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Puerto Rico QI Resources
Puerto Rico Overview

Puerto Rico Regional Group

Regional Groups are a collective body of Ryan White grantees representing a particular geographic area that collaborate to build capacity for peer learning by sharing improvement strategies and best practices among their quality management programs.  Each group is assigned an experienced consultant who provides quality improvement expertise through facilitation, coaching and mentoring.
Established March 2006, the Puerto Rico Regional Group includes eight Ryan White Part C and D grantees.  Participating programs range in setting from urban to semirural.  The Regional Group meets in-person three times annually with Onelia Crespo, the HIVQUAL-US consultant for the region.  WebEx conferencing continues throughout the year as well as regular individual onsite visits and e-mail communications with the consultant.
Having engaged in shared quality improvement (QI) work in the past focusing on retention, the Puerto Rico Regional Group discussed several possible future QI projects in a January 2009 Regional Group Meeting. Topic areas under consideration included STIs, CD4/Viral load, pap smears, and hepatitis B immunization.
Participants performed a prioritization excersise with an emphasis on relevance, measurability, improvability and accuracy for each option. The Regional Group ultimately chose improving hepatitis B immunization rates given the high incidence of hepatitis B in participating programs’ HIV-positive patient populations.  Dr. Crespo then developed a data collection procedure to be  used in conjunction with the HAB definition for hepatitis B immunization, both translated into Spanish.
The HAB measure is defined as the percentage of HIV-positive clients who completed the vaccination series for hepatitis B.  The denominator is the number of HIV-infected clients who had a medi-cal visit with a provider with prescribing priviliges at least once in the given measurement year and the numerator includes the number of HIV-infected clients with documentation of having ever completed the hepatitis B vaccination series.  Patients who were newly enrolled in care during the measurement year, or with evidence of current hepatitis B vaccination or of past hepatitis B infection with immunity were excluded.  As a data-element, the participating programs are first prompted “Is the client HIV-infected? (Y/N)”, followed by if the patient meets either of the exclusion requirements.  If the patient is not excluded, the participating program will then respond “If no, is there documentation that the client has completed the vaccine series for Hepatitis B? (Y/N)”.
Generally the Regional Group hoped to identify those in need of immunization, as well as those needing post-test counseling.  Lastly, the Regional Group planned to raise awareness among providers for prevention efforts for all forms of hepatitis.  The Regional Group reported specifically on rates for hepatitis B immunization as it pertains to secondary prevention.
Clinics participating in the shared quality improvement project include Centro de Salud de Lares, Inc. (Lares), Centro de Familiar (Arroyo), Concilio de Salud Integral de Loiza, Inc. (Loiza), Gurabo Community Health Center, Inc. (Gurabo), Migrant Health Center Western Region, Inc. (Mayaguez), Puerto Rico Community Network for Clinical Research on AIDS (CoNCRA) - Part C (Rio Piedras), Puerto Rico Community Network for Clinical Research on AIDS (CoNCRA) - Part  D (San Juan), and Ryder Memorial Hospital Cuidado Integral del SIDA (CIS) (Humacao).
Several different tools were used by the team to examine processes of care for hepatitis B immunization, including fishbone diagrams and various forms of brainstorming.  Such strategies illustrate the challenges and opportunities for problem solving in a meaningful and visual way.  In addition to root/cause analysis, the Puerto Rico Regional Group examined national statistical data on co-morbidities for hepatitis B, as well as individual programmatic implications to identify a meaningful comparison to Regional Group results and possible interventions.
Common programmatic obstacles included incorrect laboratory tests, no medical orders, staff’s lack of awareness about immunization guidelines, no tracking of no-shows, lack of patient knowledge, incorrect information in CAREWare, an overly-complicated immunization procedure, and a limited number of immunization appointments available.
Rates for hepatitis B immunization have since been collected and summarized for three semesters at this time: January to June 2009, July to December 2009 and January to June 2010.  A final data collection will be performed for the July to December 2010 interval after the Puerto Rico Regional Group meeting on December 17th.  Individual program-specific data will remain blind until the final data submission is complete.
Interventions used across multiple programs include verifcation of patient’s immunization status at each visit, letters and reminders used for immunization-appointments, and providing funding to purchase immunizations for patients not covered under insurance.
Programs’ immunization rates for hepatitis B subsequently increased by as much as 62% from baseline values at the time of publication.  “Program E” experienced the largest improvement following changes in the type of screening lab used and reminders sent via text message and phone calls.
Many of the participating clincs demonstrated exceptional innovation in clinic-specific interventions.  For example, Centro de Familiar (Arroyo) developed an immunization register to be given to each patient with copies kept by the RN for tracking reminder calls made the day before the appointment.  Ryder Memorial Hospital’s CIS Program implemented an initiative to devote clinic time to follow-up with patients with incomplete immunization.  CoNCRA - Part C now sends weekly reminders to case managers for the purposes of tracking and following-up daily with patients due for immunizations.
In order to sustain and build upon achieved gains, the Regional Group has identified and shared remaining barriers and successful interventions over the course of each in-person meeting since the start of the shared QI project.  During the December 17th meeting the Regional Group discussed which strategies they will continue to employ following the final data collection.
These regional group activities reinforced sustained performance improvement and strengthened the institutional culture of quality improvement across individual programs. The group will soon identify a topic for a shared quality improvement project for 2011.