The Spotlight on Improvement series highlights real stories of health care quality improvement. These case studies can be used to improve health care programs and spark new collaborations.
Pregnancy causes changes that cascade through a woman’s life and that of her family, and can have large health impacts—especially for those already struggling with chronic disease, poor mental health, or stressful circumstances. We now know that pregnancy timing and circumstances affect not only a prospective mother’s health but also the wellbeing of her children. A woman’s pre-pregnancy status can shape her child’s developmental trajectory and risk of chronic conditions decades later. But in Washington State, 37 percent of pregnancies are unintended, a measure that is included in the Washington State Common Measure Set for Health Care Quality and Cost. Such a rate does not allow many women and doctors to build preconception resources that support healthy pregnancy, healthy babies, and healthy parenthood.
State-of-the-art contraceptive technologies—long acting “get-it-and-forget-it” IUDs and progestin implants—are 20 times as effective as the Pill. They dramatically reduce mistimed or unwanted pregnancy, as shown by the Colorado Family Planning Initiative, which cut teen births and abortions nearly in half and reduced preterm births. Professional bodies now recommend implants and IUDs as top-tier protection for most women, including teens and those who are HIV-positive. But busy primary care providers often don’t know whether a patient wants to get pregnant or avoid pregnancy, and so may miss opportunities to help patients.
With unintended pregnancy so common and the consequences so significant, the American College of Obstetricians and Gynecologists now recommends that health care providers touch on reproductive life planning at every visit with reproductive-age women. Clinicians want to help their patients manage health conditions and stack the odds in favor of flourishing children, but are swamped with ever more tasks and topics to cover and ever smaller chunks of time in which to address them all.
The Oregon Foundation for Reproductive Health, a Portland-based nonprofit, has developed a simple, quick method called One Key Question® (OKQ) to screen routinely for pregnancy intentions in reproductive age patients. The one key question is this: “Would you like to become pregnant in the next year?” The clinician documents one of four patient responses: Yes, I’m OK either way, I’m not sure, or No, followed by evidenced-based care that supports their answer.
Patients who respond yes receive preconception counseling, which identifies health behaviors change or care that could support a healthy pregnancy. Patients who feel uncertain or ambivalent receive information about preconception care as well as contraception. A response of no leads to a conversation about family planning options, giving an opportunity to check in on current satisfaction and explore less familiar methods that might better fit. Inexpensive posters and tear sheets from the National Campaign to Prevent Teen and Unintended Pregnancy and a color coded medical eligibility chart from the CDC make it easy to step through family planning options
One Key Question is rapidly becoming a national model. One example is the state of Delaware, where Governor Jack Markell partnered with Upstream USA to retool contraceptive care statewide, so that women can receive the method of their choice same day, free of charge—including IUDs and implants. The upgrade, called Delaware CAN, included OKQ screening to identify the preventive reproductive health needs of patients.
In Oregon, OKQ is being deployed in a variety of settings, from home-visiting and WIC to primary care. A pilot project at One Community Health compared two major health centers, one in which OKQ was implemented and one without. At one month, 64% of electronic medical records for the intervention site documented appropriate screening for pregnancy desires, compared to 12% at the non-intervention site, suggesting that staff were able to incorporate the change into their normal workflow of patient care.
Even for clinicians who would like to improve reproductive outcomes for their patients, adopting a screening protocol such as One Key Question can be challenging.
- Sexuality and reproduction can be sensitive topics for providers as well as patients. In particular, those women who are young, poor, ethnic minorities, or in ill health can feel shamed or pressured unless conversations are carefully client-centered. That said, women say that they want their providers to ask.
- At a practical level, incorporating the OKQ algorithm into varying electronic health records continues to be a major barrier for health centers that want to use OKQ in a systematic and routine way.
- Asking about pregnancy intentions can uncover desire for better birth control or for preconception care, requiring staff training or other increases in capacity. (The “Beyond the Pill” program at UCSF offers onsite trainings to clinics wanting to upgrade contraceptive services, with grant funding for those that qualify.)
Keys to success
To ensure program excellence and compatibility of evaluation across settings, the non-profit Oregon Foundation for Reproductive Health trademarked One Key Question and asks for a signed memorandum of understanding prior to implementation. In settings that have adopted OKQ, the following components have been keys to success:
- Conduct comprehensive training with health center team before roll-out
- Integrate screening into current workflow practice
- Renew protocols or referrals for preconception and contraception care
- Develop a plan to evaluate impact of screening on other services provided
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CHI Franciscan is making great strides to reduce avoidable emergency room use. By focusing on providing their patients alternatives to more costly emergency room visits, they have become top performers in the region for their low rates of avoidable emergency room use.
Inappropriate use and overuse of antibiotics is a serious public health threat and is addressed by several specialty societies’ recommendations in the Choosing Wisely campaign. Learn how Virginia Mason reduced their inappropriate antibiotic use by over 50 percent in this month’s Spotlight on Improvement.
Swedish Medical Center: Rethinking the practice of ordering daily labs to reduce waste and improve careNovember 2014: Swedish Medical Center, Seattle, Wash.
Read how Swedish Medical Center is making a big impact through a simple, innovative solution—changing the practice of ordering “daily labs,” or a lab automatically ordered for every day a patient is in the hospital. Following Choosing Wisely recommendations, Swedish Medical Center encourages physicians to only order tests that are clinically relevant. The results? This simple process change is resulting in 14,000 fewer unnecessary lab tests annually.
Choosing Wisely® is a national initiative helping physicians and patients have conversations about the overuse of tests and procedures and supports physicians’ efforts to help patients make smart and effective care choices. Read how one health system has successfully embedded the recommendations into their existing quality improvement culture.
How do you successfully manage the health of a population? Pacific Medical Center did so by creating a strong patient and service-focused team environment. They built a robust quality infrastructure that uses patient registries and reporting to facilitate proactive care, developed improvement initiatives through patient care committees and focused on continuous improvement through internal and external benchmarking. Their hard work and focus on continuous quality improvement is clearly seen in their above average quality scores in the Community Checkup.
Learn about The Everett Clinic’s precedent-setting decision to begin posting self-pay prices on their website, beginning with six common imaging services. This action was met with positive attention from the media, health care professionals, patients and community members across the state.
Improving Patient Experience: How UW Neighborhood Clinics Improved Their Patients’ Experience of Care
Learn how UW Neighborhood Clinics dramatically improved the experience of their patients through a thoughtful, comprehensive strategy that puts patients first. In the Alliance’s 2012 Your Voice Matters report, UWNC had mixed results; compared to the newly released 2014 report, UWNC is one of only five medical groups who received all-above-regional scores.
Shared medical appointments are a cost-effective way to manage chronic conditions. Read how a small, independent practice in central Washington piloted a shared medical appointment program resulting in improved health outcomes and increased patient satisfaction.
Group Health used the Choosing Wisely campaign as a way to encourage provider and patient conversations on the necessity and safety of tests, treatments and procedures and to avoid unnecessary or potentially harmful care. They paired this with an electronic medical record trigger tool to help reduce unnecessary testing and reduce wasteful spending.