Running head: MICROSYSTEM ASSESSMENT

Microsystem Assessment and Innovation Plan

Rachel Soles
University of Detroit Mercy

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Microsystem Assessment and Innovation Plan

The Teen Health Corner clinics (THC) are located in rural Kalkaska County, Michigan,
and are grant-funded school-based health clinics (SBHCs) that sustain operations primarily
through funding by the Child and Adolescent Health Center Program (CAHC) through the
Michigan Department of Community Health (MDCH). The clinics are also sponsored by and
entities of Kalkaska Memorial Health Center (KMHC). A clinical outpatient microsystem
assessment was conducted using the framework outlined in the Dartmouth Institute for Health
Policy and Clinical Practice workbook (2005) in order to identify opportunities for improving
care within the THCs and develop a plan to target a specific issue impacting quality of care.
Although a number of opportunities for improvement and potential threats were
identified during the initial information-gathering phase of the microsystem assessment, the issue
identified by the majority of THC staff as most significant and needing revision was the process
for data collection for reporting and quality improvement (QI). This issue is one that impacts
multiple areas of the clinic microsystem (Purpose, Patients, Professionals, Process, Patterns) and
one that ultimately impacts quality of care delivered as a result.
Assessment
Processes
Although the other microsystem dimensions are each impacted in important ways, the
key finding in this microsystem assessment is that the process of data collection needs
improvement. The current data collection process, using a combination of paper charts, billing
sheets, and a number of logs located in the clinics and requiring a significant amount of time
spent by clinic professionals, is impeding quality improvement and actually represents a threat to
the clinics existence. CAHC informed the THCs in May 2015 that they would not be receiving

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report cards for the current fiscal year because the format of THC reporting for the first two
quarters did not meet CAHC expectations. These report cards are used to support a clinics
request for continuation funding and serve as evidence that the clinic is meeting grant
expectations. Failure to even receive a report card would be viewed negatively when the clinic is
due to apply for continuation funding in 2016.
The Institute for Healthcare Improvement (IHI) states that clinics should aim to collect
the just right amount of data (2014). When a clinic is burdened by too much data or lengthy,
difficult data collection processes, the clinic cannot use data effectively. Currently, the THCs are
required to report out a significant amount of data to CAHC quarterly, but lack the means to do
so efficiently. The THCs do not currently have electronic medical records (EMR), and in fact are
the only two remaining SBHCs in the state without EMR, and so lack the ability to easily access
information required on the quarterly reports.
Purpose
One of the primary stated goals of the THCs is to provide high quality care to clients.
CAHC emphasizes that high quality of care is its first priority and ensures that its grant-funded
clinics provide that care by requiring clinics to report primarily on key adolescent quality
indicators each quarter (MDCH, 2015). In addition to specific quality indicators reported to
CAHC, in order to provide high quality care, the THCs must engage in ongoing QI with a local
focus. The THCs have remained in compliance with CAHC-required QI activities, but have not
undertaken any QI that was not mandated by CAHC. In addition, the data collection process has
hampered meaningful QI activities. QI activities require retrieving a certain number of random
charts quarterly and performing the QI analysis on those charts. There are a number of flaws in
the process currently used in the THCs. An illustrative example is that of the chart completeness

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audit conducted quarterly by the THCs. First, charts are rarely actually selected randomly.
Instead, the medical assistant (MA) or nurse finds the billing sheets from the last quarter and
selects charts from those billing sheets, usually the first twenty charts on the list. Second, the QI
process itself is made more difficult by the paper chart format. Some of the items that are
assessed for completeness are found in as many as four different areas on the paper charts.
This requires the nurses conducting the chart review to look in different locations on the chart,
increasing the chance for errors and decreasing the integrity of the QI process. Third, when the
clinic nurses conduct the completeness analysis, because much of the paper chart data considered
is subject to interpretation (e.g. was nutrition counseling documented?), the clinic nurses often
find that the chart documentation meets expectations when an objective observer might not come
to the same conclusion.
The United States Department of Health and Human Services Health Resources and
Service Administration (HRSA) emphasizes that one of the cornerstones of QI is proper use of
data (2011). Instead of being a burden, data can and should be used to facilitate benchmarking,
establish a baseline performance level, monitor for improvement, and define what is actually
happening in the clinic and with patient outcomes (compared with expected or anticipated
outcomes). Proper use of data allows for meaningful QI in clinical microsystems. Without
meaningful QI, the THCs cannot fulfill their mission of providing care of the highest quality to
their patients.
Professionals
All clinic staff engage in data collection and analysis for reporting to some extent, but
some clinic staff have a heavier burden in the data collection and analysis process, especially
nearing quarterly reporting deadlines. Time spent on data collection, collating, compiling,

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analysis, and report-writing is time that is not spent on direct patient care. In the past, data
collection for quarterly reporting was an onerous task for primarily the MA and clinic nurses
who did the bulk of the work. The quarterly reports require gathering an enormous amount of
data, some of which can be obtained through the billing software through the use of dummycodes, but much that can only be obtained through chart review. Since the first THC clinic
opened in 2006, the THC has conducted a partial chart review process (approximately 10-15% of
quarter charts) and provided data to CAHC based on that. CAHC recently determined that
method of chart auditing was unacceptable and is now requiring 100% chart data in order for
THC to be in compliance with reporting requirements. As a result, the workload for quarterly
reports was projected to increase dramatically. In order to remain in compliance with CAHC
reporting requirements, clinic staff will spend even more time working on data collection and
have less time available for direct patient care. Clinic staff have expressed concern about
increasing the time spent on data collection because of this interference with patient care and
because it is an onerous task. Improved data collection processes should decrease the amount of
time spent on actual data collection and increase available time both for analysis of that data and
for patient care.
Innovation Aim
The identified aim of the microsystem innovation plan is to improve data collection
processes. This in turn should improve the quality of data delivered to CAHC in quarterly reports
and improve the QI processes within the clinics as more comprehensive data becomes available
and the collection and analysis process may be standardized. The clinics must work towards
achieving these goals because of the potential threat to funding that the clinics face as a result of
current data collection processes.

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Methodology

This microsystem assessment and innovation planning coincided with the end of the third
quarter in the 2014-2015 funding year for the THCs. Data collection was conducted at the
Kalkaska THC over a two week period when clinic staff were collecting data for quarterly
reports as well as conducting a number of chart reviews for QI purposes. This collection
occurred during the first quarterly reporting period that staff were asked to conduct 100% chart
reviews for quarterly reports. Data collected included:

Number of charts reviewed

Staff time spent on data collection/analysis for QI and reporting
Methods of data collection
Nature/description of data obtained

Time spent compiling the quarterly reports by the clinic manager was also requested but not
obtained.
Results
Quarterly reports and QI activities were completed at the Kalkaska THC during the twoweek timeframe. THC staff reviewed 138 unduplicated user charts for quarterly reports and 20 of
those charts separately for QI activities. Staff had been requested to write down their time spent
on activities as they did them, but most clinic staff forgot and instead provided estimates of time
spent. By clinic staff estimation, the MA spent approximately 3.5 hours on data collection, the
clinic registered nurses (RNs) spent approximately 9 hours on data collection, the physician
assistants and nurse practitioners spent a total of approximately 1 hour on data collection and
analysis, and the manager time was unavailable.
The methods and activities required for data collection varied by staff role. The MA
needed to gather the paper billing sheets from the previous quarter, remove duplicate user sheets,
manually tally up quarterly reporting items found on the billing sheets, gather 100% of the charts

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from the previous quarter (including tracking down missing charts), and determine insurance
status at visit for some clients. The RNs divided all charts and tallied up quarterly reporting data
(required looking in 3-4 different locations in charts for some data items), conducted chart
completeness audit, obesity audit, and pregnancy prevention audit on 20 random charts using
QI checksheets. The physician assistants and nurse practitioner were called on to verify findings
and explain chart discrepancies and helped locate missing data within a limited number of charts.
Data collected for purposes of the quarterly reports was extensive and varied, including
such items as number of pregnancy tests administered and number of pregnancy tests positive,
number of users with an up-to-date complete physical exam, number of users who have been to
the dentist in the past year, etc. and required collectors to look in several different places in the
chart as well as on billing sheets and in-clinic logs to ensure all data was collected. Data
collection for chart audits was specific to checksheets but also required looking in different areas
of the chart, billing sheets, and logs.
Analysis
The data collection process revealed many of the previously identified staff concerns. As
this was the first time conducting 100% chart reviews for quarterly reports, staff were frustrated
by the process and found it both boring and overwhelming at times because of the sheer volume
of information that they were tallying up. Additionally, staff were frustrated by the limitations of
the paper chart method. The MA had some difficulty locating charts and in fact two charts from
the quarter were not included in the quarterly analysis because they were not found in time. The
RNs were frustrated by having to look in so many different places to find needed information for
the reports. In addition, the volume of charts was overwhelming since they previously would
typically gather 20-25 charts for data collection.

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During the QI process, the charts selected were again not selected randomly. For
example, when the nurses did the pregnancy prevention chart audit/QI, they first used the billing
sheets to identify patients who had a family planning diagnosis. This methodology is flawed
somewhat as the QI pregnancy prevention audit is designed to evaluate all patients who have
received family planning services from the clinic, whether or not they came in for that purpose
during that quarter.
The data collected by THC for quarterly reporting will presumably be acceptable to
CAHC since it now complies with their request for 100% data, however the methods that were
used to achieve this 100% were burdensome to staff and there were numerous opportunities for
errors because of the data collection methods (paper and pencil tallies, charts spread out across
tables, information located in 3-4 different sources). This data collection process must be
changed to ensure that the data may be used effectively both for reporting and QI purposes.
Innovation Opportunities
Improve Data Collection Through EMR Customization
The Agency for Healthcare Research and Quality (AHRQ) states that systems must work
to eliminate health information technology constraints that limit data collection or quality (2014).
The THCs are poised to obtain an EMR system in December 2015. During planning meetings
with the EMR companys representatives in March 2015, the THCs determined that the standard
platform templates lack the capability to store and report out much of the data that is required in
quarterly reports and much of the data that the clinic uses in QI as they are optimized for more
typical meaningful use reporting requirements. The representatives have assured clinic staff that
the EMR is capable of storing and reporting out that information, however in order to achieve
this the clinic would need to order a customized clinic template that would require programmer

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time of 10-20 hours at approximately $200 per hour. Subsequent to that meeting, the clinic
manager determined that cost was too high, particularly since it is likely that future re-formatting
would be required as reporting requirements change. As a result, the THCs plans for data
collection in the future involve using a combination of EMR, a dummy patient chart, paper
billing sheets, and in-clinic logs.
Although the up-front additional costs for template customization are considerable, the
clinic must consider this as the primary option for optimizing data collection. This assessment
process revealed the issues with the current data collection process that are undermining quality
of care and the experience of staff. Although the clinic does not yet have EMR, the current data
collection plan for when EMR is in place call for data collectors to look in even more places to
locate needed data than they do currently. The increased cost must be balanced against the staff
time lost to this data collection and the more difficult-to-quantify potential for increased quality
with improved data collection.
Improve QI Activities with Improved Data
The current QI process at the THCs technically meets CAHC criteria, but rarely results in
meaningful analysis, change, or improvement. The THCs do not currently participate in
benchmarking, although the potential for benchmarking exists with nearly 100 SBHCs around
the state. When data is effectively collected, it can be used for meaningful QI, including for
benchmarking, comparing effectiveness, establishing a baseline, etc (HRSA, 2011). AHRQ
recommends that all practices engage in effective data collection in order to define clinical
performance measures and set benchmarks, and that this is necessary to determine quality of care
(2013).

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Given the concerns of clinic staff and the urgency of the threat, the THCs must take steps
to improve the data collection process. Doing so will enhance THCs ability to comply with
CAHC expectations for data reporting and analysis and enable the clinic to engage in more
meaningful quality improvement activities. An effective way to accomplish this is to customize
the EMR system template to clinic needs. The timing is right, as THC staff can participate in
designing the template to meet both clinic flow and data collection needs before EMR is
implemented in the clinic at all. Failing to address this process issue will continue to have
potential negative impacts on quality of care as well as on clinic professionals.

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References

Agency for Healthcare Research and Quality. (2013). Module 7: Measuring and benchmarking
Clinical performance. Retrieved from: http://www.ahrq.gov/professionals/preventionchronic-care/improve/system
Agency for Healthcare Research and Quality. (2014). Module 5: Improving data collection
across the health care system. Retrieved from:
http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system
Dartmouth Institute for Health Policy and Clinical Practice. (2005). Outpatient primary care
greenbook. Retrieved from: https://clinicalmicrosystem.org/workbooks/
Institute for Healthcare Improvement. (2014). Across the chasm: Six aims for changing the
health care system. Retrieved from:
http://www.ihi.org/resources/Pages/ImprovementStories/AcrosstheChasmSixAimsforCha
ngingtheHealthCareSystem.aspx
Michigan Department of Community Health. (2015). CAHC program data. Retrieved from:
http://www.michigan.gov/cahc.
U.S. Department of Health and Human Services Health Resources and Service Administration.
(2011). Quality improvement. Retrieved from:
http://www.hrsa.gov/quality/toolbox/508pdfs/qualityimprovement.pdf