With the exception of Utilization Management, all of these components have elements which are applicable to School-Based Health Centers and will be discussed below.

A.Standards for Quality Management and Improvement

A quality management and improvement program is the framework within which the School-Based Health Center improves the quality of clinical care and service to patients. The SBHC must be able to provide written documentation of the following:

• a description of the quality improvement program which details program structure and content. The description must be approved by the SBHC's governing body, reviewed annually and updated as necessary.
• designation of a senior administrator who is responsible for the program.
• substantial involvement of the medical director in the program.
• formation of a committee that oversees quality improvement activities. The role, structure and function of the committee, as well as frequency of meetings, are specified in the program description. Records of committee meetings are kept.
• an annual quality improvement work plan which includes objectives and planned activities for the year, monitoring of previously identified issues, and an evaluation. The plan includes activities related to both the quality of clinical care and the quality of service provided to patients. The selection of clinical issues reflects the population served in terms of age, disease categories and special risk status. The selection of clinical issues includes high-volume, high-risk services and the care of acute and chronic conditions. If practice guidelines are used, they are based on reasonable scientific evidence, updated periodically and communicated effectively. Quality indicators are objective and measurable. Appropriate methods and frequency of data collection are used for each indicator. The committee provides regular oral reports to the SBHC governing body, and submits a written annual report related to the work plan.
• standards for timeliness of preventive care appointments, primary care appointments, behavioral health services and urgent care as well as access to after-hours care. Data is collected and analyzed to measure performance against the standards. Opportunities for improvement are identified and acted upon. The effectiveness of interventions is measured.
• a formal mechanism for informing patients about services provided, access to services, charges for services, billing and collection policy, appointment scheduling, and provisions for after-hours emergency coverage. This information is available in the language(s) of the major population groups served.
• a timely and organized system for resolving patient complaints and formal grievances. The system includes procedures for registering complaints and grievances, for ensuring that a resolution is provided in a timely manner, and for aggregating and analyzing the data to use for quality improvement purposes.
• periodic assessment to assure patient satisfaction with services. Patient issues are identified and patients are surveyed to collect relevant data. The data is analyzed, opportunities for improvement are identified, and interventions are implemented. The effectiveness of interventions is measured.
• linkage between the quality improvement program and other management functions such as annual employee performance evaluations, patient grievance resolution, provider recredentialing, and vendor contracting.
• requirement to participate in quality improvement activities is incorporated into all provider contracts and employment agreements.

B. Standards for Credentialing and Recredentialing

The School-Based Health Center must have a written policy and procedures for the credentialing process which include original credentialing and recredentialing of all physicians and other licensed independent practitioners who fall under its scope of authority. The credentialing policy and procedures must be approved by the SBHC's governing body. A credentialing committee must be appointed to identify practitioners who fall under the SBHC's scope of authority, and to make recommendations regarding credentialing decisions. Recredentialing must occur at least every two years. The credentialing policy must include procedures for reducing activities of, suspending or terminating practitioners. The credentialing policy must also include the right of practitioners to review information collected in support of their own credentialing applications.

At a minimum, the credentialing process obtains and reviews verification of the following primary sources:

• current valid license to practice
• valid DEA or CDS certificate, as applicable
• education and training of practitioners including graduation from the appropriate schools(s) and attainment of appropriate degree(s) or certifications; for physicians, completion of residency and Board Certification, as applicable.
• work history
• the status of clinical privileges at the hospital(s) designated by the practitioner as the primary admitting facility, as applicable
• current, adequate malpractice insurance
• five years of professional liability claims history through National Practitioners Data Bank

The credentialing application must contain statements by the applicant regarding:

• reasons for any inability to perform the essential functions of the position, with or without accommodation.
• lack of present illegal drug use
• history of loss of license to practice
• history of felony conviction
• history of loss or limitation of privileges or initiation or disciplinary action
• attestation to the correctness/completeness of the application

The recredentialing process must also include review of data from:

• patient complaints
• quality improvement evaluations
• patient satisfaction surveys
• medical record reviews

C.Standards for Patient Rights and Responsibilities

The School-Based Health Center must have a written policy that addresses the rights and responsibilities of patients. At a minimum the policy must address the rights of patients to:

• voice grievances about the care provided and expect resolution of grievances in a timely manner
• be provided with information regarding the SBHC organization, its services, and qualifications of the practitioners under the SBHC's scope of authority
• participate in decision-making regarding their health care and
• be treated with respect and recognition of their dignity and need for privacy and the responsibility of patients to:
  • cooperate with those providing services
  • provide, to the extent possible, information that professional staff need in order to provide appropriate care
  • follow instructions and guidelines given

The policy on patients' rights and responsibilities must be approved by the SBHC's governing body. The SBHC must provide a copy of the policy to all practitioners falling under its scope of authority, and directly to patients through posting it in the facility's reception area or through making copies available in a brochure rack or other appropriate location.

D.Standards for Preventive Health Services

The School-Based Health Center must adopt preventive health guidelines for the prevention and early detection of disease in order to reduce undesirable variation in the process and outcome of care. The guidelines must be specific to the age, sex and risk status of patients. Each guideline describes the prevention or early detection intervention, the recommended frequency, and the indications or conditions under which the intervention is required.

The SBHC must engage in an active process of choosing preventive health guidelines appropriate to its patient population and it operation. The guidelines may be adopted from nationally recognized organizations. If the SBHC develops its own, the process must include the use of established sources of scientific research and recommendations. The scientific basis or authority upon which each preventive health guideline is based must be documented.

The SBHC must inform parents and patients about, and encourage parents and patients to use, the preventive health services available to them. The SBHC must annually evaluate the use of preventive health services and take action to improve the use of at least two of these services, as appropriate.

E. Standards for Medical Record Review

The School-Based Health Center must have a written policy that ensures consistent and complete documentation in the medical record. Medical records must be maintained in a manner which is current, detailed, organized and permits effective and confidential patient care and quality review. The policy should include periodic sampling of medical records for review by an appointed committee. This review should document the following:

1.Each and every page in the record contains the patient's name or ID number.

2.Personal/biographical data includes patient full name and address and parent/ guardian(s) name, address, home and work telephone numbers.

3.All entries in the medical record contain author identification.

4.All entries are dated.

5.The record is legible to someone other than the writer.

6.Significant illnesses and medical conditions are indicated on a problem list.

7.A flow sheet of immunizations and health maintenance is included.

8.Past medial history (for patients seen three or more times) is easily identified and includes serious accidents, operations, and illnesses. For children 18 years and younger, the history includes prenatal care and birth.

9.For patients 14 years old and over, notation concerning use of cigarettes, alcohol and substance abuse is present (for patients seen three or more times).

10.The history and physical documents appropriate subjective and objective information for presenting complaints.

11.Are lab and other studies ordered as appropriate?

12.Are working diagnoses consistent with findings?

13.Are plans of action/treatment consistent with diagnosis(es)?

14.Encounter forms or notes have a notation, when indicated, regarding follow-up care, calls, or visits. The specific time of return is noted in weeks, months or PRN.

15.Unresolved problems from previous office visits are addressed in subsequent visits

APPENDIX B

SAMPLE QUALITY ASSURANCE DOCUMENTS FOR ADOPTION OR ADAPTION BY SCHOOL-BASED HEALTH CENTERS

Introduction

The purpose of this document is to provide sample program descriptions, policies and procedures which meet the quality assurance standards described in Appendix A, and which a School-Based Health Center can adopt or adapt for its internal use.

A. Quality Management and Improvement Program

A Quality Improvement Committee shall be established to develop a written Quality Improvement Plan, implement the Plan, issue an annual written Quality Improvement Report to (name of governing board), update the Plan annually and administer the patient grievance process. The Committee shall be structured as follows:

1. Composition. The Quality Improvement Committee shall consist of (number) individuals as follows:

Medical Director

(at least two others to include both clinical and administrative personnel)

2. Scope. The Quality Improvement Committee is responsible for all aspects of Quality Assurance. Broadly defined, this includes administration of six overlapping functions:

• evaluation and management of clinical quality, including standards for medical records
• evaluation of access and service issues, including patient satisfaction
• patient grievance process
• overall program evaluation

The specific activities associated with each function are described below:

Evaluation and Management of Clinical Quality

The objective of this activity is to improve the quality of health services by systematically monitoring practice patterns and reporting results to the practitioners involved. The core of the process is education, and studies are designed to identify those areas where quality of care and cost effectiveness can be improved through feedback and education.

Study topics are chosen based upon patient demographic and disease characteristics. Study designs are based on objective, measurable, outcomes-based standards that directly relate to the issues of:

• accuracy and completeness of the medical record,
• appropriate use of services and medication,
• coordination and continuity of care,
• follow-up of identified problems,
• health education and promotion

The goals of the studies are to determine whether patients/parents are informed of health conditions and the services available to them, and services are delivered appropriately. To accomplish this, review efforts encompass all services - preventive, primary, specialist and ancillary.

The Committee is responsible for all phases of the quality improvement process including:

• prioritizing review topics,
• developing practice guidelines and standards and communicating these prospectively to affected providers,
• setting review schedules,
• developing data collecting strategies,
• interpreting screening and review results,
• recommending corrective action and documenting effectiveness, and
• recommending other actions/sanctions to achieve the desired behavior.

Evaluation of Access and Service Issues

The Quality Improvement Committee is responsible for assessing patient satisfaction with the quality of service provided by administration and providers. The availability and acceptability of primary and preventive care, and access to routine, urgent, specialty and emergency care will be part of this assessment.

Patient Grievance Process

The Quality Improvement Committee is responsible for organizing and managing the patient grievance process. Although it is anticipated that most patient problems can be resolved by simply making the provider or administrator aware of the situation, if the issue is not resolved at the provider/clinic level, there are provisions for Committee involvement in the case.

Overall Program Evaluation

To assure that the Quality Improvement Program is as effective and efficient as possible, the Quality Improvement Committee reviews all aspects of the program annually. Review criteria evaluate study methodologies, trends in clinical service indicators, effectiveness of corrective actions, compliance with process guidelines and standards, and timeliness of responses. In carrying out this evaluation, the Committee reviews the materials and documentation used in making decisions and audits records and logs that support the process. Review results along with relevant documentation are sent to the (name of governing body).

3. Responsibilities. The (name of governing body) has overall responsibility for the quality of care delivered to patients. The (name of governing body) delegates administrative responsibility for this activity to the Medical Director who works with the Quality Improvement Committee to carry out the process.

The Medical Director is Chairman of the Committee and is responsible for carrying out the policies and procedures outlined. This responsibility covers not only administering the process itself, but also, as clinical manager, translating process standards and recommendations into practice. Specifically, these responsibilities include communicating standards and taking any necessary action to assure that they are met, communicating results of reviews and recommendations to providers, answering questions and clarifying policy, and responding to complaints and Level 1 grievances, and communicating grievance decisions to complainants.

The (title of staff person) is responsible for day-to-day operation of the Quality Improvement Program including organizing meetings, conducting quality improvement studies and follow-up, researching grievances, maintaining all records and logs to support the quality improvement process, and organizing the reports and documentation needed for Quality Improvement Committee meetings.

The Committee members provide general consultation and recommend all quality assurance policies and administrative actions. Specifically, for quality improvement, the Committee chooses study topics, selects indicators, sets practice standards, interprets research findings, and recommends actions to address identified problems. For Level 2 grievances, the Committee reviews cases and recommends actions. Committee decisions are based on majority vote.

4. Frequency of Meetings. The Quality Improvement Committee sets monthly meetings but this may be adjusted to accommodate holidays and other commitments. Regardless, however, the Committee meets at least quarterly. In addition, meetings may be added to the monthly schedule as needed. Meetings may be face-to-face or conference call.

5. Minutes. Minutes will be kept of each meeting. At a minimum these will include:

• where, who, date, time;
• approval of minutes from last meeting;
• review of quality improvement and grievance reports;
• problems identified including a summary of discussion, conclusions, recommendations, actions taken, follow-up, and method for re-evaluation;
• unfinished business;
• new business; and
• adjournment.

B. Credentialing and Recredentialing Policy

Purpose

The purpose of the credentialing process is to assure that providers practicing at meet certain criteria for initial appointment and that these qualifications plus patient satisfaction survey and quality improvement results are re-evaluated on a regular basis.

Basic Criteria

A. Physicians

The following criteria must be met for routine acceptance as a provider. Physicians must maintain compliance with all criteria as a condition of continued participation.

1. Accurate completion of credentialing application and required documentation.

2. Current, license to practice medicine in the State of Colorado. If the license is restricted, the restriction has been reviewed and deemed acceptable.

3. Board certification in their field of medical practice. An exception may be made on an individual basis by the Credentialing Committee for physicians who are board qualified, or bring unique and necessary skills to .

4. Current unrestricted staff membership and admitting privileges granted by a general or psychiatric hospital in the service area, if applicable.

5. Have a DEA number, if appropriate.

6. Policy of professional liability insurance with a minimum of $1 million/$3 million coverage.

7. No felony convictions or pleas of guilty or nolo contendre to felony charges.

8. No conviction of any federal or state law regulating the possession, distribution or use of any controlled substance.

9. Good standing with Medicare and Medicaid in any state in which there is or has been a license.

10. No history of revocation or suspension of privileges and no relevant permanent restrictions by hospital, medical review board, licensing board or other medical body or governing agency.

11. No habitual intemperance or excessive use of any habit forming drug or controlled substance.

12. No physical or mental disability as to render the licensee unable to perform medical services with reasonable skill and with safety to the patient.

13. Provision of high quality, appropriate, timely care. (This is initially evaluated through review of malpractice history, employment history, and other information available on the application.)

B. Physician Assistant, Nurse Practitioner, Certified Midwife, Licensed Social Worker

The following criteria must be met by a non-physician provider. Providers must maintain compliance with all criteria as a condition of continued participation.

1. Accurate completion of credentialing application and required documentation.

2. A current unrestricted Colorado license and/or Colorado state certification.

3. Certificate and/or diploma from an appropriate training program.

4. Policy of professional liability insurance with a minimum of $1 million/$3 million coverage. If provider is covered under a group policy, the provider's name must be individually listed on the policy document. Coverage minimum may be waived if provider governmental immunity applies.

5. No felony convictions or pleas of guilty or nolo contendre to felony charges.

6. Good standing with Medicare and Medicaid in any state in which there is or has been a license.

7. No conviction of any federal or state law regulating the possession, distribution or use of any controlled substance.

8. No habitual intemperance or excessive use of any habit forming drug or controlled substance.

9. No history of revocation or suspension of privileges and no current restrictions by licensing board or other medical body or governing agency.

10. No physical or mental disability as to render the licensee unable to perform medical services with reasonable skill and with safety to the patient.

11. Provision of high quality, appropriate, timely care. (This is initially evaluated through review of malpractice history and other information available on the application.)

Continued Status

Providers must notify within no more than five days of:

1. Any judgement by a State Board of Medical Examiners.

2. Change in Medicare and/or Medicaid provider status, suspension or exclusion.

3. Any suspension or loss of hospital staff privileges, state licensure, or state controlled substance certificate.

4. Any physical or emotional impairment to his/her ability to practice medicine.

5. Any felony arrests or convictions.

Quality Assurance

Providers must be willing to participate in, accept the rules of, and comply with the requirements of 's Quality Assurance Program. This may include review of medical records for compliance with practice guidelines and quality improvement standards. When a question is raised regarding the appropriateness or quality of care which is at variance with established norms, the burden shall be on the provider to demonstrate that his/her practice is otherwise appropriate.

Patient Relations

Each Provider shall conduct practice in a manner that maintains positive provider-patient relationships.

Re-credentialing Criteria

Providers are re-credentialed every two years, or immediately upon notification that one of the events listed under "Current Status" has occurred. This process reconsiders the Basic Criteria listed above during the interval since the last credentialing, as well as:

1. Patient satisfaction as measured by number and type of patient complaints as well as patient satisfaction surveys.

2. Results of record review and quality assurance studies.

3. Provider support of philosophy and concept of

4. Filing of malpractice claims since initial certification.

Responsibilities

The (name of governing body) will appoint a Credentialing Committee made up of (number) individuals, at least one of which is a provider.

The (title of staff person) will be responsible for collecting and verifying applicant information and maintaining credentialing records. The credentialing process will include inspection of application documents and review of information from the National Practitioner Data Bank and the State Board of Medical Examiners.

The findings from the investigation will be compared against a check-list of the criteria. The check-list and any supporting documentation for a negative finding will then be submitted to the Credentialing Committee to make appointment decisions.

The provider application, the credentialing and recredentialing check-lists, and any sustaining information are maintained by for each provider. All credentialing documentation will be kept confidential with access restricted to the (title of staff person), members of the Credentialing Committee, and the Medical Director.

Recredentialing materials are requested from the provider four months before his/her recredentialing begins and review is completed within 60 days of receipt of the complete application. The recredentialing process is similar to the initial one except that results of quality improvement studies, including medical record audits, and patient satisfaction surveys are summarized along with the credentialing criteria for the Credentialing Committee.

Providers who meet the Basic Criteria and have satisfactory quality improvement results will be forwarded to the Credentialing Committee with a recommendation for automatic renewal. Providers who fail any of the Basic Criteria and/or have questionable quality improvement or patient satisfaction results will be forwarded for review by the Committee. The Committee may decide upon unconditional renewal, renewal with recommendations for improvement, renewal with restrictions, or non-renewal of appointments. In cases where renewal is conditional, the Committee recommends measures to correct the problem and establishes a time frame for improvement. If the provider fails to correct the problem within the specified time, the case is referred to the (name of governing body) for follow-up that may include termination of the provider.

Credentialing decisions are communicated to providers in writing. If the Committee needs more information from the provider to make a decision, it requests the information in writing and specifies a date for response. Recredentialing decisions along with any problems, corrective actions, and time frames are also communicated in writing.

Reporting and Final Approval

Recommendations of the Credentialing Committee are reported to the (name of governing body) for final approval.

C. Patient Rights and Responsibilities

Patient Rights and Responsibilities*

All patients of have the right to:

• participate in all decisions involving their care or treatment;
• give informed consent for all treatment and procedures;
• know the names, professional status, and experience of the staff that are providing care and treatment;
• know if the facility is participating in teaching programs, research, and/or experimental programs;
• refuse any drug, test, procedure, or treatment;
• care and treatment that is respectful, recognizes a person's dignity, and provides for personal privacy to the extent possible during the course of treatment;
• be informed of the facility's rules and regulations as they apply to the patient;
• be informed prior to the initiation of care or treatment of the standard charges of services and based upon insurance information supplied by the patient, to be given an estimate of any copayment, deductible, or other expenses that will not be covered by a third party payer and must be paid by the patient.

All patients of have the responsibility to:

• follow their health care provider's instructions, and to ask if instructions are not understood;
• give full and honest information on all forms and in all conversations. Patients should bring a list of all medications being taken and information about any conditions being treated;
• report any changes in general condition, symptoms, allergies, etc.
• in case of emergency, call the emergency phone numbers provided and notify of any treatment received;
• keep appointments and be on time;
• treat the staff and other patients with respect;
• provide any insurance information;
• report any changes to your address or phone number;
• pay your bills promptly, or call our patient representative if there are financial difficulties.

* adapted from document provided by Valley-Wide Health Services, Inc.

APPENDIX C

QUALITY IMPROVEMENT WORK PLAN

FOR SCHOOL-BASED HEALTH CENTERS

IN COLORADO

Introduction

In late 1997, the Colorado Association for School-Based Health Care (CASBHC) established a three-year objective to:

The action plan called for establishing three clinical outcome measures in year one (October 1, 1997 through September 30, 1998), two in year two, and the final two in year three. The expectation is that all Organizational Members of CASBHC will adopt these measures as their Quality Improvement Work Plan. CASBHC will assist its members in collecting , aggregating and analyzing data related to the measures, will use the comparative data to identify best practices and establish benchmarks, and will identify needs for technical assistance and training for School-Based Health Centers statewide.

Below are the clinical outcome measures developed to date in a format of a work plan which can be easily adopted by SBHC's.

Will conduct chart reviews on the following clinical outcome measures. Depending upon the results of these reviews, an action plan will be developed to improve compliance where necessary. Follow-up chart reviews will be conducted six to twelve months after implementation of the action plan to measure impact of the plan and make adjustments, if necessary. By September 30, 2001, the target compliance for all measures will be achieved.

Clinical Outcome Measures

1.CHILDHOOD IMMUNIZATIONS

A. For children who have had their sixth birthday but have not had their thirteenth birthday, and are patients in the SBHC, the following immunizations will have been provided and charted:

• 4-5 DPT
• 3-4 Polio
• 1 MMR
• 3 HepB
• 1 Varicella (or documentation of having the disease)
• Children six years of age should have 5 DPT and 4 Polio immunizations. However, DPT #5 and Polio #4 are not necessary if DPT #4 and Polio #3 were given after the child's fourth birthday. For these children, DPT #5 and Polio #4 need not be included in the immunization plan.

B. For children who have had their thirteenth birthday and are patients in the SBHC, the following immunizations will have been provided and charted:

• 2 MMR
• 3 HepB
• 1 Td
• 1 Varicella (or documentation of having the disease)

TARGET COMPLIANCE: 90% for all except Varicella and Td; 75% for Varicella and Td.

RATIONALE: Immunizations are an effective intervention for preventing disease in children and adolescents, and are a well recognized indicator of quality in a primary care setting. This clinical outcome measure meets the requirements of the "Recommended Childhood Immunization Schedule, United States, January through December, 1999" issued by the Centers for Disease Control (CDC) and approved by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians. The CDC schedule has been adopted by the Colorado Department of Public Health and Environment and by the Colorado Clinical Guidelines Collaborative.

The clinical outcome measure is also consistent with the HEDIS 3.0/98 standard for the immunization of two-year-olds published by the National Committee for Quality Assurance. While immunization against H. influenza Type B (HiB) is recommended for two-year-olds, we have not included it in the measure because, immunologically, normal children age five years and older do not need HiB vaccine. If the vaccine was not received prior to reaching school-age, the SBHC should not include it in a child's school-entrance immunization plan.

Similarly, children six years of age should have 5 DPT and 4 Polio immunizations. However, DPT #5 and Polio #4 are not necessary if DPT #4 and Polio #3 were given after the child's fourth birthday.

The measure exceeds the HEDIS 3.0/98 standard for the immunization of thirteen-year-olds in that HEDIS does not require Td at this age. The level of compliance for Td is lower than for other immunizations because, in the past, Td was recommended at ten years after the last DPT which, for most children, would be at age 15 to 16 rather than at age 11 to 12. The new recommendation is that Td be given at 11 to 12 years of age if at least five years have elapsed since the last DPT. Td boosters are recommended every ten years thereafter.

It should be noted that the compliance level for Varicella is also lower than for other immunizations because this requirement was added to HEDIS in 1998, and it will take at least two years before all children can be evaluated for compliance.

AUDIT PROCESS: Twenty-five charts at each SBHC site will be audited. Each site will identify one of the two age groups to be audited (children who have had their sixth birthday but have not had their thirteenth OR children who have had their thirteenth birthday). The site will generate a list of children who 1) made at least one visit (of any type) between September 1, 1998 and February 28, 1999 and 2) had the appropriate birthday prior to August 31, 1999. The list should include patient name, birthdate and date of qualifying visit. There must also be a total count of children on the list. Upon arrival, the auditor will randomly select 30 children from the list. Staff at the site will pull the selected charts and provide the auditor with space to work. Original records will not be removed from the site. However, the auditor will ask staff to copy one of the audited records and black out the patient name. This copy will be removed for purposes of testing rater-to-standard reliability.

The auditor will check the first 25 charts for the following:

birthdate (must agree with age group being audited)

evidence of visit between September 1, 1998 and February 28, 1999

evidence of immunizations per standard appropriate for age group

Compliance with each antigen will be tracked separately. In addition, children who have completed all required immunizations with or without Varicella will be noted.

Should the chart indicate 1) that the recorded birthdate makes the child ineligible for audit, 2) that there was no visit within the required time period, 3) that an immunization was not given due to a valid contraindication such as allergy to wheat, a religious exemption, or a personal exemption (parental refusal), or 4) that the child's immunization status has been evaluated, gaps have been identified, a catch-up plan has been developed, and immunizations have been administered according to the plan, that file will be laid aside and not audited. The next chart in line will be selected to take its place.

The auditor will provide a separate report for each site showing compliance rates for each immunization separately, for all immunizations required for the selected age group with and without Varicella.

When all sites are complete, the auditor will calculate an aggregate compliance rate, to include all sites, and weighted by the number of children falling into the audit criteria at each site. This aggregate compliance rate will be used as the "benchmark" for purposes of comparison. Sites should not be compared to each other, but only to the benchmark.

2. WELL-CHILD AND WELL-ADOLESCENT VISITS

A. For children who have had their sixth birthday but have not had their thirteenth birthday, and were enrolled in the SBHC for at least six months, one comprehensive well-care visit will have been completed within the past twenty-four months.

B. For children who have had their thirteenth birthday, and were enrolled in the SBHC for at least six months, one comprehensive well-care visit will have been completed within the past twelve months.

The SBHC may either have performed the visit on-site, or may have obtained evidence from parent/guardian/health plan/primary care physician of a visit performed elsewhere. A comprehensive visit is defined as having received the following: health history, including psychosocial issues and risk factors, physical exam as directed by history, immunizations as needed, and laboratory, vision and hearing screenings as indicated by history.

TARGET COMPLIANCE: 50%

RATIONALE: Well-care visits are an effective means of detecting disease and promoting good health habits. The American Academy of Pediatrics and the American Medical Association's Guidelines for Adolescent Preventive Services (GAPS) recommend a well-child visit every two years after age five, and an adolescent visit every year after age twelve. This standard is consistent with HEDIS 3.0/1998 published by the National Committee for Quality Assurance.

AUDIT PROCESS: Same as above. Auditor will check each selected chart for evidence of a well-care visit per the standard for the appropriate age group. It should be noted if a well-care visit was performed that did not meet the definition of a comprehensive visit specified above (i.e. sports or camp physical).

3. QUALITY OF MEDICAL RECORD KEEPING

The School-Based Health Center shall keep medical records consistent with the guidelines published by the National Committee for Quality Assurance (see Attachment 1).

TARGET COMPLIANCE: 100% for each of guidelines applicable to age.

RATIONALE: Consistent and complete documentation in the medical record is an essential component of quality patient care. The National Committee for Quality Assurance (NCQA) has published guidelines for medical recordkeeping practices which have become the professional standard. Records kept in accordance with these guidelines facilitate effective medical care and continuity of care among practitioners.

AUDIT PROCESS: The medical records selected for the auditing of measures 1. and 2. above will also be used for this measure. The auditor will prepare an NCQA medical record review summary sheet for each selected medical record, indicating compliance or non-compliance with each of the applicable elements. The summary sheets will then be aggregated and a compliance score given for each guideline.

4. PATIENT SATISFACTION

The School-Based Health Center shall assess patient satisfaction at least once per year. The SBHC shall administer the survey instruments developed by CASBHC (see Attachment 2), or shall develop surveys appropriate for patients (i.e. children six years of age or older) and for patients' parents or guardians. Appropriate sample size must be identified for each population and for each site. The surveys shall address, at a minimum, the following issues: access to care including ease of making appointments, time spent waiting to see the practitioner, attention given to patient's needs, thoroughness and appropriateness of treatment, scope of services provided, cultural sensitivity of practitioner, how much patient was helped by the care received, and overall perception of the quality of care. The survey results are reported to practitioners and are used to identify opportunities for improvement. Interventions to effect improvement are implemented, and remeasuring occurs.

TARGET COMPLIANCE: Improvement shall be shown in 100% of the issues targeted for improvement after the initial survey.

RATIONALE: Patient satisfaction surveys are recognized as an important tool for quality management and improvement. The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) requires providers to administer a patient satisfaction survey. The National Committee for Quality Assurance (NCQA) also requires managed care organizations to assess member satisfaction. The surveys are used to discover areas of interaction that are working well and to identify opportunities for improvement.

AUDIT PROCESS: SBHCs are encouraged to administer the patient satisfaction survey developed by CASBHC in order to take advantage of comparative data. The CASBHC survey can be used alone, or in conjunction with a site specific instrument. If the CASBHC survey is not used, the Auditor shall obtain a copy of the site's instrument(s) with the dates the survey was administered and sample size, the resulting report, and the improvement plan. The auditor shall review the survey questions to insure that the required issues are addressed.

5. ASSESSMENT OF TOBACCO EXPOSURE

For all children seen in the SBHC, the SBHC practitioner shall assess tobacco exposure and use as appropriate for age, and shall indicate in the medical record that the assessment was performed.

TARGET COMPLIANCE: 90%

RATIONALE: The American Medical Association's Guidelines for Adolescent Preventive Services (GAPS) recommends that all adolescents should be asked annually about their use of tobacco products including cigarettes and smokeless tobacco. According to the AMA, more than 4 million adolescents smoke regularly and half a million males between 12 and 17 years of age use smokeless tobacco at least weekly. Tobacco use by youth is widely recognized as a "gateway" that precedes use of other drugs. More than two-thirds of adults who smoke began their habit during adolescence. Conversely, adolescents who do not begin smoking are unlikely to begin later.

It is also widely recognized that exposure of young children to second-hand smoke exacerbates respiratory diseases such as asthma, and that children of parents who smoke are more likely than other children to become smokers.

AUDIT PROCESS: The selection of charts shall be the same as in measure 1. above. The auditor will look for an indication in the chart that tobacco exposure was assessed at least once during the previous twelve months.

For information purposes, the auditor shall obtain two samples of each piece of tobacco- related patient education literature used for counseling purposes, and the name of the cessation program to which referrals are made. In addition, the auditor will ask at least one practitioner present at the time of the audit whether he/she feels confident addressing the issue of tobacco exposure and will note the remarks made. The auditor will ask the program administrator whether any training regarding tobacco exposure was provided to practitioners in the past twelve months, and will note the response in detail, including the date and type of training, name of trainer, and any audio-visual or printed materials used. This information will be used to anecdotally assess the ability and confidence of SBHC practitioners to address the issue of tobacco exposure and use with children and parents, and, when necessary, to recommend or provide training opportunities for practitioners.

6. PEDIATRIC ASTHMA

All children who have been identified by the SBHC as having asthma will receive, at a minimum, the following components of care:

Assessment:

1. Record "personal best" peak flow
2. Identify severity of disease using the National Heart, Lung, and Blood Institute's classifications: 1) mild intermittent, 2) mild persistent, 3) moderate persistent, 4) severe persistent
3. Identify disease triggers
4. Education:
   1. What is asthma?
   2. How to use a peak flow meter
   3. How to use a nebulizer, metered dose inhaler and/or spacer devices

   Treatment:

   1. Identify peak flow values for each comfort zone (green, yellow, and red)
   2. Develop an Action Plan for each zone
   3. Prescribe (or make note of, if prescribed by another provider) drugs to be used for quick relief and long-term control, consistent with the National Heart, Lung, and Blood Institute's guidelines for the patient's identified disease severity
   4. Recommend time for next visit

TARGET COMPLIANCE:90%

RATIONALE: Asthma is the most common chronic illness in children. The most recent national survey conducted by the National Heart, Lung, and Blood Institute in 1996 found that 6.3% of children in the United States are affected. According to the Colorado Children's Campaign 2000 KidsCount in Colorado!, "The incidence of and mortality due to asthma have been increasing at alarmingly high rates. The number of children with asthma has more than doubled in the past 15 years." The most substantial increase has occurred in children from infancy to four years of age.

In Colorado, more than 67,000 children have asthma. According to the state epidemiologist, death rates from asthma doubled from the mid-1970s to the mid-1990s. It is clear that asthma is more severe among the inner-city poor. Although asthma is treatable, these children often have inadequate access to the most effective care since asthma medications and equipment can be very expensive for low-income families.

Asthma is the leading cause of school absence among all children, across ethnicity. Nationally, asthma accounts for 10 million lost school days annually. Asthma is also the third-ranking cause of hospitalization among children under 15.

AUDIT PROCESS: The SBHC will produce a list of patients who 1) made at least one visit (of any type) between September 1, 1999 and August 31, 2000 and 2) have had a primary or secondary diagnosis of asthma at any time. Diagnosis of asthma will be defined as an ICD-9-CM Code with the first three digits of 493, regardless of any additional digits after the decimal that may be indicated.

The auditor will randomly select 25 patients or 100% of the patients on the list, whichever is less, and request their medical records. Each chart will be reviewed for the presence of each component included in the measure. Compliance with each component will be tracked separately. The auditor will provide a separate report for each site showing the total number of charts audited, the number of charts in compliance and the percent of charts in compliance for each component separately. In addition, the auditor will indicate the number and percent of charts that were in compliance for all components.

7.CHILDHOOD AND ADOLESCENT DEPRESSION

The goals of this outcome measure are 1) to improve the early identification of children and adolescents at-risk for depression and 2) to improve the continuity of care for patients at-risk of depression by closing the communication loop between the medical provider and the mental health provider practicing in a school-based health center.

The following actions should be undertaken by the medical provider and evidenced in the medical record.

Assessment

Initial: Children who have had their sixth birthday, and have had a will-child visit in the past twelve months, will have responded to at least three questions intended to assess emotional well-being.

Follow-Up: Whenever a positive result is obtained on initial screening, the provider will perform a more in-depth interview or will ask the child to complete a self-administered depression scale, appropriate for age, which has proven validity and reliability. The advantage of using a depression scale is that it can be repeated periodically to measure improvement in the child's emotional health.

Education

Whenever a positive result is obtained on follow-up assessment, the child will be provided with the following information:

What is depression?

When should you seek help?

Who should you seek help from?

Referral

Whenever clinically significant depression is identified through follow-up assessment, the medical provider will make a referral to an appropriate mental health provider. Referrals should be categorized in the medical record as follows:

Emergent: Provider believes child may harm self or others; active ideation or suicide or running away is present. Child should not leave the health center without receiving counseling. If therapist is not available, parents should be contacted and child should be transported to an emergency room. Guidelines for 72-hour hold should be followed.

Urgent: Child is experiencing a life crises which provider believes may escalate. Child should be seen by a therapist within 48 hours.

Routine: Child is experiencing clinically significant depression but is not in immediate danger. Child should be seen by a therapist with 7 to 14 days.

Disposition

Whenever a referral is made, the medical provider will attempt to obtain a written release of medical records from the parent (if child is under 15 years old) or from the child. If a release is obtained, it shall be forwarded to the mental health provider with a request for at least the following information: confirmation that the child was seen including date of first visit, mental health provider's diagnosis, treatment plan, and medication prescribed, if any. If a release is not obtained, the medical provider should, at a minimum, attempt to follow-up with the parent or patient to determine if the referral was implemented.

TARGET COMPLIANCE:90%

RATIONALE:

Many teens who are considering suicide are suffering from depression. Suicide is the third leading cause of death among people 15 to 24 years old and the rate is increasing. At the time of a 1991 study by the Centers for Disease Control, 27% of high school students had thought about suicide, 16% had a plan, and 8% made an attempt. Depression has a marked effect on educational success.

AUDIT PROCESS:

Part I: Select the same 25 charts described above under Well-Child and Well-Adolescent Visits. For those charts showing evidence of a will visit, continue auditing for compliance with the initial assessment requirement under this standard. Report the total number of charts that show evidence that an initial assessment for depression was performed.

Part II: The SBHC will produce a list of patients who were determined to be "at-risk" for depression after an initial assessment performed between September 1, 2001 and August 31, 2002 (The SBHC must establish a method for identifying these patients which allows easy retrieval of charts. Recommended is the assignment of a secondary diagnosis code of V79.0)

The auditor will randomly select 25 patients or 100% of the patients on the list, whichever is less, and request their medical records. Each chart will be reviewed for the presence of a follow-up assessment. If the follow-up assessment is positive, the chart will be further audited for documentation of education, referral, and disposition. If follow-up assessment has a negative result, education, referral and disposition are unnecessary. Therefore, any chart with a negative follow-up assessment should be eliminated from further study.

The auditor will provide a separate report for each site showing the total number of charts audited, and of these, the number of charts with negative, positive and no follow-up assessment. Of those with positive follow-up assessments, the auditor will indicate the number and percent of charts in compliance with each additional component (education, referral and disposition) separately. In addition, the auditor will indicate the number and percent of charts that were in compliance for all components.

Colorado Association for School-Based Health Care
Deborah K. Costin, Consultant
June 23, 1998
rev. July 13, 1999
rev. March 19, 2001