Physician
Nurse
Clerk

Percentage of patients with a PPD planted and read

Background:

In 1999, the Leicht Clinic of Gouverneur Healthcare Services, with the assistance of the New York State Department of Health AIDS Institute HIVQUAL program, performed a focused chart review to identify clinical areas for improvement in HIV/AIDS care. The rate of PPD placement and reading for the Leicht Clinic was identified as 54 percent. A PPD project was rated as a high priority.

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 schedules 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, having sole responsibility to order the PPD, are overwhelmed during the patient visit, and therefore forget to do so
• 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:

• Decentralize responsibility for identifying the need to order the PPD from physician to include nurses. Each morning a nurse 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.
• Decrease PPD reading time from 72 hours to 48 hours, thereby building in one more day to call patients back.
• 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.

Interim observations: At the end of September, we conducted a test of the improvement project by reviewing a subset of medical records for HIV+ patients who were seen at least once at Gouverneur between July 24 and September 18, 2000.

Review of the medical record subset revealed two patterns:

• If the chart was not pre-screened and flagged by a nurse to indicate that a PPD was needed, the physician did not order the PPD.
• Of the patients whose charts were screened, but for whom 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 physicians indicated that the nurses’ flagging of the chart was very useful in prompting physicians to order PPDs.

Results:

• The percentage of patients with a PPD planted and read increased from 54 percent to 76 percent between July 2000 and March 2001.
• The percentage of patients with a PPD planted increased from 67 percent to 91 percent during the same time period.

Lessons Learned:

Decentralizing responsibility for identifying patients in need of a PPD allows for greater improvements.

Advice to Other HIV Programs:

Our project team included a person from each step in the process we flowcharted. 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.

In addition, we gained the support of the administration (of the clinic and the hospital) to do this project. Specifically, we were given dedicated time to work on this (and other) activities.

Next Steps:

• Continue emphasis on recalling patients who do not return at 48 hours
• The RN pre-screening will be incorporated into the procedure for PPDs
• We negotiated with the Urgent Care Clinic to read PPDs planted on Thursdays on Saturdays. The results will be documented in the record and a copy forwarded to our clinic for follow up.

James Schmidtberger, MD
Gouverneur Healthcare Services, Leicht Clinic
227 Madison Street
New York, NY 10002-7537
(212) 238-8176 (phone)
(212) 238-8189 (fax)