Domain 2: Service Provision

COMPONENT 1.2

Affordability/Cost

Strategies

Consider using non-financial techniques to maximize fee collection and minimize barriers to patients.

Examples include focusing staff efforts on properly assigning patients for a sliding fee and other reimbursement programs, designing procedures to collect at the time of the service, and forgoing use of mailed statements and collection agencies for sliding fee patients

Contract with local Coordinated Care Organizations (CCOs) to maximize Medicaid billing and reimbursement capabilities.
Request that uninsured patients make some payment on day of visit, but do not deny access to care.
If located along state borders, consider enrolling in the other state’s Medicaid program.¹

For Medicaid beneficiaries in underserved areas of the state, this increases patient access to providers.¹

Develop a policy and system to identify and enroll patients who are eligible for a sliding fee scale discount.

To appropriately apply the discount, perform a cost analysis/assessment to determine the cost of providing services.

Hire dedicated outreach and enrollment assistance staff to seek out and engage uninsured individuals and assist them with enrolling in health care coverage.²
Consider finding outside grants and resources or internal mechanisms to ensure all women get the contraceptives they need at each visit.³

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

COMPONENT 1.3

Special Populations/Diversity

Definitions

Special populations:

in this document, refers to those who are vulnerable, experience unequal access to health care and/or who experience the burden or risk of health disparities due in part to race, ethnicity, culture, socioeconomic status, geography, gender, age, disability status, risk status related to sex and gender, and other factors.

Transgender or Trans:

umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth. (Note: Transgender is correctly used as an adjective, not a noun, thus “transgender people” is appropriate but “transgenders” is often viewed as disrespectful.)

Non-binary:

term used by some individuals who identify as neither entirely male nor entirely female. Also termed gender-queer.

Strategies

The impact of culture on access to and quality of care is particularly important to address in health care. As Oregon’s population of diverse racial and ethnic communities and linguistic groups continues to increase, patients and providers bring with them individual, learned patterns of language and culture. All of these patterns affect the health care experience.

Develop a plan to implement the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care.¹
Provide ADA training for all clinic staff; assess clinic facility and services for ADA compliance; ensure physical access to medical care for people with mobility disabilities, and ensure effective communication for people who are deaf or have hearing loss.²
Use images, written materials and signs that can be easily understood by the diversity of patients served by the clinic and are reflective of the patient population.¹
Provide ongoing in-service training on ways to meet the unique needs of the populations served.³
Ensure that all clinicians are aware that individuals with same-sex partners may not identify as gay/lesbian, particularly teenagers and young adults. Avoid making assumptions based on identity.⁵
Training on transgender health issues and availability of clinical resources should be provided to all clinic staff and providers, including front desk staff, and should be integrated into the standard hiring and on-boarding process for all employees.^6-9
Ensure intake forms include a way to document patient’s preferred name and gender pronoun.

Institute procedures to ensure that patients preferred name is used by all clinic staff at every visit, regardless of whether the patient’s preferred name is identical to the patient’s name as listed in the electronic health record system.^{6, 9}

Assess the limitations of the clinic’s electronic health record system in providing trans care and ensure the patient is advised in advance of potential obstacles. Examples include:

Challenges that may arise with any gendered forms of care (such as Pap smears, mammograms, prostate exams, Plan B, etc.)
Rejection of coding if the gender associated with the service is incongruent with the gender on record.

Policies should either define all bathrooms as gender-neutral or specifically state that patients may choose the women’s or men’s rooms according to their own preference.^{6, 9}
Prioritize the recruitment of staff who reflect the patient population and possess skills to effectively interact with diverse patients.

Specify key characteristics such as training in cultural competency, experience providing services to diverse and underserved populations, and demographics similar to patients served.³

Hire individuals for entry-level positions (community health workers, medical assistants) with backgrounds closely matching those of patients, close community ties, firsthand knowledge of cultural practices relevant to sexual health, and the ability to speak more than one language.³
Conduct a community needs assessment or partner with the local Public Health Authority and/or CCO to do so. Gather input from an advisory board, including CCO Community Advisory Committee. Create and/or strengthen relationships with the community, patients and their families.³ Create new partnerships and programming as needed in response to these findings.
Conduct outreach activities to underserved communities such as holding town hall meetings and community health fairs, and establishing community advisory panels.
Use a system to collect distinct racial categories in demographic data, such as REAL+D race, ethnicity and language (REAL) and disability (+D).⁴

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

COMPONENT 1.4

Language/Health Literacy/ Communication

Definitions

Limited English proficiency (LEP):

refers to individuals who are unable to communicate effectively in English because their primary language is not English.

Health literacy:

defined by the HHS National Institutes of Health as the degree to which individuals have the capacity to obtain, process and understand basic health information and services they need to make appropriate health decisions. Patients with limited English proficiency (LEP) and/or limited health literacy are less able to access health care services, understand health-related information and follow health care instructions. Limited English proficiency and poor health literacy are associated with poor health outcomes and higher health care costs. Clinicians and patients need to be able to understand each other. If patients with limited English proficiency lack access to language assistance services, they will have a difficult time understanding the care they receive and will be less satisfied with services

Universal precautions for health literacy:

steps that practices take when they assume that all patients may have difficulty comprehending health information and accessing health services. Health literacy universal precautions are aimed at:

Simplifying communication with all patients and making sure they understand information, to minimize the risk of miscommunication.
Making the office environment and health care system easier to navigate.
Supporting patients’ efforts to improve their health.⁴

Non-written formats:

verbal formats and graphic formats such as visual brochures, videos, infographics, and graphic demonstrations.

Strategies

Use the Ten Attributes of a Health Literate Organization to guide thinking/implementation.¹
Offer language assistance to patients who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.²
Use “I Speak” cards with patients who do not speak enough English to respond to questions about language preference, to identify the language they speak.³
Display interpretive services posters in waiting and reception areas to make patients aware that free interpreter services are available.²
Ask all new patients what language they prefer to speak and read, and if they would like an interpreter. Record patients’ language assistance needs in the medical record.^3,4
Practice universal precautions for health literacy.^3,4
Assess whether patient materials are easy to read and understand.^3,4,5
Assess and meet the direct language needs of patients during visits by using clinicians who speak the same language, providing in-person interpretation by trained language interpreters and using visual aids.²

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

COMPONENT 2.1

Assess for Pregnancy Intentions

Strategies

Pregnancy intention screening may take different forms depending on the patient’s needs and the relationship between the patient and her/his clinician. Regardless of the format, pregnancy intention screening should be patient-centered.

Screen for pregnancy intention as part of initial continuing health assessments. Pregnancy intention screening/counseling should assess the patient’s current desire to become pregnant.^1-4

Routinely ask patients about satisfaction with their current method and extent to which current method aligns with pregnancy intention. Method satisfaction is a key factor associated with continuation/discontinuation.^2-4

Recognize that pregnancy intentions are often complex and multi-dimensional.

Many patients experience ambivalence regarding pregnancy and parenting desires.
Facets of pregnancy intention may include the strength of patient’s motivations in avoiding pregnancy, their expected emotional reaction if s/he were to become or cause their partner to become pregnant, and the perceived support of the partner.^1-4

Provide preconception and/or contraception services, based on the patient’s pregnancy intention, during the current visit, in subsequent visit(s), or through coordinated referral.^1-6

Some populations, such as males, adolescents, and LGBT patients, may be less likely to receive pregnancy and parenting intention screening in a typical clinic setting.

Research on the effectiveness of existing pregnancy intention screening tools and methods among special populations is ongoing but limited. Some adaptation may be necessary to ensure that screening is culturally appropriate and patient-centered.

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

COMPONENT 2.2

Counseling and Education

Definitions

Patient-centered counseling:

Counseling that is respectful of, and responsive to, individual patient preferences, needs and values. This approach saves time and encourages patient decision-making and responsibility.

Effective contraceptive counseling and education is a two-way process. By asking questions and listening to what patients
say, we experience bi-directional learning. Patient-centered counseling benefits patients because it addresses their concerns, focuses on their needs and results in positive health outcomes. It benefits clinicians by saving time, decreasing stress and frustration, and increasing effectiveness and professional engagement.

A range of factors can influence a patient’s choice of a contraceptive method. Personal preferences, relationship characteristics, social influences, pregnancy intentions, and cultural considerations may affect the decision-making process. The contraception care provider has an important role in assisting patients with their decisions. First, by listening to the patient—eliciting concerns, interests and goals related to pregnancy prevention. Then, by providing clear and accurate information about the full range of contraceptive options, emphasizing those most aligned with patient-expressed desires.

Strategies

Ensure clinical proficiency with one or more evidence-based or nationally endorsed patient-centered counseling techniques and approaches. Examples include:

The Five Principles for Providing Quality Counseling, as laid out by the Center for Disease Control and the Office of Population A airs in Providing Quality Family Planning Services.¹
Teach-Back Method: a practice based on the health literacy principles of plain language that confirms patient understanding and improves patient outcome. This method is also effective in ensuring the clinician can explain back to the patient what the clinician heard regarding the patient’s preferences.²
O.A.R.S.: a skills-based model of interactive techniques adapted from a patient-centered approach, using motivational interviewing principles.³
PC2 You Decide: a five-step approach to guide clinicians in helping patients choose a new contraceptive method, understand cardiovascular risks associated with combined hormonal methods, and address patient concerns.⁴

Offer annual training and resources that maintain clinician knowledge and understanding of all FDA-approved contraceptive methods. Ensure contraceptive counseling reflects current practice standards.^5,6,7

Ensure clinicians have access to the most current versions (print and/or electronic) of the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 and the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 for all contraceptive counseling and education providers.^5,6
Consider training on the tiered approach to counseling. In this approach, the most effective, reversible long-acting methods are presented before less effective methods, and include methods that may not be available on-site. Tiered counseling should start at the patient’s experience level and be based on their stated preferences and goals. It is particularly important to be mindful of historic experiences of coercion and forced sterilization among communities of color and other vulnerable populations.

As a result of counseling and education training and resources offered, clinicians should be able to demonstrate the following skills.⁸

Establish rapport: The ability to establish rapport and gain insight into the patient’s personal circumstances and challenges can help the clinician to individualize information and guidance.
Engage patients as partners in their own care: The ability to engage the patient in developing a plan that includes setting goals, discussing possible difficulties and challenging situations, and considering backup plans and follow-up (see Component 2.8: Patient Support for Contraceptive Management).
Use education and decision aids: Appropriate use of decision aids (paper or computer-based) during the counseling visit to help patients self-assess, learn about methods, and develop questions for the clinician.
Build trust: Competent interpersonal skills that build trust allow for greater insight into the patient’s cultural and personal context.
Interpersonal communication skills: Nonjudgmental listening and empathy can be especially important in sexual health discussions.

Offer training in Implicit Bias in addition to Cultural Competency. Consider innovative approaches to understanding implicit biases of clinicians, such as videotaping encounters to analyze for patterns and examining relevant data (e.g., examining contraceptive methods used by patients of different racial and ethnic backgrounds across individual clinicians to see whether there are differences in method provision).

Competencies 1.3 Special Populations/Diversity and 1.4 Language/Health Literacy/Communication include strategies and resources related to the provision of culturally and linguistically appropriate counseling and education services.

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

COMPONENT 2.3

Condoms and Vasectomy Services

Definitions

Males:

in this context, refers to patients assigned male at birth who are having sex with women.

Males are increasingly recognized as a key part of preventing unintended pregnancies, as well as planning and supporting healthy pregnancies. Several strategies can be used to increase their involvement in the spacing and timing of pregnancies.

Strategies

Order condoms in bulk to receive price discounts.

Make condoms available in restrooms and at the front desk. This allows patients access at no cost to them and without an appointment or use of clinic staff.

Offer condoms to males and females at a variety of visit types.

Make available various types of condoms (latex and non-latex; lubricated and non-lubricated; different sizes).

Demonstrate to patients the best techniques for applying and removing condoms using a penile model.

Discuss dual protection of methods (condoms provide excellent back-up to other contraceptive methods and are the only contraceptive method that also protects against the transmission of STIs).

Strategies specific to Vasectomy Services

Obtain a memorandum of understanding (MOU) or formal contract with a partner organization to accept referrals for vasectomy.
Ensure the MOU/contract addresses the provision of services across payer sources. Ensure the MOU/contract addresses who will perform the pre-procedure counseling; post-procedure semen analysis; and deal with any complications/emergencies.
Provide patient with counseling on vasectomy, including the permanent nature of the method, to ensure appropriate referral is made.
To prevent delays, obtain patient consent for sterilization using the federal sterilization consent form.

Fax or email the signed consent form and relevant medical information to the referred clinician.
At the time the patient requests the service, offer to call and schedule an appointment with the referred clinician.

Follow-up on referral as described in Component 3.3: Linkages to Primary Care and/or Chronic Disease Care Management Services.
Accept referrals for vasectomies from outside agencies and across payer sources.
Ensure that patient instructions after the procedure include direction for after hours’ emergencies, interim contraception and post-procedure semen analysis.
Have a system in place to obtain and follow up as needed on post-procedure semen analysis.
Follow nationally-recognized recommendations for all aspects of the procedure.
Ensure that referrals received are tracked. As appropriate, share information with the referring provider.

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

COMPONENT 2.4

Services for Youth

Definitions

Adolescent:

a person in a period of human growth and development that occurs after childhood and before adulthood, from ages 10 to 19.

Minor:

a person under the age of 18.

Youth:

a person under the age of 24.

Strategies

When serving adolescents, special considerations are essential for high quality services.

Confidentiality

– Ensure all clinic staff are familiar with minor rights to access and consent to health care.¹

– Schedule slightly longer visits with adolescents so they have time to ask questions and get answers to their questions.²

– Create counseling areas that provide visual and auditory privacy.

– Ensure examination areas provide visual and auditory privacy.

Ensure that all patients, particularly youth, are aware of the Oregon Confidential Communication Request law. This law gives patients enrolled in a private health insurance policy the right to request that protected health information is sent directly to them instead of the person who pays for health insurance.³

Mandatory Reporting

– Encourage youth to communicate with parents or other trusted family members as appropriate. If the adolescent has not talked with her/his parent(s) about sexual health, be sure that the adolescent lives in a safe environment before counseling her/him to do so.^2,4

– Provide staff training and support on mandatory reporting.

Cost and Billing Transparency

– Use billing procedures to maintain patient confidentiality. If this is not possible, advise the patient about the potential breach of confidentiality. Provide alternative billing options such as self-pay on a sliding fee scale.⁵

Quality adolescent services are patient-centered, respectful and developmentally appropriate.

Youth-friendly Services

– Ensure all clinic staff receives training in adolescent development and treating youth respectfully. Involve the adolescent in her/his own health management.²

– Seek youth input on clinic services, such as having youth members on a clinic advisory board and/or active youth involvement in design of and feedback about programming.

– Consider adding trained peer counselors/mentors/ instructors to team.

– Consider offering a “teen clinic” or clinic hours that accommodate teen schedules.

– Ensure services are “youth-friendly”: accessible, equitable, acceptable, appropriate, comprehensive, effective and efficient for youth, as recommended by the World Health Organization. Examples include youth-friendly/specific materials, effective communication skills, etc.

Parent/Guardian Involvement.⁶

– Communicate with each patient that they may have their examination and counseling without parents or guardians present, and that their privacy is respected.

– Inform parents and guardians of the health center’s standard procedure for the provider to spend time alone with patients to discuss their comprehensive health and wellness.

– Give clear information to parents and guardians of the patient’s right to confidentiality, privacy and informed consent.

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

COMPONENT 2.5

Services for Postpartum and/or Breastfeeding Women

Strategies

Ensure the clinic is breastfeeding-friendly for patients and staff. Breastfeeding and postpartum women will feel more comfortable seeking services in an environment that is receptive to their needs.¹

Encourage and support access to contraception services prior to resuming sexual activity, which often may occur before the routine six-week postpartum visit. Encourage contraceptive use prior to resuming sexual activity.^2,3

Offer a broad range of methods and ensure staff can counsel and support the use of each available contraceptive method, including Lactational Amenorrhea Method (LAM).^2,3

Discuss the spacing of pregnancies and the patient’s reproductive life plan during pregnancy and in the postpartum period. Offer contraception that supports patient’s plan.^2,3

Obstetric providers should counsel pregnant women about all forms of postpartum contraception in a context that allows informed decision-making. Immediate postpartum LARC should be offered as an effective option for postpartum contraception.^4,5

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

COMPONENT 2.6

Contraceptive Supplies

Definitions

Broad range of FDA approved methods:

includes a choice of combination oral contraceptives (phasic and monophasic), at least one non-oral combination contraceptive (ring or patch), a progestin-only pill and injectable, IUD and IUS, sub-dermal implant, latex and non-latex male condoms, female condoms, two types of spermicide, diaphragm or cervical cap, Fertility Awareness Method (FAM), emergency contraception pills (ECP) for immediate use, information about abstinence and withdrawal, and information and referral for sterilization.

On-site:

on the premises, such as in the clinic, in the building or on the campus, so that a patient does not have to travel to another location such as a separate retail pharmacy.

Strategies

Contraceptive choice is an important aspect of quality care as patients may be more likely to select a method that fits her/his unique circumstances.

Provide a broad range of FDA-approved methods available on- site or by referral.²

Administer EC for immediate use on-site according to proven efficacy guidelines for appropriate weight and body mass index (BMI).^3,4

Dispense up to a one-year supply of FDA-approved methods on-site. Dispensing a one-year supply of pills is associated with a 30% reduction in the odds of conceiving an unplanned pregnancy, compared with dispensing just one or three packs.⁵

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

COMPONENT 2.7

Contraceptive Procedures: LARC Insertion/Removal and Diaphragm Fitting

Strategies

Remove barriers/delays to receiving LARCs. For example, do not require Pap test or negative STI results for asymptomatic patients prior to inserting LARCs.¹
Train staff on insertion/removal procedures for all LARCs (including assistive staff). Offer annual LARC update training.¹
Arrange mentorship programs for clinic staff and provide mentoring for outside clinicians.¹
Encourage single-day insertion appointments.^1,2
Maintain an adequate supply of LARCs to ensure same-day availability and use of Paragard® as EC.^1,2
Train staff on diaphragm fitting. Offer Caya® as an alternative diaphragm that doesn’t require fitting.
Stock and dispense spermicidal formulation appropriate for use with a diaphragm.

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

COMPONENT 2.8

Patient Support for Contraception Management

Strategies

Many of the strategies and resources recommended in Component 2.2: Counseling and Education are relevant to this Component. The strategies below are also recommended to support patients and their use of contraception.

Provide education for contraceptive methods that are based on the patient’s stated needs and priorities.

Include medical contraindications as appropriate, prior to initiation and throughout reproductive health care, as patient lifestyle, reproductive goals, medications/ contraindications and side effects will change.^1,2,3,6

Use decision aids and a tiered counseling approach for nonjudgmental, accessible patient problem-solving. This will increase effective adoption, change, and maintenance of contraception of choice.^1,2,3,4,6

Co-create a patient-centered plan for contraceptive choice using the highest degree of consistent correct use of method.^1,2,3

Confirm the patient’s understanding of their method of choice.

Address safety concerns and how to contact the clinic when they have questions or concerns.
Ensure that all clinics have a 24-hour call-back policy for patient telephone calls about contraceptive concerns. Communicate this to the patient.^1,2,3,5

Create a follow-up plan to sustain the method (follow-up visit in three months, IUD check appointment in six weeks, etc.).

Encourage immediate contact with the clinic about concerns, uncertainty about maintaining methods as planned, adjustments, and emergency contraception as needed.^1,2,3,4,7

Use effective reminders such as text messages or reminder cards for Depo shots or refills.^1,7

Train staff as to how they will route triage calls from patients with contraceptive questions, or who need emergent care or to make a follow-up appointment.^1,6

For example, will staff send calls to one person or is everyone trained?

Maintain staff supports for providing quality contraceptive care: updated evidence-based training on methods, standing orders for RNs to dispense methods, updated clinic reference resources (e.g. QFP, Contraceptive Technology, etc.).^1,2,3,6

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

Linkages to Contraception Services

Strategies

Conduct an organizational assessment to identify which clinicians can o er the full range of contraception options, including procedure-based methods such as sterilization, IUDs, implants and diaphragm fittings.

Determine which ones are only comfortable with prescription-based methods.
Ensure good communication regarding which clinicians offer which services so that patients can be referred internally first.^1,2

For any contraceptive methods not available within the clinic, identify clinicians in the community who are willing to serve as a referral resource. Communicate with them about how to optimize referrals for those services.^1,2
Ensure that counseling documentation reflects the fact that all methods were offered to the patient. If the patient chooses a method not available, document the clinic to which the patient was referred.
If as a result of this self-assessment your clinic scores as an “expert-level” provider, then draft a letter to the practice managers of local provider offices that: introduces your practice as an expert-level contraception practice; reviews the contraceptive methods your practice offers; and explains your availability as a resource to provide telephone consultation or patient referrals with contraceptive complications or difficult contraceptive management issues (e.g. ultrasound on-site).

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

Linkages to Social and Behavioral Services, Including Domestic Violence/ Mental Health/Substance Abuse

Strategies

Consider screening all patients for domestic violence and distribute Safety Cards routinely (available from Futures Without Violence).¹
Consider screening all patients for depression using the Patient Health Questionnaire (PHQ-2).²
Consider screening all patients for Substance Use Disorders using the SBIRT tool.³
If patients express difficulty in meeting basic needs such as food, housing, transportation or child care, refer them to 211 Info. Or help patients, if willing, to call 211 Info from the clinic.⁴
Identify key mental health, domestic violence and substance use treatment providers in the community.

Maintain an up-to-date list of their contact information.
211 Info can also be used for this purpose—clinicians can call to find out where to send patients in their community.⁴

When a social or behavioral health concern arises as part of the patient’s visit, document any referrals made or phone numbers/ contact information given to the patient.
Mental health, substance use treatment and domestic violence providers are usually restricted from communicating back with referring clinicians, to protect the privacy of the patient. Documenting that the referral was made is usually sufficient, although it is good practice to check back with the patient to make sure they received needed services.

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

Linkages to Primary Care and/or Chronic Disease Care Management Services

Strategies

If your clinic is a specialty family planning provider, identify primary care providers in the community who are accepting new patients, including Medicaid and uninsured patients. Communicate with them about the best ways to refer patients in need of primary care and/or chronic disease management.^1,2
Primary care providers and specialty family planning providers should consider developing cross-referral agreements or contractual collaborations when they serve the same community.

Cross-referral agreements allow for primary care to refer contraceptive patients to family planning for services they do not provide, and for family planning to refer patients to primary care for services they do not provide. In this type of agreement, it is important to understand the parameters for appropriate referrals for each organization to avoid frustrating the patients.
Sharing space or co-locating with the family planning center, allows primary care to provide family planning services to its patients. More detail on these arrangements can be found at the Guttmacher Institute link below.¹

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

Evaluation of Patient Experience

Definitions

Patient experience:

defined by The Beryl Institute as “the sum of all interactions, shaped by an organization’s culture, that influence client perceptions across the continuum of care.” (The Beryl Institute, http://www.theberylinstitute.org/?page=definingpatientexp)

Strategies

Place a comment box, clinic journal or bulletin board in the clinic for patients to provide feedback and comments about their care.¹

Such passive assessments will give a highly selective perspective from a small subsection of motivated patients. Some complaints may be very situational and not necessarily useful for motivating clinic changes.
In a family planning setting, privacy concerns must be carefully protected. Thus, the handling of comments should be clearly posted (e.g., who will have access to them and how they will be discarded).

Conduct active evaluation activities such as a patient satisfaction survey (paper or online), exit interviews, telephone audit, mobile survey and focus groups.^1.2

Validated patient surveys designed to evaluate patient’s primary health care experiences and interactions with their clinicians are available. Identify survey questions that are relevant to contraceptive care and for evaluating patient perceptions of cultural competency, information delivery, patient-centered communication and interpersonal care from these sources and use them to develop a brief instrument.^2,3,4
Include an open field for patient comments to obtain feedback not captured by the survey items.
The survey can be administered to all patients for a set period (e.g., two days, one week). This can be done twice a year or less frequently, depending on available resources. Alternatively, the survey can be available at all times to all patients (see passive assessments above).

Use survey findings and resulting actions to:

Congratulate staff on their efforts,
Communicate to patients that the clinic staff care about their needs and preferences by posting information in waiting areas about current improvement efforts, and
Share with board members, funders, Coordinated Care Organizations and/or accreditation organizations.¹

Establish procedures for ongoing quality improvement based on the information collected. After conducting the evaluation (active or passive), involve clinic staff in reflection on the results without assigning blame. Encourage a culture of problem solving to improve care.^1,2,4,5,6,7

Involve staff who are being assessed in all stages of the evaluation process: data development, collection and analysis.
The Plan, Do, Study, Act model (see Institute for Health Care Improvement resource below) for systematically improving quality of care involves staff in developing a plan, pilot testing, evaluating and permanent implementation.⁸
Teach leadership how to evaluate services and share data in positive, productive, systems-focused communication styles.

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

COMPONENT 1.1

Timeliness of Care

Definitions

Quick start protocols for contraception initiation:

refers to the initiation of contraception on the day of the visit.

Third next available appointment:

refers to the average length of time in days between the day a patient makes a request for an appointment and the third next available appointment. The third next available appointment is used rather than the next available appointment because it is a more sensitive reflection of true appointment availability.

Strategies

Reduce unnecessary barriers and facilitate same-day access to and successful use of contraceptives.

For example, do not require a negative chlamydia test result prior to inserting an IUD or a Pap test/pelvic exam in asymptomatic women wanting oral contraceptives.
Follow the Centers for Disease Control and Prevention’s (CDC) U.S. Selected Practice Recommendations (US SPR) for Contraceptive Use to determine the appropriate initiation and use of specific contraceptive methods.¹
Use the “quick start” method to provide patients with protection from unplanned pregnancy faster and more reliably.²

Develop written policies that include directions for phone staff to ask patients if they need a same-day appointment.

Establish a process to schedule these appointments as requested.
Ensure clinic workflows accommodate appointments for patients with urgent needs, including double booking as needed.
Consider maintaining at least 10% of the average number of daily appointments unfilled at the start of the business day based on an audit of a representative sample.^3,4

Assess and understand the patterns of both demand (i.e., daily number of patient requests for appointments) and supply (i.e., clinical resources/members of care team available to the clinic) in clinical practice.

Adjust supply based on fluctuations in demand.
Use team members to expand access by having them provide all intake and education. Use medical providers only as needed for top-of-license work.
The Institute for Healthcare Improvement (IHI) measures access to care as the average length of time in days between the day a patient makes a request for an appointment and the actual appointment.⁵

See Domain 2. Service Provision: Component 2.6: Contraceptive Supplies, for information on stocking birth control methods on-site.

Resources for this component can be found in the Strategy and Resource Guide located in the menu on the upper right-hand side of the page

Self-Assessment Instructions

It is recommended that the Tool be used and completed by a team of staff members who are involved in the delivery of reproductive health services within the clinic, to ensure all staff roles are represented. Examples include clinicians, medical assistants, administrative and billing staff, reception and appointment schedulers, interpreters, lab and pharmacy staff, medical director, clinic manager, nurse supervisor, etc. Once your team is assembled:

Step 1:

Review the overview of the Oregon Guidance for the Provision of High-Quality Contraception Services: A Clinic Self-Assessment Tool. Or you can download the print version to review the full assessment.

Step 2:

Discuss the process and logistics for completing the Tool as a team. (Alternatively, the team may divide into several pairs or small groups to assess specific domains, followed by a team meeting to share and discuss results.) If more than one person from your clinic will be completing the assessment, you will need to use the same username and password as the person who registered.

Step 3:

Review each measure, discuss with team members and select the numbered response that best describes your clinic’s practice. Complete all measures in each component and all components in each domain. When you’ve completed an entire domain, click “Submit Domain.” You can complete the domains in whatever order you choose and can complete the assessment in more than one session.

If you have already submitted a domain, you can go back and change your answers. To save your new answers, click “Submit Domain” again

Scoring

Once you’ve completed all four domains, the Tool will tabulate your scores and provide an overall score, along with the option to download your clinic’s custom summary report.

Overall score of 70 or above: Clinics that score 70 or above are considered expert contraception providers. While these clinics would routinely provide care at the highest level, most clinics – even at expert level will have room for improvement.
Overall score of 50 to 69: Clinics that score between 50 and 69 are considered quality contraception providers.
These designations are to be considered along a continuum because clinics will have areas of relative strength and weakness. Thus, the designation of quality versus expert is likely to be fluid over time.

Step 4:

Consider the following guidance when completing the Tool:

Keep the patients’ perspective in mind when scoring each measure.
Avoid making assumptions about how another clinic staff member may score a measure. Solicit input from the appropriate staff to ensure accuracy.
Measures with “uncertain” or “do not know” responses may require further team discussion and/or consultation with another clinic staff member.
Try to score each measure in a way that represents the majority of relevant clinic staff, not the experience or capacity of any one provider within the clinic.

Step 5:

Summarize the findings with your team and determine next steps:

What are the most important domains and components for your clinic to address?
Prioritize which components your clinic would like to focus their improvement efforts on.
Review the Strategy and Resource Guide for resources and recommended strategies.
Create an action plan for improving your clinic’s scores on priority components.
Consider integrating the priority components into your clinic’s quality improvement plan.
Identify and highlight the strengths of your clinic in the provision of contraception services and consider how your clinic might build on those strengths.
Determine how your clinic can communicate the Tool results to relevant audiences and develop a plan to do so.

If you have any questions, concerns, or feedback about the Clinic Self-Assessment Tool, please contact the Oregon Reproductive Health Program at: [email protected].

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COMPONENT 2.1

Assess for Pregnancy Intentions

Strategies

Resources

COMPONENT 2.2

Counseling and Education

Definitions

Patient-centered counseling:

Strategies

Resources

COMPONENT 2.3

Condoms and Vasectomy Services

Definitions

Males:

Strategies

Strategies specific to Vasectomy Services

Resources

COMPONENT 2.4

Services for Youth

Definitions

Adolescent:

Minor:

Youth:

Strategies

Resources

COMPONENT 2.5

Services for Postpartum and/or Breastfeeding Women

Strategies

Resources

COMPONENT 2.6

Contraceptive Supplies

Definitions

Broad range of FDA approved methods:

On-site:

Strategies

Resources

COMPONENT 2.7

Contraceptive Procedures: LARC Insertion/Removal and Diaphragm Fitting

Strategies

Resources

COMPONENT 2.8

Patient Support for Contraception Management

Stategies

References

Strategies