Setting Up For Success

Step 1: Form a team

Form a TeamThe first step to successfully adopting the performance measures is forming a team dedicated to quality improvement. If you create a shared vision about the importance of the work, gain buy in at multiple levels, closely examine the definitions of the measures, and align the way providers enter the data into an electronic health record system (EHR), you will set the work up for success from the outset.

A team will comprise representatives from the school-based health care (SBHC) program’s sponsor organization (i.e. SBHC administrator), SBHC provider(s), and IT support or EHR vendor support (if available). In states with state affiliate offices and/or state government offices that fund SBHC, let them know that you have elected to adopt and report the performance measures and they may be able to provide additional supports to your team.

For more information about setting up a team focused on quality improvement, click here!

Step 2: Review performance measures

Make sure that all SBHC staff understand and are trained to use the correct CPT (procedural) and/or ICD (diagnosis) codes. Meet with IT support or EHR vendors to request help with any of the following steps. Remember that with data: quality in, quality out!

EHR PhotoStep 3: Verify that procedure/diagnosis codes are in the EHR

Entering the performance measures data into an EHR allows SBHC programs to query and extract the data. Verify that all the necessary CPT and ICD codes are in the EHR.

Step 4: Convert text fields to discrete fields

The performance measure definitions include some data points that are generally entered as free text. Determine a process to convert notes, narratives, free-text, or comment fields to discrete fields or observational terms so that data can be queried and tabulated.

Examples of text fields to convert to discrete fields:

Step 5: Build customized reports and data queries

Build customized reports to summarize performance data or create queries to extract data for analysis in Excel or other statistical programs. Rather than requesting a report that tabulates the performance measures, request data elements that are broken down into small, separate items, including all CPT and ICD codes associated with a visit. This allows for easier adjustments as performance measures or data needs change. In addition, request filters for service dates, client age ranges, and client gender, so that data ranges and sub-groups can be specified.

Metro Community Provider Network (MCPN) SBHCs in Colorado added “yes” and “no” discrete fields in their EHR to ask about sexual activity. They also ask about type of sex that the lab specimen for Chlamydia be collected from the site of exposure, i.e., urethra, vagina, oropharynx, and/or rectum, etc. The “Chlamydia Screen” is a drop down field with two choices: (1) ordered and (2) not applicable, so that information too can be easily tracked.