The population focus for this quality improvement (QI) project will be women between the ages of 18-45 years, with inclusion of race, ethnicity, employment status, education level, marital status, and sexual orientation. The rationale for not screening older women is that a review of literature has shown that the higher incidence of IPV is experienced between the ages of 16-24 years and that rates decline with age. The location will be a federally funded community health center located in a predominately low socio-economical area. Currently with a brief review of the electronic health record, there is less than 10% screening being conducted and or documented for IPV. The approach will be to use a screening tool recommended by the USPSTF that helps providers screen at the point of service and routinely. The goal is to educate each primary care provider (PCP) on the screening tool, process evaluation, and manageable change to improve IPV screenings.
Interventions and Methods
The Institute for Healthcare Improvement’s (IHI) Plan-Do-Study-Act (PDSA) model will guide this QI project and will be linked to Lewin’s Change Theory via the PDSA tools and principles and Lewin’s concepts (see Table 1). The method that will be internally used will be the Plan, Do, Study, and Act (PDSA) improvement model. In the Plan phase, the Primary Care Providers (PCP) who are involved in the project were educated on IPV background, prevalence, cultural norms that influence screening responses, risk factors, incidence, health impact, comorbidities associated with IPV, screening practices, how to proceed with a positive response, activation of a safety plan, and community resources (i.e. shelters, case workers) for identified or at risk clients. The PCP will consist of one family nurse practitioner. The setting will be in a FQHC in the family practice unit and health and wellness unit.
In the Do phase, recruitment will begin using a script that will provide screening information and details regarding these procedures. If the woman presents to the clinic with their partner, it will be explained to the woman that the partner or children age three years and older should not be present. This will be established ahead of time that it is the office policy to conduct a portion of each visit alone. If the partner resist leaving or insist on staying in the exam room after notification of this policy, the provider will attempt to separate the partner by creating a diversion tactic. An example of this tactic would be to order laboratory testing that is not medically needed to get the woman away from the exam room area. Once the participant agrees to participate, the screening will begin. The screening tool will be used by the FNP. The HARK questionnaire will be given at each encounter via face-to-face interview, and then results placed in the iEHR. Clients will have the right to decline this portion of the visit. Reminders will be placed in the exam rooms in the form of posters that remind to screen or paper handouts. The FNP will review responses and further assess any positive responses. If the woman identifies that they have been abused while the partner is in attendance, assistance with safety planning will begin in addition to a readiness to leave the relationship. Also identification of minors being involved or having witnessed the abuse; assessment of high risk harm or injury, including homicide will take place; promote a safe haven; enter phone number of a local shelter in woman’s phone under a code name, respect of autonomy and the right to make decisions about what to do; and respect of confidentiality.
In the Study phase 50 women will be screened over an eight-week period. If the screen is negative, the woman will be educated on IPV and given educational material with quick facts on IPV. For those who screen positive during the initial screen, the PCP will then further assess the type of violence the client has experienced and document in the Electronic Health Record with a referral and hand-off to behavioral health, a PMHNP, or a Licensed Clinical Social Worker (LCSW). Furthermore, a safety plan will be activated, and information on community resources such as shelters and emergency point of care will be offered.
In the Act phase based on the data collected in the study phase, interventions will include trauma-informed care with the execution of an escape plan. If the PCP does not feel comfortable with the positive screen, a provider-to-provider hand off will be given. Next, if the woman request they can be placed in an advocacy program such as housing or a women’s shelter for victims of IPV with continued education on intimate partner violence, awareness of violent triggers, escape plan (until out of the crisis), and access to healthcare. There will be continued follow up visits while discussing factors predisposing to violence, knowing when to deescalate perceived violence. Small pocket cards with emergency numbers to call will be given with information to community resources. The advanced practice team will ensure that there are resources available in the community along with follow-up on them having a plan, advice and prevention of future violence with providing motivators to leave (IHI, 2018).
In total, the primary care provider screened 50 women who identified as female during the recruitment phase, but only 33 were eligible to screen. One participant was screened twice out of the 33 women who were eligible. The completion for these screenings was at a rate of 66%. The average age of the women screened was 40 years. 87% (29) were African American, 0.6% (2) were Latino/Hispanic, and there were no women who identified as Caucasian during this screening. Screening results also showed that two (0.6%) of the women screened positive for at least two of the questions asked on the HARK tool (Appendix B, Table 2). One woman screened positive for physical abuse while the other screened positive for verbal abuse. No one disclosed that they were afraid of their partner.
The ages of the two women who screened positive were 18 and 44 years, it should be noted that two different age ranges were captured as positive. These women did not have any existing conditions or substance abuse issues documented at the time of screening. The 18-year-old was a fulltime college student and the 44-year-old was employed fulltime. Both women were scheduled at the end of their visit with warm hand-off directly to the PMHNP for continuation of care, offered community resources such as housing, a list of contact numbers, IPV fast facts, and safety planning. The client who screened the highest, was no longer engaged with the perpetrator. Overall, the screening interventions were completed safely and as documented in the procedure section.
Internal Review Board (IRB) approval was obtained prior to initiating this project. All participants were protected by the Health Insurance Portability and Accountability Act of 1996 (HIPPA) which, among other guarantees, protects the privacy of patients’ health information. All information collected as part of evaluating the effect of this project did not include any patient identifiers. All electronic health records containing patient identifiers were password protected to prevent unauthorized use. Only the principal investigator had access with their own unique password.
Implications to Practice
The project findings confirm that the sites used for the screenings need to implement reminders to screen and to develop a QI project utilized towards improving those screenings. Screening for IPV should not only occur in the obstetrical setting but should occur in every setting where women are seen for health care services. As per recommendation of the USPSTF, screening for IPV should remain the standard of care. A screening tool, such as the HARK questionnaire can utilized and is effective in centers that are fast-paced and that have time constraints. This project furthermore supports the need for continuous education of the clinical staff in regards to screening and to raise awareness of victims of violence (Alshammari, McGarry, & Higginbottom, 2018).
In addition, primary care providers should collaborate closely with the informatics personnel to further design the interpretation of the results and how to retrieve those findings from the iEHRsystem for ease of the referral process. The HARK form is already in place but providers have stated that they are not utilizing it due to unknown knowledge of its placement in iEHR or due to time restraints during patient care. It was also suggested that other support staff should be trained to screen and hand-off positive results to the provider for further evaluation. It is also recommended that the organization have reminders placed in iEHR and in the exam rooms to screen at periodically or when suspicion arises. Since screenings are already in place in the Obstetrical units, it should be expanded into the primary care and primary mental health units.
Furthermore, providers who implement the screenings should have a positive attitude towards the screening process and towards the clients who they screen, and continue to screen at every visit. It is important that providing a safe environment for the client for disclosure purposes and for support. Although providers have advanced skills to detect illnesses, trainings should be offered to other support staff that is in direct contact with the client with the aim to capture higher incidences of IPV. It is also important for collaboration of the primary care and behavioral health teams to ensure proper hand off and expedient access to resources that can improve client safety and enhance client empowerment. Proper referral is the key to promote advocacy, empowerment, decreased risk, and education on the different types of violence against women.
The key findings of this QI project include that this site can add improving IPV screenings as a performance improvement measure. The benefits of the outcomes of this project were useful. Although screenings were not routinely done, there was identification that more screening needed to take place. A screening rate of 66% showed much improvement than the previously stated 10% rate and the beginning of implementation. Limitations to the project were that there was a small sample size and that there is a possibility of screening results veracity of the clients that were screened. Improvement is needed in reminding providers of the importance of screening women regardless of the health care setting.
The screening rate of 66% of eligible women screened was able to capture at least two positive results. One was at the age of 18 and 44 years, which showed some variance of the age groups who is reported to have a higher incidence of IPV. Of the positive screens, one woman had already left the relationship while the other was not ready to leave. After collecting this data and following the flow of the implementation phase, the outcomes demonstrated that the site could safely carry out IPV screenings. Future recommendations of this project will be to continue to screen in other areas of the primary care setting and to detect violence against women sooner so that client safety is enhanced.