OATdb Archive

2011 - 2012

Health Services

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

Objective
Quality Improvement Studies
The Health Center will engage in quality improvement.

KPI
Quality Improvement Studies
The indicators for this objective are the quality improvement study reports. Our goal is to conduct at least two quality improvement studies during FY 2012.

Result
Quality Improvement Studies
The Health Center completed two quality improvement studies.  The first study addressed the impact of increasing the no-show fee on the number of patients not showing up for their appointments. The clinic has had a high rate of students not following through with their scheduled appointment. The increased fee did have an impact of a 21.5% decrease in the number of patient no-shows. 

The clinic assessed the current nursing triage practices based on the State Board of Nursing recommendations and compared our current processes to other universities' practices. This resulted in the clinic identifying that it is not following best practice standards or regulatory guidelines regarding nursing triage. Furthermore; the clinic identified ways to improve on the stated weakness by mandating that the RN will be the only employee responsible for traige.


Action
Quality Improvement Studies
The studies completed this year outlined quality improvement processes that yielded the following actions:
  • No-Shows: The SHC identified that there were a high incidence of students not presenting themselves to their appointments. By increasing the no-show fee there was an impact on the rate of no-shows. The clinic will perform ongoing assessments of this issue and if there is no future improvement in the no-show rate, the SHC will consider increasing the no-show fee.
  • Triage Processes: The clinic identified that it was not using current nursing triage practices compared to other universities' practices and the State Board of Nursing recommendations. As a result, the clinic will rewrite the triage policy and fill the triage position with an RN.


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

KPI
Re-accreditation Letter
The indicator for this objective is the letter from the accrediting agency awarding re-accreditation by September 12, 2012.

Result
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.

Action
AAAHC Re-accreditation
The department reviewed the written recommendations contained in survey report and took action regarding combining the allergy injections charts with the standard patient charts. The department will uphold the accreditation standards and make changes as necessary based upon annual revisions of the standards in order to achieve re-accreditation in 2015.

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

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

KPI
Program Activity Assessments
The assessment for the sexual wellness program will result in 90% of students stating that because of this presentation, they are more likely to use a condom when they are sexually active.

Result
Student Attitude
85% of the participants indicated that because of the sexual wellness program, they exhibited a positive attitude toward the desired behavior of using a condom during sexual activity. A review of the open comments related to this specific assessment question revealed that there is not an option for students to respond if they are currently abstinent, on birth control, married, or in a monogomous relationship. The respondents revealed that these statuses do impact their choices on condom use and their perception of the desired behavior.

Action
Student Knowledge
The program assessment revealed that there are not sexual status options for students to respond to the specific question of condom usage if they are currently abstinent, married, or in a monogomous relationship while on birth control. The department will format the assessment question to identify these statuses. This will help the department identify the students that state they will not wear a condom for negative and unhealthy reasons and identify students that were positively impacted by the program. Additionally, this change will allow the department to tailor the sexual wellness program to fit the needs of all participates.


Update to previous cycle's plan for continuous improvement

Plan for continuous improvement The Student Health Center provided 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 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 two formal quality improvement studies that outlined processes that resulted in a 21.5% decrease in the number of patient no-shows and changes in the work flow of the clinic's triage system and the requirement that the RN will be the only employee responsible for triage.  The quality of care was further validated by the department's achievement of re-accreditation. The department addressed the area of needed improvement by combining the clinic's allergy injection patient charts with the patient's standard clinical record.

The department also conducted or participated in 100 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 health outcomes related to the students' participation in specified programming activities. 

The goal areas of Quality Health Services and Health Promotions will remain relevant for FY 2013.  Based upon the findings of this year's assessment, the Student Health Center will strive to make specific improvements in 2012-2013 in these areas by:


  • Performing a periodic assessment of the clinic no-shows.



  • Rewriting the triage policy and fill the triage position with an RN.



  • Upholding the accreditation standards and make changes as necessary based upon revisions of the standards.



  • Formating the sexual wellness program assessment to identify the statuses of individuals that state they will not use a condom during sexual activity.