Transcript KEEPING THE QI FIRE BURNING

QUALITY &
PERFORMANCE
IMPROVEMENT
For Basic Manager Education
Quality & Performance Improvement Defined





Continuous cycles of improvement
Driven by our mission and vision
That stimulate individuals and teams to look at
the way they deliver care and services
To identify the root causes of problems in our
systems
And innovate to make improvements
THE GOAL:
A “Highly Reliable” Organization





The right care for every patient, at right time,
every time (Sec. Michael Leavitt, HHS, 2007)
Humans are not highly reliable
Systems and processes can be
It is the job of leadership to develop and
maintain systems that make it hard for staff to
make an error
It is also leadership’s job to hold staff
accountable for using highly reliable systems
Terminology:
What’s the Big Difference?!

QC: quality control

QA: quality assurance or assessment

QI: quality improvement

PI: performance improvement
“If I had six hours to chop down a tree, I’d spend
the first four sharpening the axe.” Abraham Lincoln



Quality Control (QC) is about
putting routine checks in place to
ensure that your service or output
will be safe and effective
It is routinely documented and is a
task that is generally easily shared
among staff; all have a role to play
in making day-to-day work safe
Examples: temp checks, routine
preventive maintenance, running
test controls (sharpening your
axe!)
“The beginning is the most important
part of work.”
Plato



Quality Assurance (QA) is
meant to determine where we
are in relation to where we
want to be; we have to start
somewhere
It compares measured
performance to a
predetermined benchmark or
threshold
Examples: medical record
documentation review; CAH
PIN clinical studies (stroke,
surgical care, patient safety)
“The significant problems we face cannot be
solved at the same level of thinking we were at
when we created them.” Albert Einstein






Quality & Performance
Improvement (QI/PI) are about
making changes for the better
This requires setting specific goals
and making changes to achieve
those goals
They rely on measuring progress
routinely
They need participation by
everyone in the organization
Quality Improvement focus is on
improving clinical quality
Performance Improvement focus is
organization-wide
Approaching improvement by
Hardwiring Excellence
Into the way we provide service
 Into the way we deliver clinical quality
 Into the way we develop our staff
 Into the way we manage our finances
 Into the way we grow our business

Quint Studer, Hardwiring Excellence, © 2003
Studer defines our systems as “pillars”



Service: consistently
exceeding customer
expectations results in
increased satisfaction
Clinical Quality: patientcentered care that is safe,
effectively, timely, efficient,
equitable (IOM, 2001)
People: well-trained,
recognized, and rewarded
staff bring commitment and
dedication to the workplace



Finance: solid planning and
management results in a positive
margin to sustain current ops and
provide future needs
Growth: a well-researched,
methodical approach involving key
stakeholders results in steady
growth
The pillars work together,
synergistically, to achieve mission
CMS: I’m from the Government
& I’m here to help.


Conditions of Participation
for Medicare and Medicaid
require hospitals to have a
hospital-wide QA/PI program
that focuses on the outcomes
of their organization’s services
Prospective Payment System
(PPS) hospital payments are
dependent on this – CAH
payments may soon be, too
Quality Conditions of Participation

Conduct annual evaluation of the CAH program

Must have an effective quality program


Includes all patient care and other services
affecting patient health and safety
Includes nosocomial infections and medication
therapy
Quality Conditions of Participation



Program must include the quality and
appropriateness of diagnosis and treatment
Considers the findings and recommendations
from the Quality Improvement Organization
(QIO) and takes corrective action
Takes appropriate remedial action to address
deficiencies found through the program, including
regulatory survey deficiencies
But we already give good care …
PROVE
IT!
All right, we will!



Performance reporting – “What gets measured
gets managed.”
BUT … not everything that can be measured is
worth managing…
…and everything that should be managed can’t
always be easily measured.
Monitoring Hospital-wide Performance

Service: customer satisfaction, complaints

Quality: patient safety, best practices, risk

People: performance evals, staff development

Finance: revenue, expenses, productivity

Growth: market share, volume, new services
National Patient Safety Goals






Medication safety (reconciliation, look alike-sound alike
drugs, concentrations, labeling)
Healthcare acquired infections (pneumonia, MRSA,
hand hygiene)
Falls (reduction program)
Patient identification (2)
Communication among caregivers (verbal order read
back, abbreviations, critical values, hand offs)
Preventable deaths are sentinel events
IHI 5 Million Lives Campaign

Protect patients from 5 million incidents of
medical harm; Dec 2006 through Dec 2008
–
–
–
–
–
–
–
Includes the 6 aims of the 100,000 Lives Campaign
Prevent harm from high-alert medications
Reduce surgical complications
Prevent pressure ulcers
Reduce MRSA infection
Deliver evidence-based care of CHF
Get boards on board
CMS Core Measures





Surgical Infection Prevention: appropriate antibiotic given
within 1 hour of cut time & discontinued within 24 hr of close
Acute Myocardial Infarction: aspirin on arrival & discharge,
beta blocker on arrival & discharge, 30 min door to drug time for
thrombolytic, lipid assessment
Heart Failure: left ventricular failure (LVF) assessment,
ACE inhibitor for LVSD, complete discharge instructions
(meds, follow up, weight, diet, activity, symptoms)
Pneumonia: appropriate antibiotics within 4 hr of arrival but
after blood cultures, blood cultures within 24 hr if obtained, O2
saturation assessment
All: smoking cessation education; pneumococcal & influenza
immunization
Department Performance
“With great power comes great responsibility”

Everyone gets to report in some way how they are
–
–
–
–
–


Ben Parker
Exceeding customer expectations
Improving the quality of care and/or services
Developing your staff
Managing your finances
Growing your service
You decide how you and your staff will measure
performance
You decide what processes need improvement and how
to improve them
“Stop a moment, cease your work, look
around you.”
Leo Tolstoy



Quality is not about
data, graphs, and reports
These are tools to show
whether or not you’ve hit
your target or reached
your destination
If you don’t know where
you’re headed then
you’re never lost
The PDCA Improvement Cycle
Data Collection – Essential Elements




Operational definition – describe in quantifiable terms
what you will measure & how to measure it consistently
(inclusion & exclusion criteria)
Know why you are collecting the data – what will you do
with it once you have it?
What stratification will be important to have – what level
of detail will you need to get to the meat of the issue
Will you collect all data points or just a sample - how will
you sample to ensure your data is valid? That is
presents a complete picture?
Data Pitfalls – Watch out!







Misunderstandings about how to collect data
Inaccurate measuring instruments
Cheating/ fear
Poor choice of collection period
Poor sampling techniques
Lost data
Bias
Data Analysis – Run Charts

Depicts data over time
100
90
80
70
60
50
40
30
20
10
0
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Data Analysis – Control Charts
100

Shows trends over time
90
80

Uses statistically
determined upper and
lower limits to define a
range of acceptability
70
60
50
40
30
20

Goal is to gain
consistency in
operation
10
0
1st Qtr
2nd Qtr
East
lower limit
3rd Qtr
upper limit
4th Qtr
mean
Data Analysis - Histograms
90

Frequency distribution
80
70
60
50

Presents data
organized in categories
40
30
20
10
0
Fri
Sat
Sun
Mon
Data Analysis – Pareto Charts
30

Tool to rank-order or
prioritize problems,
causes of a problem,
or categories of some
event or issue
25
20
15
10
5
0
adm
trans
presc
disp
Data Analysis – Cause & Effect Diagram
(Fishbone)

Identify multiple causes of any result, outcome, or problem
Data Analysis - Flowchart




Create a step by step
picture of a work process
Identify and add missing
steps
Streamline areas of
overlapping efforts &
eliminate unnecessary
steps
Standardize a process or
system
“Opportunity is missed by most people because it
is dressed in overalls and looks like work.” Thomas Edison



Failure Mode and Effects
Analysis (FMEA) is proactive risk
assessment
The object is to identify hazards
and put control measures into place
to prevent bad things from
happening
Root Cause Analysis (RCA) is
after the fact – something
undesirable has already happened,
but we can learn from it and prevent
it from happening again
“If you put off everything till you’re sure of
it, you’ll get nothing done.”
Norman Vincent Peale
Tips for a Success


Keep after it – it benefits
the patients, the hospital,
& you personally
Involve your staff; they
have some great ideas and
will be more likely to buy in
to goals and action plans
(don’t forget to assign
them data collection, too)
“To improve is to change, to succeed is to
change often.” Winston Churchill


Talk to your
comrades in other
facilities; they can
give you a different
perspective
Use the program to
help you make things
better and recognize
staff for a job well
done


Generate a sense of
teamwork in your
department and with
other departments
Celebrate your
success (no matter
how small); reward
yourself and your
staff
“Our life is frittered away by detail.
Simplify, simplify.” Henry David Thoreau


Don’t bite off more
than you can chew;
make your projects
worthwhile but not
overwhelming
Use the Quality
Coord/Director as
a resource for ideas,
data collection and
display, etc.


Don’t reinvent the
wheel; research best
practices; you don’t
have to make stuff up
Align projects with
department priorities;
we’ve got plenty to
keep us busy, we
don’t need more
busywork
“Excellence is a habit, not an event.”


Align your QI/PI
improvements with the
hospital strategic plan
and vision
Keep it in front of you;
put it on your calendar,
your task list, your office
door, your monthly staff
meeting agenda, your
refrigerator, your mirror


Aristotle
Be prepared when you
are due to report
Attitude is everything;
this doesn’t have to be a
meaningless paperpushing process; YOU
have the power to make it
meaningful to you and
your staff
“Celebrate, celebrate!!
Dance to the music!”
Three Dog Night
Find joy in your
work; if you
don’t, what’s
the point?