PPD PROCEDURE IMPROVEMENT PROJECT
Gouverneur Diagnostic & Treatment Center, Leicht Clinic

Project Background
Project Name: PPD Improvement

HIV Caseload: approximately 450

Rationale for Selections: In 1999, the Leicht Clinic performed a focused chart review to identify clinical areas for improvement with the assistance of the New York State Department of Health AIDS Institute HIVQUAL Program. From that review, the rate of PPD placement and reading for the Leicht Clinic was identified as 54%.

A PPD project scored as a high priority on the Performance Improvement Proposal Scoring Grid.
Team Members:

• Physician
• Nurse
• Clerk

Success Story
Improvement Goal: To increase the percentage of patients with a PPD planted and read to 80%

Methodology: The project team met weekly beginning in May 2000. Using a flow diagram, the team outlined the process for PPD placement and reading as:

1. Physician orders PPD.
2. Clerk flags chart for nurses and provides an appointment for reading in 72 hours.
3. Nurse plants PPD.
4. Patient returns.
5. PPD is read by nurse and documented in the chart.

The project team identified three primary areas of concern:

• Physicians have sole responsibility to order the PPD, are overwhelmed during the patient visit, and therefore forget to order the PPD.
• Patients do not return for reading.
• PPD readings are not documented in the chart (no documentation = not done).

Changes Tested: The project team reviewed the process and proposed the following changes.

1. Decentralize responsibility for identifying the need to order the PPD from physician to include nurses. Each morning an RN pre-screens the day’s charts to identify patients who are due for a PPD and flags the chart. Physicians maintain responsibility to order the PPD.
2. Change PPD reading time from 72 hours to 48 hours, thereby building in one more day to call patients back.
3. Maintain PPD log with patient phone contact. Patients who do not return in 48 hours are called by the nurse and told to come in the next day. Recalls are documented in the chart and in the log.

The proposed changes were brought to the leadership group and the proposal was approved as a pilot. The pilot was implemented beginning July 24, 2000.

Results: At the end of September a test of the pilot was conducted, as follows:

1. MIS identified 345 HIV+ patients who were seen at least once at Gouverneur between July 24 and September 18. MIS assembled the list in medical record number order.
2. The MIS list was narrowed to create a list of charts to be reviewed by selecting every third medical record. This process identified 89 charts. 10 were unavailable, and 3 were not seen (or were not HIV+) and therefore excluded.
3. 76 charts were eligible. 21 patients known to be PPD+ were excluded. 24 patients who had already had a PPD placed prior to July 24 were also excluded (because another PPD would not be indicated). This left 31 charts eligible for the new pilot PPD Procedure.

Review of the above reveals two patterns. First, if the chart was not screened, the physician did not order the PPD. Second, of the charts which were screened but a PPD was not ordered, 7 of 9 occurred on a Thursday. (Historically, PPDs are not placed on Thursdays because the clinic is not open to read them on Saturday.)

Feedback from the physicians indicated that the RN’s flagging the chart was very useful in prompting MDs to order PPDs.
Baseline and Follow-up Data: Data collected in March 2001 showed that the percentage of patients with a PPD planted and read increased from 54% to 76%. (The percentage of patients with a PPD planted increased from 67% to 91%.)
Summary
Lessons Learned: It is important to decentralize responsibility for identifying the need to order the PPD.

Advice to Other HIV Programs: What helped us is the fact that the project team included a person from each step in the process. This allowed the team members to flesh out what actually happens during each step and to discuss potential solutions with the full picture in front of them. It also gave a sense of shared ownership.

An additional item that I think was important was that we were supported by the administration (both within the clinic and the larger hospital) to do these activities. For example, we were given dedicated time to work on this (and other) activities.
Next Steps:

• Continued emphasis on recalling patients who do not return at 48 hours
• The RN pre-screening will be incorporated into the procedure for PPDs
• PPDs planted on Thursdays will be read by the Walk In Clinic (negotiated successfully)

For more information, please contact:
James Schmidtberger, MD
Submission Date: March 2002

Gouverneur Diagnostic & Treatment Center, Leicht Clinic
227 Madison Street
New York, NY 10002-7537
(212) 238-8176 (phone)
(212) 238-8189 (fax)