The Center for Quality Improvement & Innovation recognized the Eskenazi Health Infectious Diseases Clinic for outstanding work in quality improvement for engaging staff and patients in data-driven change and raising cervical cancer screening rates through quality improvement by presenting Eskenazi Health with the 2025 Quality Award in the category of Measurable Improvements in HIV Care.

The mission of the Infectious Diseases Clinic is to provide person-centered services, education and support to prevent and treat infectious diseases so that those served may lead healthy and fulfilling lives. The interdisciplinary team, including care coordinators, doctors, interpreters, nurses, nurse practitioners, pharmacists and social workers, partners with each of their more than 1,500 Ryan White HIV/AIDS Program clients to deliver high-quality care through individualized treatment plans, education and access to clinical trials. This includes care coordination services supported by the Indiana Department of Health and the Marion County Public Health Department in which social workers and care coordinators help prevent interruptions in care and promote healthy living by linking clients to psychosocial and support services.

In March 2023, the Infectious Diseases Clinic embarked on a two-year quality improvement project to increase the percentage of patients with the Ryan White HIV/AIDS Program who are up to date with the Adult and Adolescent Opportunistic Infections guidelines. The department chose to focus on cervical cancer screenings because it had been the lowest-performing Health Resources and Services Administration HIV/AIDS Bureau performance measure for many years. Baseline data from the end of 2022 showed that only 43.8% of eligible patients received a cervical cancer screening.

To decide on interventions for improving cervical cancer screening compliance, an interdisciplinary subcommittee of the Infectious Diseases Clinic’s Clinical Quality Management Committee first identified specific barriers faced by the client population by completing an Ishikawa (fishbone) diagram. These barriers included a lack of connection to a primary care provider, time to get an appointment with a gynecologist, lack of trust in providers outside of the Infectious Diseases Clinic, and lack of education around the increased risk of cervical cancer in people with HIV. The interventions employed were tailored to address these unique challenges, which were related to patient factors (like knowledge and fear), provider practices or systemic issues (like cost and access). It was clear that a combination of approaches would be needed to improve compliance with screening.

Using the Plan-Do-Study-Act methodology as the framework to guide their project, the Infectious Diseases Clinic team tested four interventions that were key to driving improved performance. First, to increase access to gynecological services, the team brought in a gynecologist for one four-hour clinic session per week. Next, the team developed a report in Epic to determine which patients needed a screening. In advance of patient appointments, medical case managers would review the monthly report, contact eligible patients by phone and notify them that their provider plans to perform a cervical cancer screening at their next appointment. This allowed patients time to prepare for the procedure and to consider any questions they wanted to ask their provider. Lastly, Infectious Diseases Clinic providers modified their note templates to standardize documentation of discussions and education related to cervical cancer screening at every visit. By the end of the project, cervical cancer screenings increased from 43.8% at baseline on April 1, 2023, to 65.7% at the end of the project on March 31, 2025.

For this project, the team built a report in Epic to accurately define the patient population and track cervical cancer screenings to supplement reports generated by CAREWare, the electronic health and social support services information system for Ryan White HIV/AIDS Program recipients and providers. The Epic report became the backbone for monthly monitoring and helped foster accountability. Results were shared in staff and quality improvement meetings, keeping the project highlighted, and sparking discussion of barriers and next steps.

Early on, one of the biggest hurdles was getting buy-in from all clinic staff, including providers, care coordinators and case managers. Although everyone understood the importance of cervical cancer screening, the clinic prioritized viral suppression. Philip Winternheimer, a nurse practitioner, stated the “number one challenge was that we didn't have a culture of making sure that we were doing cervical cancer screening and reducing the risk for our women who are HIV positive.”

To overcome this barrier, the team explored different approaches to staff and patient education. After hearing provider concerns about missing exam supplies, the team developed a visual tip sheet with photos of all required supplies for each exam room. This eliminated guesswork for those restocking rooms and ensured providers had everything they needed to conduct cervical exams and cancer screenings. The team also created a small working group who developed an educational flyer and an “ask me about cervical cancer screening” button that providers wore to help raise awareness and start a dialogue.

In 2024, several members of Infectious Diseases Clinic participated in the Center for Quality Improvement & Innovation’s Training of Quality Leaders. Multiple committee members also completed Lean Six Sigma Green Belt certification. Lucia Schliessmann, RN, program analyst, shared that these “trainings have taught us to really drill down to the root causes [of care issues] rather than making assumptions. It’s about identifying an issue and testing [an idea to improve it] – not across all 1,575 clients at once but starting with a smaller group of 20 or 30.”

The Infectious Diseases Clinic’s clinical quality management program applied the Plan-Do-Study-Act methodology as the framework to guide its improvement work. The committee designed, approved and monitored the cervical cancer screening project. The committee was composed of staff and clients and used qualitative and quantitative data to inform the quality improvement project progress. After transitioning the cervical cancer screening initiative into the “maintenance phase,” the committee is building on the success of and lessons learned by preparing to launch an anal cancer screening quality improvement project.

When asked about the secret to their success in achieving measurable improvements, the Infectious Diseases Clinic’s quality improvement team emphasized the importance of having champion providers who serve as examples by motivating other providers to continue making improvements and creating momentum for sustained change. The team also made sure to include staff who were initially resistant to changes in quality improvement processes. The team’s advice for those just starting out in quality improvement is, “Don’t give up – not everyone is going to adapt as quickly as you want them to, so continue to push through and be open to adapting.”

For more information about Infectious Diseases Clinic, please visit their webpage.