WEBER STATE UNIVERSITY Student Health Center

MC 1128

626-6459

TO: Toni Weight, Dean of Resource Management

FROM: Juliana P. Larsen, Director Student Health Center

DATE: June 7, 2001

SUBJECT: Student Affairs Division Expectations

2000-2001 Report

During this academic year, the Health Center identified three of the elements from the Division Expectations and Goals for Student Affairs on which to do outcomes.

“There will be an advisory board for each Student Affairs Department and, where relevant, advisory boards should also be formed for specific programs.” (Division Expectation #1)

The Health Center already had an existing Advisory Board with by-laws and officers in place. Our goal for the year was to hold a board meeting at least once a semester. During Fall semester, two meetings were held where there was a good student participation. Issues around getting more information out to students about the health center and increasing the frequency of patient satisfaction surveys were discussed.

Unfortunately, because the chair, a community physician, relocated his practice and his time was limited, we were unable to convene the board for a spring semester meeting. The chair and health center director are currently planning the first meeting for early in fall semester.

“Each department head will be responsible to develop and maintain a current web site. Training for staff will be provided.” (Division Expectation #4)

Web sites for both the Student Health Center and the Health Education/Drug & Alcohol Program are in place. There are still some adjustments needed with cross links to other campus and program reference sites. The Health Center web page has been verified to be ADA compliant, the Health Education/Drug & Alcohol web page is up but hasn’t been ADA checked as of this date.

NOTE: Because of the e-mail link created on the health center web site, several students have been able to have their questions answered via this method.

“Each department head will be responsible to insure that all staff members achieve required computer competencies.” (Division Expectation #5)

All health center staff completed group wise e-mail training

Two more computers were purchased for the clinic in order to facilitate staff computer accessability.

Staff attempted to utilize training manuals to increase their computer skills

All staff have over the past academic year become more computer “literate”. Not everyone has completed a formal training process in all computer programs, but skills among the staff have increased significantly. They are utilizing the computer to accomplish more daily tasks and enhance their productivity in the clinic. As a group, the staff recognize that what they have learned to this point is just a stepping stone in the world of computers. Plans are in place to continue the learning process and acquire additional skills which will increase their computer understanding.

Quality Improvement Report Form

Indicator:

Glucometer quality assurance

Indicator: A comparison study on low glucometer readings. Glucometer readings below 70 mg / % were to be confirmed by a reference lab.

Report Date: May 17, 2001

Findings:

Total Glucose tests done 161

Total below 70 7

Total sent to reference lab 2

The comparison of the low values on our glucometer and the values of the reference lab differ greatly. We believe that the low readings were due to different personnel using the machine. As confidence in using the glucometer improved, the results were better. According to the manufacturer, serum glucose values should be 1.18 times higher than whole blood. Our value on one was 65 and the reference lab was 92. The second sample here was 27 and the reference value was 71. Sample amount could have contributed to the low value. There could be benefit in following this study for another year.

Indicator:

Access to Care

INDICATOR: (Adequacy and availability of necessary supplies)

The clinic staff maintains an inventory process which tracks and makes certain that all necessary medical supplies are available. A weekly visual inventory of major storage areas verifies the quantities of supplies present, allows for ordering that week, and insures that supplies will be available to clinic staff as needed for procedures.

FINDINGS: Some of the aspects of the plan were in place and some were not.

*A cardex log of supply locations is in place. It does need to be updated. There is no log in place to no note that system is reviewed on a monthly basis.

*A weekly visual inventory of major supply areas is being done. A log is not in place to document this.

*A record of supplies ordered weekly is in place.

RECOMMENDATIONS:

*Update cardex log. Add monthly review notation to maintenance log already in place. This has been done.

*Add to maintenance log already in place, that a weekly visual inventory is being done. This is in place.

*Update present weekly inventory log to generate a new form. Add weekly notation to maintenance log already in place. This notation has been added.

MEDICAL RECORDS AUDIT

Summer Semester 2000-2001

Audit Date: May 21, 2001

Twenty-five medical records were randomly selected to be audited. The review included all components of Patient History and Physical Data, Problem List, Consent for Treatment form, patient name and records number on all forms and slips, current year sticker, provider signatures and co-signatures.

Findings: 14 charts had deficiencies.

• 6 of those charts were missing the Problem List*

• 7 charts needed updates on allergies*

• 3 charts were missing witness signatures on the blue Consent Form

• 1 chart had no blue Consent Form

• 6 charts needed co-signatures of physician for nurse practitioner

• 1 chart needed physician signature

• All charts had names on all sheets with records number, current year stickers and necessary date on Patient Health and Personal Data intake form

Percentage: 28% (7) of charts were in compliance

*It should be noted that during the 2000-2001 academic year that the Problem List was not used by the providers during a period of time as there was some discussion as to whether or not to continue with them. With that noted, 44% (11) charts would be in compliance.

Threshold:80%

Recommendations:

• Continue checking medical records for deficiencies each patient visit

• Have appropriate staff check Problem List / allergy updates at all patient visits

• Check for signatures / co-signatures on all forms before return to file

• Train hourly staff on all components of chart assembly, compliance and filing

Clinical Audit for 2000-2002

Update on Treatment of Chronic Pain Syndrome

The goal of providing WSU Student Health Center patients pain relief for chronic pain conditions was partially met for 2000-2001. Please refer to Quality Improvement Report 2000-2001 for details.

The goal for the 2000-2002 Clinical Audit will remain the same: Provide pain relief using bibliotherapy for selected patients with chronic pain conditions including back/neck/shoulder pain, headaches and fibromyalgia.

Indicators for Patients with Chronic Pain 2000-2002 will remain the same but clinical audit action steps will be modified.

The major difficulty preventing successful completion of the prior Indicators related to the fact that students with chronic pain did not formally contact WSU SHC personnel and enroll in the study. An informal observation by the providers revealed that Bibliotherapy was a useful intervention but we were unable to quantitate the improvement.

Why did students fail to enroll in an anonymous study of Bibliotherapy and chronic pain? A number of reasons are suggested:

1. The invitation to enroll was passive and required that the student read the handout carefully

2. One more task for the already overwhelmed student to complete

3. Minimal incentive for entering

As a result, the action steps have been modified:

Action Steps:

1. Enroll the student in the study while in the clinic at the time any of the books are borrowed. The use of the books will serve as the incentive for student participation. (Providers will be responsible)

2. Include a WSU self addressed postcard that requests feedback along with the books to be borrowed (Provider will be responsible)

3. Purchase two more copies of Sarno’s Books to increase the capacity of the library (Clinic Director will be responsible)

4. Create questions to be included on the postcard (Physician will be responsible, time dated: creation of survey postcard by September 1, 2001)

5. Incorporate Clinical Audit Quarterly Assessment Phase meetings into routine staff meeting but formally set aside time for this component on the agenda (meetings: October 2001, February 2002, May 2002).

Quality Improvement Report Form

Indicator:

Positive Strep Throat cultures

Background:

The original indicator is composed of four steps, Input, Environment, Outcome and Assessment. In the outcome step it states, “Students having a throat cultures one at the student health center, will follow up on throat cultures in a timely manner.” In order to ensure compliance and provide sound medical aid, both providers of the clinic routinely follow up on all positive strep throat cultures rather than leaving that step in the students hands. Also, in the assessment step, it states a “weekly chart review of students who had positive throat cultures.” This needs to be changed since we only conduct an annual audit.

FINDINGS:

Between 1 July 2000 and 30 April 2001, we had a total of 786 throat cultures performed in the student health center. Numbers for May and June are unavailable. Of that number, we had 41 positive cultures. These numbers give us a 5.2% strep rate of all the cultures taken. In reviewing all charts with positive cultures, there was a 100% compliance in following up with these students. Follow up consisted primarily of phone contact with the student informing them of their throat culture status and educating them as to their treatment regimen.

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