Introduction

"Clinicians must take every opportunity to deliver preventive services, especially to those with limited access to care." (1)

Most clinicians acknowledge the importance of incorporating preventive care into their practices; however, delivery of preventive services, even those about which all authorities agree, is far from satisfactory. Providing consistent delivery of preventive care requires organizational commitment, time, and a critical analysis of the systems designed to deliver that care. Ensuring the consistent delivery of preventive services may require changes in office systems or clinic organization.

In the current health care environment, accurate documentation of the delivery of preventive services has become essential. Delivery of clinical preventive services is now one of several indicators used to rate the performance of clinicians, their practices, and health plans.

One example of such measures is the Health Plan Employer Data and Information Set (HEDIS), a set of health care quality indicators developed by the National Committee for Quality Assurance. The preventive services currently being monitored include immunizations, mammography, and smoking cessation counseling. Performance ratings in the area of preventive services serve as potential criteria for accreditation as well as the awarding of contracts.

Following are practical instructions for implementing a system for delivering preventive care services. These 10 steps will facilitate putting prevention into your practice.

(1) A principal finding of the U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd Edition. Washington, DC. U.S. Department of Health and Human Services, 1996.

1. Assess the Need for a New System

If preventive care services are being provided, assess how well your current system works. The services provided by some practices may not require significant changes. Determining the current status of a preventive care delivery system is important before implementing big changes. The best way to assess the need for a new system is to examine clinical records. A baseline chart audit can help determine if changes are needed and can also establish a baseline for demonstrating future improvements.

2. Assess Readiness to Make a Systems Change

As is true about any process that requires change, assessing readiness to change is beneficial. Two commonly cited barriers to implementing preventive care in clinical practice are clinicians' attitudes about prevention and problems within office systems (eg, lack of time, staff, and resources). The effect of these barriers can be minimized if they are viewed in the context of "readiness" for change. The following questions should be addressed as part of readiness assessment:

• Is prevention an important aspect of the care provided by this organization?
• Is increasing the quality and consistency of preventive services a priority?
• Are adequate resources available to incorporate preventive care services?
• Is change feasible (in terms of time, capacity, and cost)?
• Is the staff committed to changing the system?
• Will the administration and key stakeholders support change?

If the answer to the majority of the questions is "yes," implementation of a preventive care system can begin. If the majority of answers is "no," attention should focus on resolving the issues associated with the questions before attempting to make a change. Use of this simple questionnaire will save significant time and energy by identifying potential barriers that need to be addressed and potential facilitators of the process and allowing time to plan for successful implementation based on information collected.

3. Enlist Staff Support

Communication and teamwork are critical factors to successful implementation. Involving the staff is critical to ensuring that preventive services are a routine part of office practice. Include everyone who will be impacted by the changes in the planning and implementation process. Clearly define the role of all staff members and include them in the planning and problem-solving. You may discover untapped resources by encouraging staff members to creatively consider their roles in prevention delivery.

4. Perform a Chart Audit

Select a small sample of records from a specific patient population (e.g., adults, children, males, females).

Determine which preventive care elements are to be assessed (e.g., Pap testing, cholesterol screening, smoking counseling) and which guidelines to use (Recommendations of Major Authorities in individual chapters).

Use information from the health history forms, problem lists, or progress notes from the most recent visit to determine whether the client has had:

• Health-risk behavior assessed or identified in the past year.
• Appropriate screening exams for age, sex, and risk in the appropriate time frame.
• Documented counseling for health risk factors.

Determine what percentage of the sample population received age- and gender-appropriate preventive care services in a timely manner.

Preventive Care         Documentation       Treatment or Education      
Guideline Parameters                        Provided 
                                 
                                                 
Cholesterol             Current date:       Counseling done      yes   no 

   Women q 5 yrs        _____________       Prescription given   yes   no 
   (45-65 y.o.)
                              
   Men q 5 yrs          Date of last:       Referred to outside    
   (35-65 y.o.)                             program/class        yes   no
                        _____________              
   
                        Result:________ 


Smoking Behavior        Smoker ___          Counseling done      yes   no

   Assess every visit   Non-Smoker ___      Prescription given   yes   no

                        Not assessed ___    Referred to outside
                                            program/class        yes   no


DTaP/DTP Immunization   Age at last visit:  _______________

   Children <6 y.o.     has child received:     
   5 doses               
                        1st dose (2 mos)              yes  no    n/a 

                        2nd dose (4 mos)              yes  no    n/a 

                        3rd dose (6 mos)              yes  no    n/a 

                        4th dose (15-18 mos)          yes  no    n/a 

                        5th dose (4-6 yrs)            yes  no    n/a 

5. Establish Preventive Care Protocols

Develop a protocol of preventive care that meets the particular needs of your specific practice and its patients. The Clinician's Handbook is designed to facilitate this process. Recommendations of major authorities, emphasizing age and periodicity for preventive screening, appear at the beginning of each chapter. By reviewing these recommendations, clinicians can decide which guidelines to select or can set their own standards based on current recommendations. A set of standards, even if minimal, needs to be identified and adopted as a policy. Concentrate efforts on selecting preventive services that truly can be provided in light of limited time, available staff, and other resources. Periodically examine the selected standards, updating them as needed based on current research and the changing needs of the patient population.

Once policy is set, familiarize the entire staff with the criteria and incorporate the standards into a preventive care flow sheet for tracking purposes. The flow sheet permits quick determination of a particular patient's need for preventive care services and allows the provider to deliver preventive care at all patient visits. If time limitations prevent delivery of such services during a visit, the patient may be informed of what care is needed, and a plan to obtain it can be established (e.g., referral, follow-up appointment). After protocols for preventive care service are identified, the next step is to establish systems that ensure consistent, efficient delivery of these services.

6. Analyze Service Delivery and Patient Flow

The physical layout of a practice and the direction of patient flow can significantly influence the delivery of preventive services. Effective organization of clinic systems and patient flow, along with utilization of all staff members' skills, can improve delivery of services. Analyzing patient flow patterns can be as simple as mapping a patient's path through the office on paper, thus identifying areas where health education messages can be provided or reinforced. The analysis should consider who the patient encounters and what is done at each step. Such an analysis can provide a basis upon which clinic efficiency can be improved.

7. Use Basic Tools

The use of simple office tools can improve the delivery of preventive health care. The following tools are components of the Put Prevention Into Practice initiative. Many of the tools can be altered to meet individual specifications.

8. Use Other Helpful Tools

Other useful office tools include chart reminders, behavioral change contracts, health risk appraisals, and electronic medical records.

• Chart reminders alert clinicians to the specific preventive care needs of individual patients.
• Prevention prescriptions and behavioral change contracts facilitate behavior change by clearly defining the patient's and the clinician's expectations. In addition, a written plan of action, based on an agreement between the patient and the clinician, emphasizes the patient's ability and responsibility to contribute to his/her own disease prevention and health promotion. Follow-up telephone calls to determine progress are also helpful for encouraging compliance with health-related recommendations.
• Health risk appraisals can ensure that clients are questioned about all possible risk factors, increase patient awareness of health risks, and provide the clinician with a second source of information other than the patient interview. However, health risk appraisals should be done in the proper context and with an appropriate amount of time allotted for follow-up counseling to ensure that patients understand the implications of such assessments and the steps to be taken in addressing the various risk factors revealed.
• Computerized tracking and prompting systems are commercially available. Some features to look for include: the ability to prompt for preventive services, customize preventive care schedules, send out patient reminders, and determine a practice's performance.

9. Delegate Tasks and Staff Roles

The most efficient approach to implementing prevention care services is to delegate and share responsibilities among as many staff members as possible. Tasks, such as reviewing charts, administering immunizations, counseling patients, and screening, can be successfully provided by members of the office staff. Another important role for staff is facilitating patients' access to community resources, such as local mammography centers or smoking cessation support groups. Appropriate standards for assuring patient privacy must be maintained, regardless of the number of staff involved in a patient's care.

10. Perform Follow-up Evaluations

Follow-up chart audits will assist in evaluating both the consistency with which tools are used and the impact of tools on service delivery. Use this information as feedback in quality improvement activities in order to modify your service delivery plan.

In Summary

• Assess your current preventive service delivery system.
• Elicit input from entire staff.
• Establish a preventive care protocol.
• Choose tools that are suited to your setting and system.
• Personalize or adapt tools using input from all staff members involved in the process.
• Ensure that all staff members understand the intent and purpose of the tools.
• Distribute responsibilities across the entire staff.
• Perform follow-up evaluations.

A description of prevention materials and availability are provided under Tools & Resources and Ordering Information.

Clinical Scenario

The following is one example of a systematic approach to the delivery of preventive care services: Before a patient arrives:

• The medical record is reviewed by a designated staff member and flagged with notes or stickers for preventive care needs determined from the record.
• A staff member sends a postcard or calls the patient to encourage making an appointment for preventive care services.

Before a patient encounters the provider:

• The receptionist or nurse provides patient with a Personal Health Guide and explains how to use it; if a patient has previously received a Personal Health Guide, the receptionist or nurse checks to determine if he/she has brought it and reviews the Guide.
• The nursing staff completes a health-risk assessment, elicits a health history, determines which preventive care screening exams are needed, cues the clinician to complete or order exams, and reinforces health counseling.
• The nursing staff initiates health education or risk-reduction counseling.

During the encounter with the provider:

• The clinician assesses health risk and health history information, verifying/updating as necessary.
• The clinician questions the patient about identified health risks and his/her compliance with behavioral change contracts at every visit.
• The clinician encourages the patient to ask questions about preventive health topics.
• The clinician completes or orders screening services as necessary.
• The clinician provides appropriate referrals.

After the encounter:

• A staff member assists the patient in recording information (exam dates and test results) in the Personal Health Guide and encourages the patient to bring the Guide to every visit.
• A staff member provides patient education and encourages the patient to ask questions.
• A staff member provides patient-relevant health promotion literature.
• A staff member reinforces recommended behavior changes, using a prevention prescription pad or a patient contract.
• A staff member ensures that the patient understands any instructions and knows when to return for services.
• A staff member completes follow-up with reminder postcards or telephone calls.

Internet Citation

10 Steps: Implementation Guide. Put Prevention Into Practice. Adapted from The Clinician's Handbook of Preventive Services, 2nd Edition, Publication No. APPIP 98-0025, 1998. Agency for Healthcare Research and Quality, Rockville, MD. http://hstat.nlm.nih.gov/ftrs/directBrowse.pl?collect=ppip&dbname=steps

Adapted from The Clinician's Handbook of Preventive Services, 2nd Edition, Publication No. APPIP 98-0025, 1998.