CQI Example 1: Improving TB screening of HIV-infected patients
Identifying the Problem
At their first quarterly TB prevention review meeting in June, Facility A’s CQI/TB Prevention Committee reported that it had conducted a chart review to gather key indicator data for intensified case finding. This was required because the percentage of patients screened for TB at their last visit could not be captured from the existing HIV register.
The committee reviewed 20 records of patients seen at the HIV clinic in the prior month who were not being treated for TB, and reported the following: 3 of the patients were clearly TB suspects and appropriately evaluated, while 7 patients had documentation of a negative TB symptom screen. However, for the other 10 patients the reviewer could not determine whether or not a TB symptom screen had been performed, even though 3 of those patients had been documented in the physician’s notes as having unexplained weight loss.
Setting the Aim
At the meeting, the team agreed that given how busy everyone was, it was quite possible that a patient with TB symptoms could be missed. They were concerned especially about the 3 patients who apparently were not screened for TB even though weight loss was written in their notes and confirmed on the chart review.The CQI/TB Prevention Committee decided to work on this issue, and developed the following aim statement:
“In our ongoing efforts to prevent TB in our community, we, the staff at Facility A, shall improve both the performance of, and the documentation of, TB screening of HIV-infected patients. By the end of January of next year (six months from now), we will be able to document through chart review that at least 85% of patient visits include a TB symptom screen, and that that standard will be maintained thereafter.”
Developing Change Strategies
The team met again and developed several strategies that might lead to this improvement. Their first idea was to revise the patient encounter form so that it would be easy to tick symptom screening questions and to indicate what was done for patients with a positive TB screen. Two providers were asked to develop the form and review it with their colleagues the following week and make any recommended changes after feedback from the group.
Testing Strategies with PDSA
The new form was then tested by one provider for one day. After the test, it was again revised based on the provider’s feedback. The revised form was then tested with two providers for a week, revised again, and then tested for two more weeks by all providers at the clinic. At the end of July, the CQI/TB Prevention Committee again reviewed 20 charts and found that this revised encounter form did appear to be helping to increase screening rates.
The team decided to test their next idea, which involved having the triage nurse double check documentation of TB screening results on patient charts. Again, the team tried a quick, small test: the triage nurse checked documentation on one day, and reported back to the committee how this process went. The nurse found that her day was very busy, and that she was only able to check charts at the end of the day. This was not helpful to providers, who saw too many patients in a day to remember the results. In light of this information, the team suggested that the exit nurse, rather than the triage nurse, check the charts. This way, providers could be reminded soon after patient visits that they needed to document the findings of their TB screenings. This was tested the next day, and was found to be a better process and well received by the clinicians on staff. The team expanded this test to a week, and again it was seen to be a useful addition to their process.
Documenting the Changes
After piloting these changes for six months and confirming that they were sustainable and useful, the clinic decided to make these two process changes permanent. Below is the time series, or “run chart” showing the results from the clinic’s improvement project.