in my presentation. This presentation will not include discussion of pharmaceutical or devices that have not been approved by the FDA or if you will be discussing unapproved or “off-label” uses of pharmaceuticals or devices. 2

3. Need of the Hospital QA/QI Tool • MN does not have a mandate for EHDI. • Although most QI tools come with the screening equipment’s software, few hospitals have used them to evaluate their programs. • 111 birth hospitals with 51 using OAE only, 40 using AABR only and 22 using both • Many hospitals, large state, few staff for on-site technical assistance 3

4. Goals of the Hospital QI Tool • Promote consistent standards for all in-hospital and outpatient screening programs across the state • Assist coordinators in evaluating their programs no matter what technology, equipment or data systems they use • Develop a standardized tool for program evaluation • Provide tips for quality improvement • Determine technical assistance needs 4

5. Design of the QI Tool - Handout Elements of data: • % of Screened before discharge, excluding factors beyond hospital’s control • % of newborns with “refer” results • % of newborns not screened before discharge • % of inpatient newborns with a “refer” result who completed outpatient screening/testing – follow-up rate and # of Lost-to-follow-up Exclusions: Deceased, Transferred 5

6. Design of the QI Tool - continued Focus on what hospitals can do for QI Tips for QI as educational assistance: • How to achieve a refer rate of 4% or less • How to achieve to goal of 1% or fewer for newborns not screened before discharge • How to improve outpatient follow-up 6

7. Selection of the Pilot Hospitals • One large Metro Hospital with 2490 annual births • Six medium- size hospitals with births of 225 to 613, all in rural MN • Good working relationship with a MDH UNHSI/EHDI team member 7

8. Pilot of the Tool A cover letter and evaluation form were sent to 7 hospitals (April 2005) – (handouts) • Inpatient Hearing Screening Program Quality Improvement Tool • Outpatient Hearing Screening Program Quality Assessment Tool 8

9. Summary of the Pilot Results • 4 hospitals returned results, 1 incomplete • 2 hospitals refused • 1 hospital has yet to return results All 3 hospitals with completed Evaluation of the tool agreed that the tool identified areas for improvement, documented their performance, highlighted the successes of the program, and did not provide information to help them determining staffing. Some hospitals felt the tool identified the training needs, provided information to allocate resources and assistance that they could not get from other sources 9

10. Summary of the Pilot Results - continued All 3 hospitals with completed Evaluation agreed that the tool: • identified areas for improvement • documented their performance • highlighted the successes of the program • did not provide information to help them determining staffing 10

11. Summary of the Pilot Results - continued Some hospitals felt the tool: • identified the training needs • provided information to allocate resources and assistance that they could not get from other sources 11

12. Summary of the Pilot Results - continued • Biggest challenges in screening 100% newborns: Transferring out to another facility within hours of birth • Biggest challenges in reporting 100% of screened infants to the state: Do not receive F/U referral soon enough as many hospitals require signed form to report re-screens (HIPAA interpretation) 12

13. Lessons Learned: • The most favorable format for QA/QI: A website with options for downloading and/or completing an interactive document that could be printed and saved • Making the QA/QI tool available in multiple formats • An Excel document with pre-programmed calculations to make it easier to use • Regular communication, on-site consultation, training with CE credits • Introduce the tool as “Self-educational” versus “QA/QI“ 13

14. Next steps….? • More pilot hospitals/outpatient clinics may be needed • May add 23 more hospitals for the second stage pilot • May conduct statewide use of the tool, or • Promote as educational tool for TA requests 14

15. Questions for Audience: • How do you do hospital QA/QI? • With so many equipment built-in QA tools, what is the best way for the state EHDI surveillance system to monitor hospital program QA? 15

16. For more information, contact: Yaoli Li - EHDI Coordinator, Minnesota Department of Health Yaoli.li@health.state.mn.us 651-281-9943 (phone) Additional information may be found at: www.health.state.mn.us/newbornscreening 16

17. Acknowledgments: Gwen Washburn, MS CCC-A MDH Audiology Consultant Vicki Anderson, AuD MDH Audiology Consultant Karen Muñoz, MS CCC-A NCHAM Region V Consultant Les R. Schmeltz, Au.D.NCHAM Region VI Consultant 17