OATdb Archive

2009 - 2010

Health Services

Goal
Quality Health Care Services
The Health Center will provide quality health care services.

Objective
Accreditation Association For Ambulatory Health Care (AAAHC) Re-accreditation
The Health Center will achieve AAAHC re-accreditation.

Indicator
Re-accreditation Letter
The indicator for this objective is the letter from the accrediting agency awarding re-accreditation.

Criterion
Full Re-accreditation
The criterion for success is a full 3-year re-accreditation decision.

Finding
Re-accreditation Decision And Survey Report
The Student Health Center received notification in a letter from the AAAHC stating that it achieved full three-year accreditation.  The survey report indicated that there were 435 applicable standards rated “Substantial Compliance,” “Partial Compliance,” or “Non-Compliance,”  The department scored “Substantial Compliance” on 433 standards, “Partial Compliance” on two standards, and “Non-Compliance” on zero standards.

Action
AAAHC Re-accreditation
The department reviewed the written recommendations contained in survey report and took action on the two recommendations in the accreditation survey report.  The actions included the implementing an emergency room referral form (see attached QI study) and gaining access to database for updating information regarding providers.  The department will continue to uphold the accreditation standards and make changes as necessary based upon revisions of the standards in order to achieve re-accreditation in 2012.

Objective
Quality Improvement Studies
The Health Center will conduct at least two quality improvement studies during FY 2010.

Indicator
Quality Improvement Studies
The indicators for this objective are the quality improvement study reports.

Criterion
Quality Improvement Studies
The criterion for success is the completion of two formal quality improvement studies prior to the end of FY 2010.

Finding
Quality Improvement Studies
The Health Center completed three quality improvement studies.  The completed studies addressed follow-up after emergency room referrals, cost of care issues related to Herpes testing, and annual cervical cancer screening practices. 

Action
Quality Improvement Studies
The Health Center will carry over this objective for FY 2011.  The studies completed this year outlined quality improvement processes that yielded the following results:
  • 118% increase in Herpes testing due to decreased cost
  • Consistent (100%) post-ER referral follow-up due to the creation and implementation of an ER Referral Form
  • Changes in cervical cancer screening guidelines to offer deferment of annual cancer screening until 21 years of age
The department will restudy the ER follow-up at a later date to validate consistency.

Goal
Access To Health Care Services
The Health Center will increase the accessibility of its services.

Objective
Patient Volume
The Health Center will increase its patient volume by 10%.

Indicator
Patient Visit Report
The indicator for this objective is the Patient Visit Report comparing the total number of patient visits from FY 2009 and FY 2010.

Criterion
Patient Visits
The criterion for success is a 10% increase in the total number of patient visits from FY 2009.

Finding
Patient Visits
The Health Center experienced 17,109 visits during FY 2010.  This represents a 23.6% increase over the number of patient visits that occurred in FY 2009. 

Action
Access To Health Care Services
The department plans on slightly increasing its medical practitioner FTEs in FY 2011 by .20.  However, the Health Center must make provisions for additional increases in its patient volume capacity to meet students’ healthcare needs by exploring funding options for additional staff and facility expansion.  The director will continue to work with administration in the planning process to address these needs.  


Goal
Health Promotion
The Health Center will equip and encourage students to make healthy lifestyle choices.

Objective
Student Knowledge
The Health Center will develop outreach activities that increase students' knowledge of health-related topics.

Indicator
Program Assessment
The program assessment results for specified activities will serve as evidence of the successful completion of this objective.

Criterion
Student Knowledge
85% of the activity participants will demonstrate knowledge regarding the specified subject matter by achieving the related learning objective(s).

Finding
Student Knowledge
89% of the participants achieved the related learning objectives.

Action
Student Knowledge
The department will continue to assess its efforts to positively affect students' knowledge, attitudes, and behaviors related to health-related issues.  In FY 2011, we will attempt, when feasible, to directly assess the students' application of knowledge.

Objective
Student Attitude And Behavior
The Health Center will conduct outreach activities that improve students' attitudes toward healthy behaviors and increase the likelihood they will exhibit them.

Indicator
Program Activity Assessment
The program assessment for specified activities will serve as evidence of the successful completion of this objective.

Criterion
Student Attitude
60% of the activity participants will indicate a positive attitude toward the desired behavior.

Finding
Student Attitude
91% of the participants indicated a positive attitude toward the desired behavior.

Criterion
Student Behavior
10% of the activity participants will indicate an increased likelihood to exhibit the desired behavior.

Finding
Student Behavior
69% of participants indicated an increased likelihood that they would exhibit the desired behavior.

Action
Student Attitude And Behavior
The department will continue to assess its efforts to positively affect students' knowledge, attitudes, and behaviors related to health-related issues.  In FY 2011, we will attempt, when feasible, to directly assess the students' behavior instead of depending solely upon self-reporting.


Update to previous cycle's plan for continuous improvement

Plan for continuous improvement The Student Health Center continued to provide SHSU students with access to quality health care services and health promotion activities.  The department achieved all of its objectives in the areas of Quality Health Care Services, Access to Health Care Services, and Health Promotion.

The department furthered the quality of its medical services this year through quality improvement activities.  In addition to on-going quality assurance measures, the department completed three formal quality improvement studies that outlined processes that resulted in consistent post ER-referral follow-up, a 118% increase in Herpes testing, as well as a change in cervical cancer screening guidelines.  The quality of care was further validated by the department's achievement of re-accreditation. The re-accreditation survey report indicated that there were 435 applicable standards rated “Substantial Compliance,” “Partial Compliance,” or “Non-Compliance,”  The department scored “Substantial Compliance” on 433 standards, “Partial Compliance” on two standards, and “Non-Compliance” on zero standards.  The department addressed the two areas rated "Partial Compliance," by improving post-ER follow-up with the creation and implementation of an emergency room referral form and bolstering its re-appointment process by obtaining updated information regarding medical providers through a federal database.

The Health Center experienced 17,109 patient visits during FY 2010.  This represented a 23.6% increase in patient volume which was made possible by a 12% increase in medical practitioner FTEs.  The department will explore additional opportunities to increase its patient volume through the addition of medical practitioner FTEs.  The department plans on slightly increasing its medical practitioner FTEs in FY 2011 by .20 in order to further increase patient volume.  

The department also conducted or participated in 103 programs as part of its efforts in order to positively affect students' knowledge, attitudes, and behaviors related to health-related issues.  As a result of the disconnect between self-reported behavior and actual behavior, we will attempt, when feasible, to directly assess actual behavioral outcomes related to the students' participation in specified programming activities. 

The goal areas of Quality Health Care Services, Access to Health Care Services, and Health Promotions will remain relevant for FY 2011.  Based upon the findings of this year's assessment, the Student Health Center will strive to make specific improvements in 2010-2011 in these areas by:






  • Conducting quality improvement studies related to front office and pharmacy operations.



  • Increasing medical practitioner FTEs in an attempt to increase patient volume.



  • Enhancing the assessment of targeted health promotion activities by measuring actual behavioral outcomes when appropriate.