Implementing Measures and Interpreting the Data

Although the measures each service site uses may vary, all sites should address the following cross-cutting considerations when implementing the measures and interpreting the data.217

• Understand that performance measures cannot address or solve every problem. They can signal that there is an issue, but teams should be prepared to dedicate additional effort to dig deeper and understand what really needs to be fixed.
• Be aware of the ways that “improving” performance may inadvertently lead to coercive practices. In one example, a service site identified measures for increasing sexual risk assessment and chlamydia screening for tracking improvement during a QI project. The team also developed balancing measures to provide a marker of potential unintended consequences of improvement activities or gaps in improvement. These measures included unnecessary screening of patients who were not documented as sexually active, and no screening for sexually active patients. Another possibility is for service sites to use the PCCC measure and contraceptive provision measure in tandem to ensure contraceptive provision is not accompanied by bias, reproductive coercion, and/or an otherwise negative patient experience (Exhibit 18).
• Whenever possible, stratify by demographics (for example, race, ethnicity, preferred language, age, sex, sexual orientation and gender identity, disability status, payment used for visit, federal poverty level, and/ or other socioeconomic indicators) and visit characteristics (for example, visit type, provider). Service sites can monitor differences to determine what service delivery processes, systems, and policies may be driving suboptimal performance and inequities, and where opportunities for improvement exist to advance SRHE. In one example, 75 percent of respondents to a service site’s PCCC survey selected “excellent” in response to questions that addressed the domains of patient experience of counseling: interpersonal connection, adequate information, and decision support. After disaggregating scores by preferred language, data showed that respondents to surveys in Spanish were less likely to report a top score than respondents who completed surveys in English (60 percent vs. 78 percent).
• If measurable differences are observed between different groups, service sites should engage with patients, community members, and community advisory boards. Actionable feedback can be provided on experiences of care, perceived barriers, and interventions and supports that might help alleviate these barriers. In response to the disparate PCCC scores referenced above, the service site shadowed several Spanish-speaking patients throughout their visit to gain insight into how this group experienced care; and, at the end of the visit, they asked each patient what went well and what did not go well. The service site also sought feedback on potential barriers to an optimal patient experience from its community advisory board, which included patients, frontline community health and social service providers, and representatives from community-based organizations.
• Consider implementation-related and external factors. Service sites can develop approaches that consider a range of factors, which are impacted by capacity (linked to setting type and funding source), community context, state and local requirements, and political climate. For example, some Title X multidisciplinary teams have come together with the shared goal of increasing chlamydia screening rates. Through learning sessions and action periods over six to 15 months, they learn from subject matter experts, engage with other teams to learn from each other, and apply and test improvements in their own clinical settings.218 The evidence-based interventions they choose to implement (for example, integrating screening into routine care, adopting opt-out language in scripts and education materials, and utilizing diverse payment options to address cost barriers) will vary based on baseline performance, capacity, patient population, and community needs, but all focus on achieving the same overall goal.219

Exhibit 18. Spotlight on Contraceptive Performance Measures