Transcript Slide 1
Workshop 2a
Quality Management Infrastructure
August 29, 2011 2:15pm to 3:30 pm Presenters: Barbara Boshard
2 Agenda – Quality Management Infrastructure Day 1: August 29, 2011
Agenda Item
Part I – Quality Management Infrastructure Components of Infrastructure Leadership Support Quality Improvement Committees Part II – Quality Management Infrastructure Quality Management Plans Group Process Resources QI Cheat Sheets
Time
2:15-3:30 pm 5 min.
10 min.
1 hr.
3:45-5:00 pm 20 min.
10 min.
45 min.
Facilitator
BJ Boshard BJ Boshard
3 Learning Objectives • Understand the Components of Infrastructure • The Value of Leadership Support • The Role of the Quality Improvement Committee
4 Who Am I?
• QI Coordinator for Internal Medicine at the University of Missouri • NQC and HIVQUAL Consultant for the AIDS Institute, NYSDOH • QI Coordinator for Case Management for the Missouri Department of Health for 8 years • Facilitated MACMIP (MO AIDS CM Improvement Project)
Components of Infrastructure Leadership Support Quality Improvement Committee 5
PART I: QUALITY MANAGEMENT INFRASTRUCTURE
6 Quality Improvement Activities are Supported by a Quality Infrastructure
7 Objectives • Discuss Components of QI Infrastructure • Share Infrastructure Resources and Tools • Discuss the basic functions of a Part D QM Committee • Use an OA • Discuss network-specific issues related to Contracting for Quality • Discuss how to Foster Internal/External Buy-in for Quality Management
8 Name Some Components of Infrastructure • Leadership Support • Quality Management Committees • Representative Active Team Members • Designated Team Roles • Quality Management Plans • Workplan/Timelines • Effective Group Process • Adequate Resources
9
LEADERSHIP SUPPORT
10 Key Points • Leaders need to support and be actively involved in the quality program • They need to build their organization’s abilities in response to the goal of quality • Quality-focused organizations need: • Skills with data analysis and measurement • Ideals that focus on systems rather than individuals • Vision to generate ideas for change • Flexibility to test ideas and make changes • Cooperation to allow for individual contribution towards a common goal
11 Leaders Support Others in Improvement Areas: • Support a systemic approach to quality • Communicate priorities to staff and stakeholders • Educate staff on quality • Encourage sustained improvement • Facilitate innovation and learning
12 How can Leaders Support a Systemic Approach to Quality?
• Attend quality meetings • Ask teams to justify their decisions • Trust the data • Use data in decision-making • Support quality improvement changes • Allocate resources, not just money
13 How can Leaders Communicate Priorities?
• Facilitate the development of quality-oriented priorities • Develop and reinforce a sense of common purpose • Guide staff through conflicting priorities • Clarify the quality goals of the organization
14 How Can Leaders Educate Staff • Reassurance • Guidance • Support quality efforts
15 How can Leaders Facilitate Innovation and Learning?
• Quality improvement → new issues about how staff members interact • Support staff as they learn new skills • Create a safe environment for learning and for experimentation
16 Case Study 1 - Leadership Support?
• What do you want to accomplish?
• Who cares and what do they care about?
• How is it demonstrated?
• What else do you need?
• How can you get it?
Your Department Director considers QI important but she stays removed from activities. You do a check in once per month with the Director with a written report of activities but that is the extent of her support. She does not have a background in quality. There are several Divisions each with a lead. They work in silos. You have worked on a project that will need more active support from her to be successful and sustainable across the entire department
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What might you do?
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TOOL BOX
18 Self-check: Leadership Clearly articulated mission and vision statement Ongoing measurement of performance Ongoing assessment by leaders Active coaching by leaders
19 Last Words From a Quality Leader “The problem now is very clear: The buck stops not with the workforce, but with governance and senior leadership. The improvements will happen because of senior leadership, or not at all.”
Don Berwick
20
QUALITY IMPROVEMENT COMMITTEE
21 Why do you need a QI Committee?
• The quality management committee builds the HIV program’s capacity and capability for quality improvement • Quality management committee is responsible for: • strategic planning • facilitating innovation • providing guidance • establishing a common culture • allocating resources • Sets direction of QI • Implements projects • Assess needs and capabilities • Evaluate effectiveness of quality management work annually
22 Key Question What committees and other structures do we need to run a sound quality management program?
23 Sample Organizational Chart for Quality Organization-wide Quality Committee HIV/AIDS Center Medical Director HIV/AIDS Center Medical Director HIV/AIDS Center Quality Committee
24 The Quality Management Committee: • Builds the HIV program’s capacity and capability for quality improvement • Involves program leaders and other key staff to cement their personal commitment to quality • In a large organization, links the HIV quality program with the organization’s overall quality program
25 Facilitating Innovation and Change • Removes barriers to making and sustaining improvements • Prepares staff for change • Promotes communication: gives everyone at the facility a voice in the quality management program
26
TOOL BOX
27 Example of Committee Minutes
Meeting Name: Date: Time: Attendees: Outpatient QI Team Meeting BJ Jim Item Discussion Assigned Roles: Leader: Facilitator: Recorder: Time Keeper: Meeting Start Time: Meeting Stop Time: Action
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29
Team Members
QUALITY IMPROVEMENT COMMITTEE
30 Who Might Be on the Committee?
For a Teaching Hospital (HIV Caseload: 700) • • • • • • • • • • Chief of Infectious Diseases AIDS Center Administrator Director of Ambulatory Care Director of Quality Improvement Director of Nursing AIDS Center Nurse Practitioner Clinic Coordinator for Case Management Senior Staff Nurse Patient Representative Part D Provider For a Neighborhood Health Center (HIV Caseload: 100) • • • • • Medical Director Senior Staff Nurse HIV Nurse Case Manager Patient Representative
31 Getting Committee Work Done • Identify a chair for the committee • Set meeting frequency and duration • Document your progress • Establish communication channels • Train committee members on quality improvement
32 Tips for Success • Select a chair who will be the quality program’s champion • Build a cross-functional group: draw from different service areas in the program • Include individuals who have influence and can get things done • Start small: recruit those most critical to the program’s success • Include consumers
33 Tips for Engagement of Stakeholders • Outline internal and external stakeholder functions/responsibilities • Include • Providers • Consumers • Subgrantees • other Ryan White CARE Act Titles • List proposed training opportunities
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TOOL BOX
35
Stakeholders
Stakeholder Worksheet
Attractors Barriers
36 Who has a QI Team?
Who is on your Team?
Who might you want on your Team?
37
Team Roles
QUALITY IMPROVEMENT COMMITTEE
38 Strategic Planning • Develops the HIV quality management plan • Prioritizes goals and projects • Outlines the quality program infrastructure • Identifies performance measures • Plans for program evaluation
39 Providing Guidance and Reassurance • Oversees the progress of quality activities • Helps quality improvement teams in their work • Supports changes that result from quality improvement projects • Listens, observes, responds to staff concerns
40 Establishing a Common Culture • Demonstrates a true commitment to the quality program • Successful buy-in to the quality program means “not to get people to do what they are told but to do what they are not told”
41 Ways to Strengthen the HIV Quality Program • Convey the importance of quality to others • Organize educational activities to promote quality • Recognize staff for their quality improvement efforts • Institutionalize quality improvements • Demonstrate program successes
42 The Annual Assessment Looks At: • How effectively the HIV program’s quality infrastructure supports quality activities • Clinical and non-clinical indicators, and external quality evaluations performed by external agencies, to identify future improvement opportunities • The improvements made by project teams and how well these improvements have been sustained over time • Educational efforts for staff and clients and how well these have built knowledge and expertise about quality
43 Infrastructure Questions • Was the quality management committee effective in its efforts to improve the quality of HIV care?
• Does the quality infrastructure require any changes to improve how quality improvement work gets done?
44 Measurement Questions • Were the performance measures appropriate to assess the clinical and non-clinical HIV care in the facility? • Are the results in the expected range of performance?
45 Improvement Questions • Were annual quality goals for quality improvement activities met?
• How effectively did you meet your goals? • What were the strengths and limitations?
46 Education Questions Did the appropriate people have the ability to participate in quality improvement training opportunities?
Staff Consumers
47
TOOL BOX
48 Quality Program Assessment Tool • Part-specific Organizational Assessment Tools to assess the HIV-specific quality program.
• Benefits of using these tools include: - increased inter-rater reliability due to standardized scoring tools - allowing for comparisons over time - comparisons with other HIV programs
49 Quality Program Assessment Tool • Available for each Part • Series of key questions to assess quality plan, quality infrastructure, performance measurement, staff/consumer involvement and quality activities • Scoring instrument from 0 (rudimentary) to 5 (advanced) • Written scoring instructions Quality Management Plan
A.1. Is a comprehensive HIV-specific, Part D Network-wide quality management plan in place with clear definitions of leadership, Part D roles, resources and accountability? Score 0 Score 1 Score 2 Score 3 Score 4 Score 5
Score 0 Score 1 Score 2 Part D program has no or minimal written quality plan in place; if any in existence, written plan does not reflect current day-to-day operations. Part D program has only loosely outlined a quality management plan; written plan reflects only in part current day-to-day operations. Score 3 A written Part D Network-wide quality management plan is developed describing the quality infrastructure, frequency of meetings, indication of leadership and objectives; the quality plan is shared with staff; the quality plan is reviewed and revised at least annually; some areas of detail and integration are not present. Score 4 Score 5
Comment:
A comprehensive and detailed HIV-specific, citywide quality management plan is developed/refined, with a clear indication of responsibilities and accountability, quality committee infrastructure, outline of performance measurement strategies, and elaboration of processes for ongoing evaluation and assessment; engagement of other department representatives is described; quality plan fits within the framework of other citywide QI/QA activities; staff and providers are aware of the plan and are involved in reviewing and updating the plan.
50 Assessment Tools Can be Found by Clicking:
Part A Part B Part C Part D
51 Share your Experiences Using an OA Tool
52 Quality Management Plan Group Process Resources QI Cheat Sheets
PART II: QUALITY MANAGEMENT INFRASTRUCTURE
53
QUALITY MANAGEMENT PLAN
54 Quality Management Program The term ‘Quality Management Program’ encompasses all grantee-specific quality activities , including the formal organizational quality infrastructure committee structures, roles for stakeholders, providers and consumers) and (e.g., quality improvement related activities (performance measurement, quality improvement projects and quality training activities).
55 Quality Management Plan A quality management plan is a written document that outlines the grantee-wide HIV quality program evaluation and assessment of the program.
, including a clear indication of responsibilities and accountability, performance measurement strategies and goals, and elaboration of processes for ongoing
56 Quality Management Plan Diagram
Grant-wide Vision Strategic QM Plan (3-5 yrs) QM Plan (annual) Annual Evaluation Annual Goals Execution Work plan
57 Elements of a Quality Management Plan 1. Quality statement 2. Quality infrastructure 3. Performance measurement 4. Annual quality goals 5. Engagement of stakeholders 6. Evaluation
58 Quality Statement: What Do We Want to Be?
A brief mission statement describing the end goal of the HIV quality program to which all other activities are directed
59 Tips for the Quality Statement • Be brief • Be visionary • Include internal and external expectations • Make references to Ryan White legislative requirements on quality management
60 Create or Share a Quality Statement
61 Infrastructure: How are We Organized?
• Leadership • Accountability • Quality committee(s) structure • Resources
62 Tips for the Quality Infrastructure 3 to 5 pages All stakeholders Job functions List linkages
63 Performance Measurement: How Will We Assess Progress?
• • • Identify what’s important Develop ways to measure; Include process, outcome, and satisfaction measures
64 Tips for Performance Measurement • Develop quality indicators • relevance • measurability • accuracy • improvability • Include a portfolio of process • Who, When & How • Reporting strategies
65 Annual Quality Goals: What are the Priorities for the Quality Program?
Quality goals are endpoints or conditions toward which a quality program will direct its efforts and resources.
Three things to look at in designing goals: • Frequency: How many patients/clients received and how many did not receive the standard of care/services?
• Impact: What is the effect on patient health if they do not receive this care/service?
• Feasibility: Can something be done about this problem with the resources available?
66 Tips for Annual Quality Goals No more than 5 measurable goals Use a broad range of goals Establish performance targets to achieve
67 Let’s Write A Sample Goal • In what direction the agency wants to be headed, broadly defined.
• Example: To improve the quality of health care so that all clients served at this agency receive care according to the USPHS guidelines.
68 Engagement of Stakeholders How will staff, providers, consumers and others be involved in the QM program?
• Engage internal and external stakeholders • Communicate information about quality improvement activities • Provide opportunities for learning about quality
69 Evaluation: How Will We Assess the Quality Management Program’s Performance?
Infrastructure QI activities Performance measures
• Did we improve HIV care and services?
• Do we require further adjustment?
• Were goals met?
• How effectively?
• Did work plan go as planned?
• Were established milestones hit?
• Were stakeholders informed?
• Was training provided?
• Are results in the expected range?
70 Tips for Evaluation • Detail when and who is performing the evaluation • Compare annual quality goals with year-end results • Use findings to plan next year’s activities; learn and respond from past performance • Routinely use organizational assessment tools
71 Elements of a Quality Management Plan 1. Quality statement 2. Quality infrastructure 3. Performance measurement 4. Annual quality goals 5. Engagement of stakeholders 6. Evaluation
72 TA Resource: Quality Management Plan Checklist Checklist for the review of an HIV specific Quality Management Plan: http://www.nationalqualityce
nter.org/index.cfm/5852 Elements include: • Quality statement • Quality infrastructure • QM Plan implementation • Performance measurement • Annual quality goals • Engagement of stakeholders • Evaluation • Capacity Building • Process to update QM Plan • Communication • Formatting
73 The 10 QM Plan Rules 1. Do not reinvent the wheel, use established frameworks to get started 2. ‘Steal Shamelessly, Share Senselessly’ 3. Size does not matter 4. 80% planning, 20% writing (old software programming rule) 5. A few visionary annual goals are better than plenty of useful ones
74 The 10 QM Plan Rules (cont.) 6. Be inclusive, even it takes longer to get your final QM plan 7. If you have not touched your plan in the last 6 months, bring it to the next quality committee meeting 8. A perfect plan is never written 9. Plans are only as good as their implementation 10. Get started
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GROUP PROCESS
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Implementing Change
Change Management
…the process of engaging people at all levels in the design and implementation of an organization’s transition to a desired future…
Change Management: who’s in charge 77 (Slide borrowed from presentation for ACT by Dr. Kristin Hahn –Cover, University of Missouri, Columbia, Missouri )
What Hats do You Like to Wear in a Group?
Blue Hat: Facilitator/ Organizer/ Summarizer Red Hat: Emotive/ Feeling Yellow Hat: Supportive/ Sunny White Hat: Data Black Hat: Rules/ Regulations/ Obstacles Green Hat: Creative/ New Ideas DeBono E, Six Thinking Hats, Little, Brown, & Co, Boston, 1985.
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79 Purpose of 6 Hat Thinking • Promotes Parallel/Directional Thinking • Manages multiple “thoughts” • Allows one “think” at a time • Changes the direction of the train • Easy to use • Removes judgment about right or wrong • Allows us to focus on “what we can do!”
Adopter Categories
Innovators Early Adopters 2.5% Early Majority Late Majority 13.5% 34% 34%
Source: E.M. Rogers, Diffusion of Innovations (1995)
Historians 16%
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81 Sustaining Quality Efforts – Eat Your Sauerkraut!
Perceptions • • • • • Perceived Benefit Compatibility Complexity (KIS) Trialability Observability Contextual/ Managerial factors • Leadership • Support for change Characteristics of Individuals: • • • • • Innovators Early Adopters Early Majority Late Majority Traditionalists • Communication • Modeling • Formal/Informal Mechanisms • Culture Berwick DM, Disseminating Innovations in Health Care, JAMA, 2003;289(15): 1969-1975, http://jama.ama assn.org/cqi/content/full/289/15/1969 .
82 Scale Down the Time Frame • Years • Quarters • Months • Weeks • Days • Hours • Minutes
Drop down two levels! (years to months, weeks to hours) What can I do by the next time we meet?
83
RESOURCES
84 Allocating Resources • Makes staff time available for quality committee meetings and quality improvement project team work • Ensures that staff has the tools, knowledge and data necessary to participate in quality improvement work
85 • Time • Space • Training • Support • Data Systems • Vision • Prioritization What do you need?
• Tools • Team • Plan • Timeline • Testimony • Equipment • Alignment
86
TOOL BOX
Translation: English to QI
QI Process Question QI Step
1. What do we want to accomplish? 1. Create preliminary aim statement & conduct lit review 2. Who cares and what do they care about? 2. ID current stakeholders & get their input 3. What are we doing now and how well are we doing it? 4. What prevents us from doing better? What are the underlying problems?
5. What can we do better? What changes can we make to do better?
6. Do it.
7. How did we do? Do we need to “tweak”?
8. If it worked, how can we do it every time?
• Create preliminary aim and begin Fishbone.
4. Continue to build Fishbone 5. Brainstorm & propose solutions; look at effort vs. yield 6. Implement first P(lan)-D(o)-S(tudy)-A(ct) 7. Re-collect data, evaluate, implement new PDSA? 8. Hardwire into practice – change culture.
9. What did we learn?
Updated 06/01/2010 9. Spread findings. Celebrate Successes
Model for Improvement
Model for Improvement Updated 06/01/2010
90 Bibliography on Leadership • • • • • • • • Berwick, Donald M. MD, MPP, and Thomas W. Nolan, "Physicians as Leaders in Improving Health Care: A New Series in the Annals of Internal Medicine." Ann Intern Med. 1998;128:289-292 Clemmer, Terry P. MD et. al., "Cooperation: The Foundation of Improvement." Ann Intern Med. 1998;128: 004-1009.
Nolan, Thomas W., "Understanding Medical Systems," Ann Intern Med. 1998;128:293-298.
Plsek, Paul. “Innovative Thinking for the Improvement of Medical Systems.” Ann Intern Med. 1999;131:438-444.
Reinertsen, James L. "Physicians as Leaders in the Improvement of Health Care Systems, Ann Intern Med. 1998:128: 833-838. Caldwell, C. "Mentoring: The Evolving Role of Senior Leaders in a TQM Environment." Quality Management in Health Care. 1993. Vol 1. No 2. pp. 13-21.
Reinertsen, James, Michael Pew and Thomas W. Nolan. “Executive Review of Improvement Projects: A Primer for CEOs and other Senior Leaders.” Can be accessed at http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/Leadership/Tools/ExecutiveReviewofP rojectsIHI+Tool.htm
Kotter, John P. Leading Change. Boston, MA: Harvard Business School Press, 1996.
91 Bibliography on Teams & Processes • ‘HIVQUAL Workbook’ A guide for HIV providers to learn about quality management and quality improvement. A publication of the New York State Department of Health, AIDS Institute, 2006. The guide can be downloaded at: http://www.nationalqualitycenter.org/index.cfm/5659 • The Nine Step Model from HRSA can downloaded at: http://hab.hrsa.gov/tools/QM/ • Organization Assessment tools http://nationalqualitycenter.org/index.cfm/5852
92 • • • • Bibliography for QMP HRSA’s Quality Management TA Manual outlines a nine-step plan for implementing quality management programs. The manual provides concrete examples and outlines the expectations and legislative requirements of CARE Act grantees. The manual can be downloaded from: http://hab.hrsa.gov/tools/QM http://hab.hrsa.gov/tools/QMespanol/ . The manual is now also available in Spanish: Supervisión de la Calidad: Manual de Asistencia Técnica, at: For guidance in teaching small groups how to develop a quality improvement management plan, see the HIVQUAL Group Learning Guide "Quality Improvement Management Plan" exercise. You can download this publication at www.hivguidelines.org
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For possible quality of care indicators: • New York State DOH AIDS Institute (www.hivguidelines.org) • Improving Care for People Living with HIV/AIDS Disease. Institute for Health Care Improvement, HRSA/HAB. HIV/AIDS Bureau Collaborative. Order via the HRSA Information Center ( www.ask.hrsa.gov/detail.cfm?id=HAB00289 ) or call 888-ASK HRSA.
• National Quality Measures Clearinghouse ( www.qualitymeasures.ahrq.gov
) For examples and other general tips: The HIVQUAL Workbook, especially pp. 38-54. You can download this publication at www.hivguidelines.org
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Lead Presenter: 93 Barbara Boshard, MS, BS, RN Coordinator of Quality Improvement University of Missouri School of Medicine Department of Internal Medicine One Hospital Drive Columbia, Missouri 65212 Phone: 573-884-0770 FAX: 573-884-4533 E-Mail: [email protected]
94 Contact Information
National Quality Center (NQC)
212-417-4730 NationalQualityCenter.org
HIVQUAL-US
212-417-4620 HIVQUAL.org
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How do you rate the overall effectiveness of this workshop?
1. Very effective 2. Effective 3. Somewhat effective 4. Ineffective 5. Very ineffective 95
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How effective was this workshop in providing you practical solutions and strategies for your program?
1. Very effective 2. Effective 3. Somewhat effective 4. Ineffective 5. Very ineffective 96
This workshop have the right blend of lecture and group discussion?
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1. Strongly agree 2. Agree 3. Somewhat agree 4. Disagree 5. Strongly disagree 97
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NQC offer additional webinars on this topic in the future?
1. Strongly agree 2. Agree 3. Somewhat agree 4. Disagree 5. Strongly disagree 98