3. Develop a Preventive Care Protocol

Select Figure 3.1 for steps you can take (14 KB).

A preventive care protocol—a plan that specifies who should get which services and how often they should be delivered—needs to be developed as a first step in designing a system for delivering preventive care.

• The first step in developing a preventive care protocol is to review screening standards from various organizations, including the U.S. Preventive Services Task Force (USPSTF) (see the Introduction, "Establish Preventive Care Protocols,") and use them to establish preventive care standards to meet your setting's needs.
• The second step is to conduct baseline chart audits to determine how well your setting is meeting the standards you have set.
• The third step is to establish short-term or intermediate goals and evaluate how well your setting is meeting them.

These steps are described in greater detail in the remainder of this chapter. Worksheets to help you implement the steps described are included here and in Appendix B.

Start Small

If you are still daunted by the whole process, ease into it by first tackling a subset of your population or one piece of the implementation process. Here are two suggestions:

1. Implement PPIP for a definable subset of your population, such as new patients; or initiate PPIP in a single unit of a multi-unit clinic; or choose one or two items on which to focus, such as cervical cancer screening and mammography. Then add one or two additional items every 1-3 months as staff become comfortable with the process.
2. Place reminders on the charts prior to patients' visits. Putting needed preventive services on a reminder note on the front of the chart is a simple task. Studies have shown that the delivery of appropriate screening tests, counseling, and immunizations can improve greatly with this reminder alone (Chang et al., 1995; Cohen et al., 1989).

Establish Preventive Care Standards

To help your setting establish preventive care standards, gather standards or recommendations from one or more sources. The sources listed below offer recommendations for preventive health services (select for more contact information). The standards should be provided to all staff members and a time should be scheduled to discuss them.

• The U.S. Preventive Services Task Force (USPSTF) systematically reviews the evidence of effectiveness of a wide range of clinical preventive services and develops recommendations for preventive care in the primary care setting. See the Guide to Clinical Preventive Services, Third Edition: Periodic Updates and the second edition.
• The National Guideline Clearinghouse, sponsored by the Agency for Healthcare Research and Quality (AHRQ), is a comprehensive database of evidence-based clinical practice guidelines.
• The National Committee for Quality Assurance sponsors the Health Plan Employer Data and Information Set (HEDIS), a set of standardized performance measures for health care prevention and treatment. Many plans base their preventive care standards on HEDIS performance measures.
• The Texas Department of Health (TDH) Adult Health Program Manual for Clinical Preventive Services includes model standards for adult preventive health care.
• The Massachusetts Health Quality Partnership, the Atlanta Quality Council, the Colorado Clinical Guidelines Collaborative, the Foundation for Healthy Communities, and other groups offer clinical preventive services guidelines and standards.
• The Task Force on Community Preventive Services, coordinated by the Centers for Disease Control and Prevention, develops evidence-based recommendations on community preventive services. See the Guide to Community Preventive Services.

Establish your own preventive care standards by adapting and modifying existing standards to fit your setting's priorities and needs. Set minimum standards of care: your initial protocol may include only a subset of what you would eventually like to do. It is easier to start small than to try to do too much. You can always add more standards after your setting has successfully implemented a basic protocol. Following is a sample of basic preventive care standards.

Sample Basic Preventive Care Standards

Immunizations

• All adults will receive a Tetanus-diphtheria (Td) vaccine every 10 years.
• All adults aged 65 and older will receive a pneumococcal vaccine.
• All adults aged 65 and older will receive an influenza vaccine every year.

Screenings

• All men aged 35 and older and all women aged 45 and older will have their cholesterol checked every 5 years.
• All adults aged 50 and older will have a fecal occult blood test annually and sigmoidoscopy every 5 years.
• All sexually active women aged 25 and younger will be screened for chlamydia.
• All sexually active women who have a cervix will receive a Pap smear every 3 years.
• All women aged 40 and older will receive a mammogram every 1-2 years.

Assessment and Counseling

• All patients will receive an initial physical exam within their first year as a patient in this practice.
• Once a year, all adult patients will be assessed for risks related to smoking, physical activity, nutrition, alcohol, and aspirin and coronary heart disease. They will be counseled, referred, screened, or treated in relation to all risks.

Specify Steps for Each Standard

According to Frame (2000), protocols should be specific about how to deliver each recommended preventive service, particularly counseling. For example, if a protocol states that providers should counsel for injury prevention, what are they expected to do? Should they spend 10 minutes talking to their patients? Should they give patients printed information? Should they ask them to watch a video? Any of these is reasonable, but the protocol should specify the steps needed to comply with the recommendation.

Standing orders, defined as interventions in which nonphysician personnel prescribe or deliver clinical preventive services to patients without direct physician involvement at the time of visit, can also be included in protocols. Standing orders have been found to be effective in improving vaccine coverage among adults used alone or as part of a multicomponent intervention in a number of settings.

Conduct Chart Audits

After you have established your own preventive care standards, the next step is to determine how well your setting is meeting them. To obtain this information, examine clinical records through chart audits. From these audits you can determine not only how health risks are being identified and addressed in your setting but also the percentage of patients who are receiving the appropriate screening, counseling, immunization, and chemoprevention. Select for instructions and examples on conducting chart audits.

Establish Goals for Your Setting

After establishing standards of preventive care and conducting chart audits, the next step is to review the results of your assessment activities. You will then be ready to set goals toward meeting your standards. You may decide to begin by establishing short-term or intermediate goals. A short-term or intermediate goal may be to increase the delivery of one preventive service within the next 6 months. For example, you may decide to immunize 90 percent of patients aged 65 and older against pneumococcal disease within the next year; or you may decide to counsel all smokers who visit your office within the next 6 months.

You will also need to set goals for a systems change to help your setting increase the delivery of clinical preventive services. For example, you may decide to include a health risk profile and preventive care flow sheet in each chart (go to Chapter 6 for example). Once you have an implementation system in place, you may want to add new preventive services, expand the target populations served, or make other changes in your system.

The Worksheet for a Plan to Deliver Clinical Preventive Services (PDF File, 10 KB; PDF Help) will help you decide how to begin delivering preventive services. Your next steps will be to develop a plan to evaluate your delivery of clinical preventive services and then develop a process for implementing your plan, which will be explained in Chapter 4.

Set and Evaluate Short-term or Intermediate Goals

Practice X adopted the following standard: All patients will be asked about tobacco use at all office visits, and all tobacco users will be urged to quit smoking. However, when Practice X conducted a baseline chart audit, staff found that within the last year only 60 percent of their patients had been asked about tobacco use and only 30 percent of these had been urged to quit smoking. Practice X then adopted a short-term goal: Within the next 6 months, at least 85 percent of all patients will be asked about tobacco use and all identified tobacco users will be counseled to stop using tobacco.

Chart audits should be repeated periodically to help you determine how well your setting is meeting its goals. This evaluation should be planned before implementing the Put Prevention Into Practice (PPIP) program.

Design an Evaluation Process

Systems change and evolve over time.

Plan to evaluate your delivery of clinical preventive services while you are designing your implementation program. The evaluation should be based not only on your program goals but also on your progress toward reaching them. In tracking your delivery of clinical preventive services, you may find that a certain process (such as the flow of patients through your setting or the physician reminder system) does not work well and needs modification.

As you design you evaluation process, consider how you will evaluate your providers' delivery of one or more clinical preventive services, and how you will convey your evaluation to them. This intervention has been proven effective in improving vaccine coverage among adults.

Decide how and when to review your progress. To track your progress, schedule frequent, regular opportunities to evaluate the status of your preventive services delivery system. Regularly scheduled meetings offer opportunities for staff to share what is and what is not working for them. Encourage staff to explore all possibilities for changing routines and for attempting new solutions by openly listening and responding to all ideas. Since the implementation process will be reviewed and modified often, there will be many opportunities for creative solutions.

Completing the worksheet (PDF File, 8 KB; PDF Help) will help you design an evaluation process for your setting. Chapter 5 provides specific information to help you evaluate your system for delivering clinical preventive services.

How to Conduct Chart Audits

The following are first steps to take in preparing to conduct a chart audit:

1. Determine the number of charts needed to give you a good overview of the delivery of preventive services in your clinical setting (e.g., at least 10 percent to 15 percent of active charts).
2. Choose a time period to cover; 6 months often is used. In a patient population that is not well-defined, especially in fee-for-service or mixed practices, it is best to measure the provision of preventive services among patients who have visited your setting within a defined period (usually 2 years).
3. Use the appointment log from the chosen time period. Choose two morning and two afternoon appointments per day to reach the desired number of charts to audit for that time period. Be sure to cover all days of the week (including weekends and nights, if applicable) and to include all practitioners.
4. Decide which preventive services to evaluate. You will need to review the preventive care standards your setting has adopted. You may start with one service, such as Pap smears, for your initial assessment. In this way, you can assess each patient's chart and find out whether it is up to date for that particular service (see Simple Chart Audit).

You are now ready to conduct an audit. Three sample audits are presented. These range from simple to complex to more complex (Examples 1, 2, and 3). Of course, you can adapt these forms or choose other forms to suit your needs.

Simple Chart Audit

Select for a simple chart audit (Example 1: PDF File, 51 KB; PDF Help).

Complex Chart Audit

The following instructions and sample chart (Example 2: PDF File, 10 KB; PDF Help) will help you conduct a complex chart audit.

1. Use the information recorded on a patient's flow sheet, health history form, or most recent progress report to complete this form.
2. Use one line for each patient.
3. Record the indicated demographic data in the first three columns.
4. Complete the columns as follows: "Y" indicates "yes," "NA" indicates "not applicable," "N" indicates "no," and "NI" indicates "no information found." Record comments in the last column.

You can begin with the health screening areas cited in the chart. You should decide as a group which preventive services you would like to evaluate. For each patient, record the most recent date a procedure was performed, recommended, or scheduled, regardless of where it was done.

More Complex Chart Audit

The following instructions and Examples 3A-3D will help you conduct a more complex chart audit. These instructions and examples are adapted from an instrument developed by Smith (1999); see also Smith et al. (1999).

1. Create a Protocol for the More Complex Chart Audit
   1. Establish minimum standards of preventive care Example 3A).
   2. Create patient categories for specific age groups by gender. List the minimum preventive care requirements for these categories Example 3B).
2. Use Instruments for Conducting the Audit
   1. Complete Instrument 1: Document Delivery of Assessment and Counseling for Behavioral and Clinical Risk Factors (Example 3C).
   2. Complete Instrument 2: Determine Scores on Delivery of Screening Tests, Immunizations, and Counseling (Example 3D).

If you have gone through this chapter step by step, you will be able to establish standards for delivering clinical preventive services, set goals for meeting these standards, and evaluate your setting's progress. Your standards for delivering preventive services will change over time, requiring you to set new goals and conduct new evaluations using the chart audits described in this chapter.

The next chapter explains how to develop a process that will help you deliver appropriate clinical preventive services to your patients. The key elements of this process are engaging staff, assigning responsibilities for specific tasks, and determining the flow of information and materials.

References

Carney PA, Dietrich AJ, Keller A, et al. Tools, teamwork, and tenacity: An office system for cancer prevention. J Fam Pract 35(4):388-94, 1992.

Chang HC, Zimmerman LH, Beck JM. Impact of chart reminders on smoking cessation practices of pulmonary physicians. Am J RespirCrit Care Med 152:984-7, 1995.

Cohen SJ, Stookey GK, Katz BP, et al. Encouraging primary care physicians to help smokers quit. Ann Intern Med 110:648-52, 1989.

Dietrich AJ, Woodruff CB, Carney PA. Changing office routines to enhance preventive care: The preventive GAPS approach. Arch Fam Med 3(2):176-83, 1994.

Frame PS. Developing office systems for preventive care. Preventive Medicine in Managed Care 1:45-50, 2000.

Smith MM. A patient education site score using needs assessment linked to counseling; evidence from the Texas Put Prevention Into Practice demonstration project. (Doctoral Dissertation, University of Texas at Austin, 1999.) Dissertation Abstracts International 60/09A, 1999.

Smith MM, Meyer B, Goodson P, et al. Chart documentation of clinical preventive services in 9 Texas clinics. Tex Med 95(8):56-62, 1999.

U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion, 1996.

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