Transcript Continuous Quality Improvement 101

Continuous Quality
Improvement 101
Amelia Broussard, PhD, RN,
MPH
[email protected]
WHY DO WE NEED TO KNOW
ABOUT CQI?
• Provision of Quality Care
• CQI tools and techniques work in
healthcare.
• Bureau of Primary Health Care
requires quality improvement
• New process relates health care plan,
QI, UDS info, needs assessment
• Focus on Core Clinical Measures
A Few Questions to Ask…
Services provided in timely manner?
Was necessary care provided?
Efficient provision of care?
Was the expected outcome achieved?
Are patients, clients and customers
satisfied with provided services?
Success is achieved through
meeting the needs of those we
serve.
Quality Assurance vs. Quality
Control
Quality assurance and quality control
are often used interchangeably to
refer to ways of ensuring the quality of
a service or product.
The terms, however, have different
meanings.
Quality Assurance
“The planned and
systematic activities
implemented in a quality
system so that quality
requirements for a product
or service will be fulfilled.”
American Society for Quality
Examples of Quality Assurance
Activities
Activities that are based on public health standards,
licensing standards, institutional policies, etc.
• Annual infection control and safety training
• Review medication closet for outdated meds
• Review emergency chart once a week for supplies
and outdated meds
Can help identify a problem, but are more often used
to comply with the standards.
Quality Control
“The observation
techniques and
activities used to fulfill
requirements for
quality.”
American Society for
Quality
Examples of Quality Control
• Infection control training
sign-in sheets crossreferenced with staff roster
• Review sheet of emergency
cart
• Direct observation of
counseling session
Quality Improvement
“Continuous improvement is
an ongoing effort to improve
products, services or
processes. These efforts can
seek “incremental”
improvement over time or
“breakthrough” improvement
all at once.”
American Society for Quality
Philosophy of CQI
• Based on concept of balance between
quality improvement & performance
measurement
• QI programs are built upon foundation
of program support & infrastructure
• Emphasizes development of systems &
processes to support QI
Guiding Principles
• Ongoing QI activities improve patient
care
• Performance measurement lays
foundation for QI
• Infrastructure supports systematic
implementation of QI
• Indicators are based on clinical
guidelines & formal group-decision
making
Core Clinical Measures for
Health Care Plan
• Diabetes
• Cardiovascular
Disease
• Prenatal Care
• Perinatal Care
•
•
•
•
Child health
Behavioral Health
Oral Health
Other x2
Goals of Quality
Improvement
• The goals of QI
– to understand process, reduce
unintended variation in care, eliminate
errors, remove unnecessary steps, and
improve communication and
accountability.
– process is designed toward outcomes.
– Quality improvement depends on
measurement.
Core Concepts of CQI
• Quality defined as meeting and/or
exceeding expectations of customers.
• Success is achieved through meeting
the needs of those we serve.
• Most problems are found in
processes, not in people.
• CQI does not seek to blame, but
rather to improve processes.
CORE CONCEPTS OF CQI
• Unintended variation in
processes can lead to
unwanted variation in
outcomes
• Possible to achieve continual
improvement through small,
incremental changes using the
scientific method.
• CQI most effective when it
becomes natural part of way
everyday work is done.
Comparison of QA & QI
QA
QI
Motivation
Measuring
compliance with
standards
Continuously improving
processes to meet
standards
Means
Inspection
Prevention, monitor over
time
Attitude
Required, defensive
Chosen, proactive
Focus
Outliers or “bad
apples”, individuals
Processes, systems,
majority
Players
Selected
departments
Organization wide,
benchmarking
Disciplines
Within profession
Multidisciplinary approach
Scope
Medical profession
focused
Patient care focused
Responsibility
Few
All
QA versus QI
Exercise on Quality
• What is the benefit for:
– Patients
– Staff
– Organization
Putting It All Together
QA + CQI + Peer Review
+ Consumer Satisfaction
= QM
Process Indicator:
Are we doing what we said
we’d do?
Outcome:
Is it working for the clients?
GUIDING VALUES of CQI
• Most problems are found in
processes, not in people.
• If you “focus” on everything, you can’t
focus on anything.
• The best solutions are staff designed.
Roles and Responsibilities
• Leadership/Board/Consumers: Oversight
and resources. Help set priorities.
• QI Committee: Review data, pick projects
and goals, review results of tests.
• Project Team: Brainstorm ideas and design
tests.
• All Staff: Help perform tests and collect
data.
PITFALLS OF CQI
• The paperwork can bury you
SET PRIORITIES
PITFALLS OF CQI
• Staff view it as a ball and chain,
hindering their daily work
PITFALLS OF CQI
• The Process can tie you up in
knots
Lessons Learned
• “The shorter the timeframes
between test cycles, the more
tests can be conducted and
therefore, more opportunities for
learning will emerge.” - HIVQUAL Workbook
• “Let’s be as opportunistic as a
virus!” - Anonymous
Common Themes among QI
Models
• Improvement is about learning
– trial and error (scientific method)
– improvements requires change, however not all changes are an
improvement
• Measure your progress
– only data can tell you whether improvements are made
– integrate measurement into the daily routine
• Improvements thru continuous cycles of changes
– Plan-Do-Study-Act approach
– changes are initiated on a small scale to test them before
implementation
• Leadership is needed
– establish organizational commitment and support staff and activities
One MODEL FOR
IMPROVEMENT
• Model consists
of:
– three questions
(aim, measure,
change) to form
context for
improvement
– Plan-Do-Study-Act
(PDSA) Cycle to
structure tests
Model for Improvement
What are we trying
to accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Model
for
Improvement
Act
Plan
Study
Do
Model for Improvement
What are we trying
to accomplish?
How will we know
that a change is an
improvement?
What change can we
make that will result in
improvement?
Model for Improvement
What are we trying
to accomplish?
How will we know
that a change is an
improvement?
What change can we
make that will result in
improvement?
Model for Improvement
What are we trying
to accomplish?
How will we know
that a change is an
improvement?
What change can we
make that will result in
improvement?
PDSA CYCLE
• Plan - Plan a
change
• Do - Try it out on a
small-scale
• Study - Observe
the results
• Adopt, adapt, or
abandon -Refine
the change as
necessary
PRINCIPLES OF PDSA CYCLES
 Short cycles of changes to accelerate rate of


improvement
 small scale tests (“What can you test till next Tuesday”)
 collect just enough information
Create flow of ideas, then emphasize implementation
 increase frequency of tests
 build knowledge sequentially - use multiple cycles to adapt a
change to your system
Adopt existing knowledge (‘not more research but
more application of existing knowledge’)
 ‘Steal shamelessly, Share senselessly’
 Promote peer learning
Tips for PDSA Cycles
- formulate question and
predict results
- test first in ‘safe zones’
(with team members,
volunteers)
- ‘Just-do-it’ mentality
- collect useful just
enough data, not perfect
data
- think a couple of cycles
ahead
- scale down size of test
(# of patients, clinics)
- be innovative to make
test feasible
PDSA Cycles: Testing a pap
Cuing Plan
Improved
Decision
Support
Cycle 1D: Implement
thruout clinic and
monitor the impact.
Use of
flowsheet will
improve care to
known
standards
A P
S D
Cycle 1C: Test with all patients for a full
week, document feedback and time
required.
Cycle 1B: Debrief staff; did it help, how long did it
take? Test with Dr. Strange’s patients for a full week.
Cycle 1A: On Mon., prescreen Fred’s Tues. pts, mark
appointment sheet for those who are due for paps.
Smaller Scale Tests: Scale
Down Timeframe
• Years
• Quarters
• Months
• Weeks
• Days
• Hours
• Minutes
Reduce your
timeframe to
plan Test Cycle!
Analysis Tools: Flowcharts
• Flowchart is picture of any process,
• Flowcharts help visualize process
• Easier to understand and easier to
improve.
• Identifies potential sources of
problems and solutions
FLOWCHART
• Flowchart symbols
• Oval: shows beginning or ending step
in a process
• Rectangle depicts particular step or task
• Arrow: shows direction of process flow
• Diamond: indicates a decision point
FLOWCHART EXAMPLE
Patient arrives at front desk
Receptionist asks for patient’s
name & searches database for
his/her file
Patient in system?
YES
Ask patient to be seated in the
Waiting room
ETC.
Medical assistant
takes patient into
exam room
NO
Receptionist asks patient
to complete paperwork for new clients
and return it to front desk
CAUSE-AND-EFFECT
DIAGRAM
• Used to map variables that may
influence a problem, outcome, or
effect
• Also called:
– Ishikawa diagram
– Fishbone diagram
CAUSE-AND-EFFECT
DIAGRAM
CAUSES
• The four M’s
– Methods, Materials, Machines,
Manpower
• The four P’s
– Place, Procedures, Policies, People
• The four S’s
– Surroundings, Suppliers, Systems, Skills
CAUSE-AND-EFFECT
DIAGRAM
SAMPLE
Skeleton
Equipment
Environment
Computer
System down
for routine
maintenance
Low show rate
for appointments
Patients
Procedures
People
Patient unaware
of appointment
Exercise
• Construct Cause and Effect Diagram
with staff
Performance
Measurement and
Data
Why Measure?
• Separates what you think is happening from
what is really happening
• Establishes a baseline
• Helps to avoid putting ineffective solutions in
place
• To monitor improvements and prevent slippage
What is a good indicator?
• Relevance. Does the indicator relate to a condition that occurs
frequently or have a great impact on the patients at your facility?
• Measurability. Can the indicator realistically and efficiently be
measured given the facility’s finite resources?
• Accuracy. Is the indicator based on accepted guidelines or
developed through formal group-decision making methods?
• Improvability. Can the performance rate associated with the
indicator realistically be improved given the limitations of your
clinical services and patient population?