Transcript QUALITY IMPROVEMENT 101

Implementing a Quality
Improvement Plan
Presented by Kathy Revell, RN MS NCAC II CPHQ
and Roger A. Revell, MBA
2010 Kansas Addiction Summit II
July 20, 2010
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 The
participants will know the basics of
implementing a Quality Improvement(QI)
Plan including:
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Reviewing the historical context of Quality
Improvement
Selecting staff to champion QI
Selecting data sources to trend
Establishing a facility/agency QI Committee
Structuring a data analysis report (Aggregate
Analysis)
Understanding the process of moving from
Quality Assurance compliance to Performance
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Improvement©that
measures
outcomes
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Ѕ=α + ß(1-C)
WHAT IS THIS?
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Ѕ=α + ß(1-C)
Linear relationship between the rate of
complaints (C) and the rate of satisfaction
with services, S, is represented by this
formula. In this formula, α and ß are
constants calculated from the complaint
and satisfaction rates of a large number of
health care organizations. Empirical
evidence supports the claim that
complaints and satisfaction are related
concepts.
If you came here for math analysis, go get a
cup of coffee now!
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 QUALITY
IMPROVEMENT IS THE PROCESS
BY WHICH ORGANIZATIONS
APPLY BEST PRACTICES OF CARE
 OPERATE EFFICIENTLY AND EFFECTIVELY
 OBTAIN BEST OUTCOMES FOR THEIR
CLIENTS.

 Quality
Improvement is defined as
doing the right thing at the right
time
every time.
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Armand Feigenbaum:
“An effective system for integrating
quality development, quality
maintenance and quality improvement
efforts of the various groups within an
organization, so as to enable
production and service at the most
economical levels that allow full
customer satisfaction”.
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Quality Improvement
Two Domains
Quality Assurance
( Assure compliance to a standard)
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Performance Improvement
(Improve beyond the basic
compliance such as
improved processes)
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 During
the early days of manufacturing,
the work of employee was inspected and a
decision made whether to accept or reject
it. This was QI focused to reduce $$$.
 In the 1920’s statistical theory began to be
applied to quality control. In 1924,
Shewhart made the first sketch of a chart
to document and trend findings.
 In late 1940’s with its industries in ruins
Japan became a “incubator of QI” with the
help of some notable quality gurus – Juran,
Deming and Feigenbaum.
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. Edwards Deming while in Japan
placed great importance and
responsibility on management, at
both the individual and company
level, believing management to be
responsible for 94% of quality
problems.
W
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 The
quality revolution in the West was slow
to follow, and did not begin until the early
1980’s, when companies introduced their
own quality programs.
 In
the 1970-80's American Western QI
leaders, notably Philip Crosby and others,
further extended the Quality Management
concepts in the U.S. after the Japanese
successes.
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 This
of:
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included the development and/or use
Plan, Do, Check, Act (PDCA) cycle
Pareto analysis 80/20
Cause and effect diagrams (Fishbone)
Stratification
Check-sheets
Histograms
Scatter-charts
Process control chart
Tolerance design ('Taguchi methodology)
Quality Improvement Teams (QIT)
Just In Time (JIT) manufacturing
Management By Walking About (MBWA)
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The 80’s saw great strides applying Quality
Improvement processes and concepts across all
industries.
FINALLY IT ARRIVES IN HEALTH CARE!
 QI in health care began with the Medicare Peer
Review Organization (PRO) program in the mid
1980s. This was in response to concerns with
medical necessity and quality of care of
services delivered to the elderly and disabled,
and paid for by the federal Medicare program.
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(C. Weinmann, 1998, Evaluations & the Health Professions Vol 21:4)
5.
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
Today there are many types of QI
processes including “SIX SIGMA” which is
currently popular. Why "Sigma"? The word
is a statistical term that measures how far
a given process deviates from perfection.
A six-sigma process is one in which 99.99966%
of the products manufactured are free of
defects, compared to a one-sigma process in
which only 31% are free of defects. Motorola
(1981) set a goal of "six sigmas" for all of its
manufacturing operations.
 The
standards for Quality Improvement in
health care nationwide (HEDIS) are set by
the National Committee of Quality
Assurance (NCQA).
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 The
Healthcare Effectiveness Data and
Information Set (HEDIS) is a tool used by
more than 90 percent of America's health
plans to measure performance on
important dimensions of care and service.
(Access, Availability and Effectiveness)
 Over
70 measurements are all collected
exactly the same way for all health plans
including Commercial, Medicare and
Medicaid.
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 Initiation
= Percentage of adolescents and
adults aged 13 years and older diagnosed
with AOD dependence and receiving a
related service who initiate treatment
 Engagement
= Assessment of the degree to
which patients engage in treatment with
two additional AOD treatments within 30
days after initiating treatment.
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
QI is the responsibility of the CEO/Executive
Director. The CEO is responsible to:
Provide leadership for QI initiatives
 Ensure that resources are dedicated to QI
 Participate in the facility/agency QI committee
 Sponsor the recommendations of the QI committee
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It must permeate all levels of an organization and
be supported and modeled by senior leadership.
QI is about both Administrative and Clinical
processes.
QI can reduce administrative expenses by reducing
re-work, work-arounds, and cost of responding to
negative events.
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Employees are an Agency’s most valuable
resource for successfully developing and
growing the organization.
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All employees need to understand what the QI
program is about and how it operates and fits
into the Agency and it’s Mission.
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No quality management system works unless
employees are committed and take
responsibility for quality as a daily ongoing
process.
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For it to be effective, quality concepts must
become part of employees’ behavior and
attitudes at all levels of the organization.
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“Key components of a positive
patient safety climate include
strong leadership, commitment to
patient safety, open discussion of
errors, and a habit of learning from
mistakes.”(J.R. Reason, Human Error 1990)
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Regulatory guidelines/standards provide
“minimum” measurement.
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An Agency having difficulty meeting the AAPS
licensure standards most likely has QI
issues/processes that need to be evaluated.
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Evidence-based practices help raise the bar
above the minimum.
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SAMHSA’s National Registry of Evidence-based
programs and practices has 164 mental health
and substance abuse prevention and
treatment Evidenced-based practices in the
U.S. that you can view.
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Another Great Site
http://www.tie.samhsa.gov/
The Treatment Improvement Exchange
(TIE) is a resource sponsored by the
Division of State and Community Assistance
of the Center for Substance Abuse
Treatment to provide information
exchange between CSAT staff and State and
local alcohol and substance abuse agencies.
TIE is funded by the Center for Substance
Abuse Treatment, Substance Abuse and
Mental Health Services Administration.
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1) Be sure that CEO/Executive Director and the
Governing Board are committed to “doing” QI well
and “being” a QI driven organization.
2) The CEO/Executive Director has the responsibility
to be the KEYSTONE for Agency QI.
3) In turn the Leaders and Managers set the
direction for the front line staff to follow. They
model that QI is very important and integral to the
Agency.
4) Carefully choose a QI Lead/Manager who believes
in QI and has the required attributes or potential
for development.
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 Be
a linear thinker (“First, second, third,
fourth, etc.”) with solid mathematical
skills, and be able to SUSTAIN these skills.
 Demonstrate
healthy curiosity (asks
“Why?” frequently).
 Have
analytical capacity. Data collection is
only the first task of QI; analysis is
essential.
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Be a good one-on-one communicator both verbal and
written.
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Possess courage and persistence.
Believe in the potential for both Administrative and
Clinical QI to improve Agency outcomes, and reduce
costs.
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The QI Lead/Manager is not the “QI COP” and is not
responsible to give feedback to employees regarding
non-compliance to QI processes. That responsibility
remains with the employee’s direct supervisor.
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Avoid the counter-productive tendency to select an
internal candidate who is your “least productive”
clinician. An individual with the right basic QI potential
can more easily learn what is required about the clinical
arena than vice-versa.
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5) Ensure that the QI Lead/Manager has
mentoring and opportunities to learn QI
concepts and processes.
6) Form QA/PI Committee composed of
members representing all Agency
services.
7) Develop and approve the QA/PI
Committee Charter that provides the
Committee’s operational guidelines.
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 Members
of the QI Committee should have
representation from all departments of the
Agency including clinical, financial and
operational representatives.
 Attendance becomes a job expectation.
 The role of QI Committee is to make
recommendations on data presented and
assign QI follow-up activities among
themselves.
 Documentation includes written Agenda
and formal MINUTES - crucial for follow
through.
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8) Decide what data sets you are going
to collect and from where.
9) Develop or decide what tools or
forms you are going to use to collect
data.
10) Develop, write and approve a QI
Workplan once the data sets have
been chosen.
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11) Write specific Policies and Procedures that
support the process and which can be used as
accountability tools.
12) Internally “market” the Agency’s QI
activities.
Highlight QI activities on Employee bulletin boards.
 Post the QI Workplan.
 Be sure QI is part of all new employee orientation.
 Present/discuss data reports at staff meetings.
 Ask for input from staff.
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 Information/Data
that comes to the QI
Committee includes but is not limited to:
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Data that has been analyzed and formally
written into what is known as an Aggregate
Analysis.
Reports/outcomes of licensure visits
Discussion of Serious Occurrences that need
Committee input as to the potential root cause
for each occurrence.
Discussion of status of any CAPs the Agency is
under with regulatory entities.
Guest speakers on QI topics.
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 Choose
measurable data that you can
collect and analyze over time.
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Must be able to be collected from the same
source using the same method all year
Some examples: Adverse Incidents, claims
denials, client satisfaction, AMAs, number of
admission, readmissions, ALOS, etc.
Start with data you already are collecting.
Document and maintain data in the same
method and format across the Agency.
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Excel
Access
Create a form that all departments will be required
to use, etc.
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We all get confused occasionally about the
meanings of words. This is ever-so-true in
the case of measurements. Let’s clear that
up.
 Data refers to where we are gathering
information from - the source
documentation. Data are typically onedimensional or single purpose. Data are
often viewed as the lowest level of
abstraction from which information and
knowledge are derived. Examples:
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21 families served
2,750 brochures distributed
31 AA meetings
980 clients admitted
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
Measurement is the unit of “assigned value” that
has the ability to show that there has been a
change in data over time. What was true in one
period (week, month, quarter, year, etc.) must
be compared to what was true (for a
corresponding event) in a later period using the
“measurement” and the change in that
measurement. Examples:
21.3% increase in admissions (Q1 to Q2)
 5 % increase in private pay clients this quarter
 11.2% reduction in expenses (April from March)
 500 fewer brochures distributed in 2009 (over 2008)
Note: percentages (%) and numerical brochure count
(500) are the “assigned measurement values.”
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 To
capture measurement change requires a
baseline to which another period is
compared. Therefore, measurement
change is at least two-dimensional (i.e.,
measurement of the activity and time).
(Five family groups this month to six family
groups next month. Thus, baseline is five
family groups)
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Where no measurement change exits,
gathering data in the first period (week,
month, quarter, year, etc.) leads to a
baseline, but there is no measurement
change until data are available for a second
period.
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
Analyzing data refers to studying the
measurement change for at least two time
periods from the baseline to identify trending,
interaction or cause and effect.
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One frequent mistake is not to gather and
trend data for a sufficient time period before
drawing a conclusion. The number (N = volume
of the items/activities measured) is an
important component of data validity.
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
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Validity = Does it measure what it is supposed to be
measuring?
Reliability = The extent to which a measurement
gives consistent results.
An example often used to illustrate the difference
between reliability and validity in the experimental
sciences involves a bathroom scale. If someone who is
200 pounds steps on a scale 10 times and gets
readings of 15, 250, 95, 140, etc., the scale is not
reliable. If the scale consistently reads "150", then it
is reliable, but not valid. If it reads "200" each time,
then the measurement is both reliable and valid. This
is what is meant by the statement, "Reliability is
necessary but not sufficient for validity."
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
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Adequate data analysis leads to questions regarding the
data changes and potential factors contributing to these
changes.
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What is the trend?
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What could be the cause(s) of this change?
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What needs to be done to reverse the trend, sustain the trend, or
increase it?
Interventions also called “Action Plans” are written
plans created after the data are analyzed to plan
interventions on the process(s) and facilitate favorable
change.
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Interventions/Action Plans last for defined periods of time.
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The Action Plan includes a list of prioritized activities - what you
are going to do, who is going to do it, and when each activity is to
be completed.
Evaluate the impact of the Action Plan.
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Did we get what we wanted?
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Was there a change in the data from impact of the intervention?
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Are there any surprises?
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What did we learn?
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A substance abuse treatment programs QI data
showed that the majority of clients that left AMA
where leaving on the weekends. The agency reviewed
the charts of the clients for one quarter to see if
there were any common trends. It was discovered
that 75 % of them left on a shift that one particular
counselor was on duty. It was the Agency’s policy to
have a counselor talk to clients who were trying to
leave. Upon further investigation it was found the
counselor “believed” that if clients wanted to leave
“Well, they have not hit bottom yet.”
With focused in-service and assigned mentoring with
another counselor, the rate dropped 30% for AMA’s in
the next quarter when that counselor was on duty.
WHAT BENEFITS CAME FROM THIS?
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 Focus
on the client - we are here for
them
 Secure leadership support
 Plan before you implement using the 12
steps in this handout
 Be process oriented
 Make business and clinical decisions that
are driven by data
FACTS ARE FRIENDLY!
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Thank you for your attention and best wishes
in your QI journey
Kathy Revell, RN MS NCAC II CPHQ
[email protected]
Roger A. Revell, MBA
[email protected]
1-800-781-7008
REVELL, INC.
www.revellinc.com
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Behavioral Health Quality Improvement Web Resources
http://www.cms.hhs.gov/center/quality.asp
CMS Quality of Care Center for Medicare and Medicaid
http://www.nattc.org/eof/subscription06/spreadtheword.asp
Subscribe and receiving a monthly newsletter from ATTC with
Links to newest research on substance abuse.
http://www.pubmedcentral.nih.gov/
This site provides free access to archives of many Life Science Journals.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmed
This is the Search function screen for PUBMED
http://web.ncqa.org/
National Committee for Quality Assurance which is the certification body for
Managed Care Organizations. HEDIS information is here also.
http://www.samhsa.gov/index.aspx
Substance Abuse and Mental Health Services Administration
http://www.tie.samhsa.gov
The Treatment Improvement Exchange from SAMHSA
https://www.cahps.ahrq.gov/default.asp
Consumer Assessment of Healthcare Providers and Systems/Agency for Healthcare
Research and Quality
http://www.nimh.nih.gov/
National Institute of Mental Health
http://www.cqaimh.org/toolkit.website.pdf
Selecting Process Measures for Quality Improvement in Mental Healthcare
http://www.cqaimh.org/index.html
The Center for Quality Assessment and Improvement in Mental Health (CQAIMH )
http://www.urac.org/
Utilization Review Accreditation Commission (URAC)
URAC accredits many types of health care organizations to assure that they are
practicing to national standards.
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Roger A. Revell, MBA
President
REVELL INC.
Roger A. Revell has nearly twenty years of experience as a leader/manager. Until his consulting
career began in 1984, he was responsible for the work of up to four hundred people. Revell has a
master’s of business administration (MBA), and has been a senior officer of a Fortune 500 company.
He brings clarity to clients around issues of leadership, organizational change, performance
management, and planning. In recent years, working with CEOs, he has done extensive projects
regarding mergers, acquisitions, divestitures and the creation of strategic partnerships. Clients
regularly comment on his expertise at working with change and conflict, and in helping them learn to
deal effectively with these and other workplace issues.
Kathy Revell, RN, MS, CPHQ, NCAC II
Vice President/Senior Consultant
REVELL INC.
Kathy Revell has had more than thirty-five (35) years experience in the healthcare industry, twentyfive (25) of which where in the psychiatric and chemical dependency field. She has held clinical and
management positions in both inpatient and outpatient settings where she also did individual and
family counseling. In addition, she has over thirteen (13) years of experience in the managed mental
health care industry including product and network development, provider contracting and education,
utilization management, appeals processes, case management design, reimbursement issues and
quality improvement. Her managed care experience included multiple product design and operations
including PPO, HMO, self-insured, and specialty products. She has been vice president of clinical
operations for a mental health Medicaid HMO. In addition to being a registered nurse and nationally
certified substance abuse counselor (NCAC II), she is a certified professional in healthcare quality
(CPHQ). A published author, she holds a bachelor’s degree in nursing and a master’s degree in
human relations and business. Ms. Revell’s consulting specialties include organizational assessment
and change, interpersonal communication, provider contracting, policy and procedure development,
managed care case management design, and healthcare quality improvement.
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