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California State University, Long Beach
Student Health Services
Continuous Quality Management and Improvement Summary Report
July 2007- June 2008


Continuous Quality Management and Improvement (CQMI) Team Members:

  • Nop Ratanasiripong, RN,MSN (Chair)
  • Bonnie Cegles, NP
  • Deborah Bernal, RN, MS
  • Heidi Burkey, MPH
  • Jean Huckins, MS
  • Galina Sinkevich
  • Jennifer Layno
  • Kristine Howe
  • Andrea Hykes
  • Jeffrey Salamanca

The CQMI Team reports to the Executive Team.

Meeting frequency: Once per month. See Attachment A for organization chart, CQMI Team, and meeting calendar.


Primary goals and objectives are:

  • Improve patient health, safety, and satisfaction
  • Increase skills, experience, and expertise of staff
  • Obtain greater efficiencies of care (money, time, resources)
  • Meet accreditation and regulatory requirements
  • Ensure that all concerns have been addressed
  • Evaluate operational practices for potential changes to SHS' policies and procedures
  • Provide and assess training programs
  • Address clinical, administrative and actual patient outcomes

CQMI accomplished goals for July 2007-June 2008

  1. List of Error-Prone abbreviations, symbols, and dose designations to be implemented in the EMR system. COMPLETED.
  2. SHS Patient Education Handouts to be updated and available on the S: and EMR. IN PROGRESS.
  3. SHS Infectious Control Program to be initiated to coordinate with CSULB Risk and Safety Management. COMPLETED- see details on Infectious Control Policy & Procedureand accomplishments in Attachment B.
  4. Prepare for the accreditation. IN PROGRESS. More than 75% of P&Ps have been updated.

Summary of CQMI tasks from July 2007-June 2008:

  1. Conducted or coordinated clinical studies and administrative studies/surveys. The details of study schedules and responsible parties/managers can be found in Attachment C.
    1. Repeated studies:
      1. Patient Satisfaction Survey: conducted in September 07 (SHS only) and February 08 (CSU benchmark).
      2. Non-user Survey: conducted in October 07. The Team recommended combining the Patient Satisfaction Survey and Non-User Survey. The Team also approved the use of an electronic survey tool (Surveyshare.com) for the next repeated survey in October 2008.
      3. Ottawa Ankle Rule Study: conducted in June 2007 and March 2008. The study will not be repeated.
      4. Waiting Time Study: conducted in February 2008. The study will be repeated in Spring 2009.
      5. ACHA Pap Smear and Sexually Transmitted Infection survey was submitted to ACHA in March 2008. The CQMI is waiting for ACHA results for benchmarking. The CQMI Team will continue to participate in this study.
      6. Birth Control Pill Refill Prescription: This study was a clinician peer review topic. The CQMI Team recommended the Chief of Medical Staff to re-measure the interventions by conducting a repeated study in June 2008. The study will be repeated in June 2009.
    2. On-going studies:
      1. Men's Health Clinic Study: The purpose of the study is to measure the effects of MHC on knowledge, behavioral change, and service satisfaction for Student Health Services male patients. 69 subjects are enrolled in the study. The study is in the follow-up visit period.
      2. The QUITNOW Study. The purpose of the study was to evaluate patient's knowledge, behavioral change, and service satisfaction on smoking cessation (QUITNOW) program. 41 subjects were enrolled in the study.
    3. New studies:
      1. Pap Test Preparatory Knowledge Prior To Appointment Study. The purpose of the study is to evaluate the effectiveness of preparation education provided to patients. The targeted sample size is 50 women who come for a pap test appointment at SHS.
      2. Incomplete/inaccurate Prescription Study. A retrospective review of all prescriptions from April 2, 2008- August 2, 2008. The purpose of the study is to evaluate the completeness and accuracy of prescriptions sent to the pharmacy.
  2. Reviewed and recommended mandatory peer reviews
    1. Clinician peer review:
      1. Chart review in December 2007
      2. Topic review (Chlamydia treatment and follow-up) in April-May 2008. It was recommended to re-measure the interventions by conducting a study (as a CQMI study) in Spring 2009.
    2. Nursing peer review:
      1. Competency review in November-December 2007. The competency topic was ear irrigation.
      2. Chart review in March 2008. The Policy & Procedure 5.2 and nursing chart review tool have been revised to improve the nursing peer review procedure.
  3. RProvided or assisted with in-services. The details of training schedules and responsible parties/managers can be found in Attachment D.
    1. Annual trainings:
      1. Emergency procedure (laydown yard), bloodborne pathogens/sharp injury prevention, single use respirators & respiratory protection, and N-95 mask fitting & training.
      2. HIPAA update
      3. CPR/AED training
    2. On-going trainings:
      1. EMR Basic
    3. In-services:
      1. Gardasil vaccine update
      2. LINK-vaccination tracking system
      3. Chantix for smoking cessation
      4. HIPAA: what physician should know
      5. Transgender sensitivity
      6. Audiometry
      7. Microsoft office update
      8. HPV abnormal pap smear management update
      9. Coast-Library online at CSULB
      10. Loestrin
    4. Unit in-services:
      1. Nursing in-services includes intramuscular administration for Rocephin, Locating IM sites, Orthostatic BP measurement, EKG, Immunization, Vital signs update, Two-step TST, Nursing orientation powerpoint, and Nursing Peer Review: Purpose & Method.
  4. Provided general recommendations and corrective actions to enhance Student Health Services' standards. See Attachment E for CQMI recommendation log.
  5. Proposed and developed SHS Policy and Procedures.
  6. Other activities from July 2007-June 2008
    1. Two additional CQMI members were added to represent the Front Office and HRC.
    2. Created Patient Education Handout Subcommittee to ensure accurate and updated health education tools that are provided to students. See details on Patient Education Handout Policy & Procedure and the committee accomplishments in Attachment F.
    3. Identified long term goals for 2008-2009 to improve patient quality of care. See CQMI long term goal sheet in Attachment H.
    4. Started AAAHC application process.

CQMI goals for July 2008-June 2009

  1. Improve the accuracy of patient identification.
  2. Accurately and completely reconcile medications, including over-the-counter medications across the continuum of care.
  3. Successfully renew AAAHC accreditation.
  4. Train all SHS staff regarding new and updated Policies & Procedures.
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