Transcript CQI 101: Building and Sustaining an Effective Infrastructure Kimberly Gentry Sperber, Ph.D.

CQI 101:
Building and Sustaining an Effective Infrastructure
Kimberly Gentry Sperber, Ph.D.
Achieving Quality
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Responsibility for quality falls on both the
organization and the individual.
The individual and the organization should be
linked in a formal framework designed to
continually improve quality.
Quality Assurance (QA)
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Retrospective review process
Emphasis on regulatory and contract compliance
Catching people being bad leads to hide and
seek behavior
Continuous Quality Improvement (CQI)
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CQI is a prospective process
Holds quality as a central priority within the organization
Focus on customer needs; relies on feedback from internal
and external customers
Emphasizes systematic use of data
Not blame-seeking
Trust, respect, and communication
Move toward staff responsibility for quality, problem solving
and ownership of services
Objectives of CQI
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To facilitate the Agency’s mission
To ensure appropriateness of services
To improve efficiency of services/processes
To improve effectiveness of directing services to client
needs
To foster a culture of learning
To ensure compliance with funding and regulatory
standards
Creating Infrastructure
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Dedicated position
Use of committees
Written CQI plan
Designated process requirements
Inclusion in strategic plan
Positioning within agency
Role of external stakeholders
Creating a CQI Infrastructure
Executive CQI Committee
Risk Management
Committee
Human Subjects
Committee
Safety Committee
Corporate Compliance
Committee
Diversity Committee
Cluster CQI
Committees
Morbidity & Mortality
Conference
Program Peer Review
Committees
Written Plan
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Vision/purpose
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Definitions
Authority to ensure compliance
Compliance procedures/definitions
Documentation of process
Peer Review
Committees
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Membership
Objectives
Satisfaction
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Objectives
Clients
Employees
External stakeholders
Choosing indicators
Use of data
Why Examine Documentation?
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Clinical Implications
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Operational Implications
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Good documentation should drive decision-making.
Means of communication
Risk Management Implications
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Documentation is not separate from service delivery.
Did the client receive the services he/she needed?
If it isn’t documented, it didn’t happen.
Permanent record of what occurred in the facility
Source of Staff Training
Reflection of the provider and organization’s competency:
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EBP
Outcome of care
Peer Review Committees
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Requires standardized, objective method for assessing
charts.
Random selection of charts and monthly reviews
Goal is to identify trends and brainstorm solutions
These staff serve as front line for corporate compliance,
risk management, and quality documentation
Peer Review Measures
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Completeness of Records checks
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Assessment is present and complete.
Service plan present and complete.
Consent for Treatment present and signed.
Quality Issues
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Services based on assessed needs.
Progress notes reflect implementation of service plan.
Documentation shows client actively participated in creation of service
plan.
Progress notes reflect client progress.
Peer Review Process
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Identification of review elements
Assigning staff responsibilities
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Workload analysis
Creating process for selecting files for review
Determining review rotation
Reporting and use of data
Establishing Indicators
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Relevant to the services offered
Align with existing research
Measurable
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No “homegrown” instruments
Reliable and valid standardized measures
Examples of Indicators
Process Indicators
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Percentage of clients with a serious MH issue referred to community services
within 14 days of intake.
Percentage of clients with family involved in treatment (defined as min.
number of face-to-face contacts).
Percentage of clients whose first billable service is within 72 hours (case mgt).
Percentage of positive case closures for probation/parole.
Percentage of high risk clients on Abscond Status for probation/parole.
Percentage of restitution/fines collected.
Percentage of clients participating in treatment services.
Examples of Indicators
Outcome Indicators
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Clients will demonstrate a reduction in antisocial attitudes.
Clients will demonstrate a reduction in LSI scores.
Clients will demonstrate an increase in treatment readiness.
Clients will obtain a GED.
Clients will obtain full-time employment.
Clients will demonstrate a reduction in Symptom Distress.
Client will demonstrate sobriety.
Client Satisfaction
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Identify the dimensions
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Access
Involvement in treatment/case planning
Emergency response
Respect from staff
Respect from staff for cultural background
All programs use the same survey
Items are scored on a 1-4 Likert scale
Falling below a 3.0 generates an action plan
Operationalizing the Process
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Distribution and collection of surveys
Coding, analysis, and reporting of data
Use of data
Establishing Thresholds
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Establish internal baselines
Compare to similar programs
Compare to state or national data
Action Plans
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Plan of correction
Proactive approach to problem-solving
Empowers staff
Using objective data to inform decision making
Who Creates Action Plans?
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Anyone and everyone can create action plans
Focus should be on who has knowledge or
expertise to contribute
Focus should not be on the person’s title
Focus on Causes not Symptoms
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Focus on processes/systems rather than
individuals or specific errors
Identification of risk points and their contribution
to the problem
Identify changes in these processes that reduce
risk of re-occurrence
Process Evaluation
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Are we serving our target population?
Are the services being delivered?
Did we implement the program as designed (tx
fidelity)?
Are there areas that need improvement?
Outcome Evaluation
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Are our services effective?
Do clients benefit (change) from the services?
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Intermediate outcomes
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Reduction in risk
Reduction in antisocial values
Long-term outcomes
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Recidivism
Sobriety
Minimum Requirements
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Buy-in from staff at all levels of the organization
Sufficient resources allocated for staff training
Sufficient resources allocated for staff to participate in
the process
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Peer Review Meetings
Other relevant committee meetings
Data collection
Sufficient information systems
Barriers to Implementation
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Agency culture
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Costs
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The “black hole” of data that leads to staff cynicism and burnout
Conflicting messages about targets/goals in various work domains
Problem letting go of old ways
“We’re clinicians not statisticians”
Staff time
IS capabilities
Data collection instruments
Coordination of the process and dissemination of the data
Multiple and sometimes conflicting demands of multiple funders
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Different priorities
Don’t speak the same language causing confusion for line staff
Overcoming Resistance
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Administration must walk the walk
Insure early successes to increase buy-in
Recognition of staff for using the process
Openly acknowledge the extra work required
Demonstrate front-end planning to minimize workload
issues
Benefits of Program Evaluation
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Proof of effective services
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Maintain or secure funding
Improve staff morale and retention
Educate key stakeholders about services
Highlights opportunities for improvement
Data to inform quality improvement initiatives
Establish/enhance best practices
Monitor/ensure treatment fidelity
Why Invest in CQI?
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A CEO’s Perspective:
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Because it’s the right thing to do!
Better for clients (i.e., better outcomes)
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Mission-driven
Increased staff satisfaction
Increased staff retention
Improved referral source satisfaction
More business for related projects
Outcomes to sell to business community and other payers
Demonstrates fiscal responsibility (i.e., effective use of
dollars)
Strategic Use of CQI Data
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CQI data used to provide testimony before legislature
CQI data and infrastructure used to secure new
contracts and grants
CQI data used in newsletters, media relations, levy
campaigns, etc.
CQI data used to negotiate programmatic changes with
stakeholders
The Role of QA/QI in Community Corrections
(based on UC Halfway House and CBCF study)
% Change in Recidivism
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6
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4
2
1
0
Internal QA
No Internal QA
NPC Research on Drug Courts
Drug Court Uses Evaluation Feedback to Make Modifications
Percent Improvement in Outcome Costs*
50%
44%
40%
30%
20%
11%
10%
0%
Yes
N=4
No
N=6
* "Percent improvement in outcome costs" refers to the percent savings for
drug court compared to business-as-usual
Getting Started
Identifying Key Decision Points
Looking at Infrastructure
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Identification of those with powers for decision
making and resource allocation
Current capabilities
Ideas for infrastructure
Planned needs
Documentation Review
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Feasibility of documentation review
Identify sources of review elements
Operationalize routine file reviews
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Who
When
How many
Choosing Indicators
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Identify possible measures
Value of measures
Methods of measurement
Operationalize data collection
Creating a Client Satisfaction Process
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Identify sample survey items
Prioritize items
Operationalize distribution and reporting
Identify staff responsibilities
Mechanisms for sharing results
Program Evaluation
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Examples of past projects
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Were they beneficial?
Ideas for new process and outcome evaluation
projects
Available data
Required resources
Creating a Work Plan
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Identify all questions that need answered and
who has the authority to answer them
Identify beginning tasks
Assign responsible parties and deadlines
Create written implementation plan
Questions and Answers
Contact Information:
[email protected]