The Checklist for Recommendations to Improve Primary Care for SGM Patients (Template 5.1; Appendix A) is a resource for the Implementation Team to think through what needs to happen to improve primary care. For instance, the checklist might reveal that clinic forms include SO/GI questions but that the clinic personnel responsible for collecting these data are not receiving the training and support they need to do so effectively. For each group of recommendations identified in the checklist, the team should determine what next steps would be best for the clinic, based on what is already in place and working.
For each category of recommendations, the team should discuss the importance and potential benefit of moving forward with specific measures it has yet to implement or could do a better job implementing. We have developed a Recommendation Planning Form to help you think through several issues related to the measures that the team is considering. These measures will represent the recommendation goals that are used to organize Action Plans.
When choosing recommendation goals, teams should try to balance the degree to which they represent improvement opportunities and are both acceptable and feasible:
Improvement opportunity, or the extent to which achievement of the goal is likely to result in positive organizational change and/or beneficial impact.
Acceptable, or how clinic stakeholders perceive the recommendation goal as agreeable, appropriate, and satisfactory.
Feasible, or the relative ease involved in realistically attaining the recommendation goal.
Template 8.1 (Appendix A) showcases a Recommendation Planning Form for thinking through such issues. When considering an improvement opportunity, reflect on what is already in place and what needs to happen to engender change. Because some clinic stakeholders may harbor negative attitudes about SGM people, low levels of acceptability should not dissuade the team from moving forward with a particular recommendation but instead prompt ideas for how the team will remove such barriers.
Similarly, when contemplating feasibility, the team should think about anticipated levels of support or push-back, the expense of implementation and clinic personnel time, and barriers that might get in the way of successful implementation. However, the team should also think about possible facilitators, like the presence of solid implementation leadership and change champions, and how it will overcome anticipated challenges that contribute to concerns about feasibility.
| TEMPLATE 8.1 Recommendation Planning Form | |||
| For each recommendation, please rank each criteria item on a scale of 1-5. (1=low, 5=high). | Improvement Opportunity | Acceptable | Feasible |
| The clinic maintains a Patient Non-Discrimination Policy or Patient Bill of Rights that explicitly includes sexual orientation and gender identity. | |||
| The clinic has a systematic process for sharing the Patient Non-Discrimination Policy or Patient Bill of Rights with all patients. | |||
| The clinic has a systematic process for sharing the Patient Non-Discrimination Policy or Patient Bill of Rights with all staff and providers who have direct contact with patients. | |||
The Implementation Team should not move forward with all possible changes or too many goals at once but move forward incrementally, building on successes and lessons learned each step of the way. On the one hand, trying to make too much change too fast can lead to confusion and frustration for all persons involved and decrease success. On the other hand, selecting only easy-to-implement changes may not result in better access and quality of care for SGM patients.
After deciding on its goals, the Implementation Team should brainstorm what will need to happen to achieve them, thinking about what is likely to go smoothly, considering possible roadblocks to implementation, and consulting data from the organizational assessment as part of this process. Based on this brainstorming, the team will develop Action Plans to articulate the work and resource requirements for achieving each of its goals.
Team members should check in with clinic leaders to make sure they know about the goals and support the work. The goals should also be shared with as many coworkers as possible to encourage their participation during implementation. This step will help the team generate insight from diverse clinic personnel and clarify areas of concern or resistance from colleagues that may need to be addressed in the Action Plan. After the team has gathered input from clinic staff and leadership, it can create a plan that lays out the “who, what, when, and how” for each goal.
Template 8.2 (Appendix A) features a sample Action Plan that focuses on the goal of making modifications to an EHR. The team should feel free to modify this plan so that it will work for the clinic. The categories used to frame this particular plan are ones that the team might want to adopt for other Action Plans: Implementation Strategy; Action Steps/Activity; Responsible Party; When; and Resources.
| TEMPLATE 8.2 Action Plan |
Clinic Name: New Mexico Primary Care Clinic | Implementation Team Lead: Carla 0. | Date: 12/06/2021 | |
| Implementation Team Members: Alva R. (IT), Greg C (HR)., Carol A., Leroy B. (Communications), and Carla O. (Nurse Manager/Medical Director) | Others Involved: Jason T. (Training consultant) | ||
Recommendation Goal: Updating EHR System to collect sexual orientation and gender identity information | Duration of Action Plan: 10 months | ||
| Implementation Strategy | Action Steps/Activity | Responsible Party | When | Resources |
| 1. Updating EHR System | A. Assess current system’s collection of SO/GI data and ability of system to be customized. For example, can fields be added? Are there fields that can be used for entering data not captured elsewhere? Are there banners or other indicators that can be utilized? | Alva R. | 1/30/22 | IT personnel, EHR company representative |
| B. Determine what SO/GI data should be captured by the EHR system | Entire Imp. Team | 1/30/22 | HRSA, National LGBT Health Education Center | |
| C. Create structured and discrete data fields based on recommended SO/GI questions while considering placement of fields, limiting free-text responses, and differentiating between default and unknown/missing values | Alva R. | 2/27/22 | IT personnel, EHR company representative | |
| D. Decide which staff will have permission to enter, modify, and view data | Alva R. | 2/27/22 | Clinic director, Lead medical assistant (MA) | |
| E. Review alignment of EHR data fields and data collection forms; determine which data should appear and when and where this data should appear | Alva R. and Carol A. | 3/30/22 | IT personnel, EHR company representative | |
| F. Launch EHR changes | Alva R. | 5/1/22 | IT personnel, EHR company representative, identified change champions, small incentives for staff users | |
| G. Review data collection and EHR system for further adjustments or corrections | Alva R. | 6/1/22 | Health Resources and Services Administration (HRSA), IT personnel, EHR company representative |
| TEMPLATE 8.2 Action Plan (Continued) |
| Implementation Strategy | Action Steps/Activity | Responsible Party | When | Resources |
| 2. Updating intake/registration forms | A. Update intake/registration forms to collect SO/GI information deemed necessary for collection in EHRs | Carol A. | 2/27/22 | Clinic director, Lead MA |
| B. Review alignment of data collection forms and EHR updates | Carol A. and Alva R | 3/30/22 | Lead MA, IT personnel | |
| C. Begin use of new forms | Carol A. | 5/1/22 | Change champions, small incentives for staff users | |
| D. Review data collection and new forms for further adjustments or corrections | Carol A. | 6/1/22 | Focus group activity with MAs and providers | |
| 3. Training staff on new data collection | A. All staff training on LGBT terminology, concepts, and health disparities, communication best practices | Greg C., Carla O., and Jason T. | 2/15/22 | Local HIV prevention organization and LGBT resource center, Human Rights Campaign |
| B. All staff training on why SO/GI data collection is important, how SO/GI data will be collected, and how it will be used for patient care | Greg C., Carla O., and Jason T. | 3/15/22 | National LGBT Health Education Center, University Health Clinic, Human Rights Campaign | |
| C. Clinical staff training: focus on sexual orientation, gender identity, and gender expression; and how to ask and talk about SO/GI data and enter it | Carla O. and Jason T. | 3/21/22 | National LGBT Health Education Center, University Health Clinic | |
| D. Non-clinical staff training: focus on responding to questions/concerns about SO/GI data, how to enter it; and patient information needed for insurance | Greg C. and Jason T. | 3/21/22 | HIV prevention organization, National LGBT Health Education Center | |
| E. Refresher training for all staff on data collection | Carla O. and Greg C. | 4/15/22 | Local HIV prevention organization, state government department of health, Human Rights Campaign |
| Template 8.2 Action Plan (Continued) |
| Implementation Strategy | Action Steps/Activity | Responsible Party | When | Resources |
| 4. Education for patients on new data collection | A. Create an educational brochure or flier about new SO/GI data collection | Leroy B. | 3/30/22 | LGBT Health-Link, office supply |
| B. Display brochure or flier in waiting areas and exam rooms | Leroy B. | 4/1/22 | Clinical director | |
| C. Email blast or mailers to client base notifying of updated EHR and registration/intake forms | Leroy B. | 4/20/22 | Administrative assistant | |
| 5. Checking data and clinical quality reports | A. Run quality check of EHR data collection | Alva R. | 6/1/22, 7/1/22, 8/1/22, 9/1/22 | HRSA |
| B. Decide which areas to include in quarterly clinical quality reports | Entire Imp. Team | 8/1/22 | HRSA, Clinical director, Board of Directors | |
| C. Run first clinical quality report | Alva R. | 10/1/22 | Clinical director, Board of Directors, Third-party evaluation contractor |