Systems change: Baseline assessment

Do: Step 1
This process has four elements, in this order: Plan, Do, Study and Act.

After a scope of work has been established, the first step is to conduct a baseline assessment. A baseline assessment will measure the clinic’s current screening rate (or other determined measure). This is important to document, as it will serve as a reference point for assessing whether the intervention was effective in accomplishing the intended objective. Plan a reassessment of measurements six months to one year after implementing the intervention.

There are a number of considerations when determining which type of baseline assessment is right for each clinic. If the clinic uses paper charts, a chart audit will be necessary. Keep in mind that chart audits are time-intensive and may require outside technical assistance. It is ideal to coordinate this assistance for the clinic if possible, to reduce any burden on their staff time.
If the clinic has an electronic health record (EHR), a review of the required data may be possible. Many clinics have upgraded to an EHR recently, so older health records are still in paper form. Therefore, a combination of a chart audit and EHR review may be necessary to arrive at the most accurate numbers.

Someone at your LPHA may have the expertise to conduct a chart audit, or you may have to seek an outside consultant. Qualifications for a chart auditor include:
  • A background in biostatistics, epidemiology or related field.
  • Knowledge on how to find and interpret chart information.
The person must have the time to devote to performing the audit. A chart audit typically draws data from a representative sample of the patient population.