Transcript Using a Comprehensive Organizational Assessment as a Tool to Build a Sustainable Quality Program Margaret Palumbo, MPH, HEALTHQUAL Int’l Sherry Martin, Quality Management Consultant Bethany Blackburn,

Using a Comprehensive
Organizational Assessment as a
Tool to Build a Sustainable Quality
Program
Margaret Palumbo, MPH, HEALTHQUAL Int’l
Sherry Martin, Quality Management Consultant
Bethany Blackburn, MBA, University of Pittsburgh
Wednesday, November 28, 3:30 to 5 pm
RWA-0214
Funded by HRSA
HIV/AIDS Bureau
NQC and Quality Workshops at 2012 AGM
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NQC at 2012 AGM
• Networking Opportunities Interact with your peers…
 Tue, Nov 27 12pm: HIVQUAL
Regional Group– Thurgood Marshall
Ballroom West
 Wed, Nov 28 12pm: in+care Campaign
- Thurgood Marshall Ballroom South
• NQC Exhibit Booth - Stop by our
booth…
• NQC Office Hours - Meet one of
our NQC coaches...
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National Quality Center (NQC)
Workshop Agenda
• Context of Quality Management Infrastructure –
Margaret Palumbo (5 min)
• The Baldridge Performance Excellence Program – Sherry
Martin (20 min)
• Organizational Assessment (OA) Version 2 Review –
Margaret Palumbo (15 min)
• A Grantee’s Experience utilizing the OA: University of
Pittsburgh – Bethany Blackburn (10 min)
• Group work: Self Assessment and Discussion of key OA
Components (40 min)
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National Quality Center (NQC)
Quality Management Program:
Definitions
• Practically speaking, a quality management program
encompasses
the structures, functions and processes that support systematic
implementation of performance measurement and quality improvement
activities
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National Quality Center (NQC)
Quality Management Infrastructure
• Although Quality Improvement projects can be
undertaken successfully and demonstrate results,
ongoing, sustainable improvements will be short-lived
without infrastructure to maintain them.
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National Quality Center (NQC)
Quality Management Infrastructure
• The tasks of initiating, sustaining, and spreading QI
throughout a healthcare delivery system are daunting
and require more than individual effort.
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National Quality Center (NQC)
Quality Management Infrastructure
• Infrastructure required for QI success and sustainability
involves
 a receptive organization
 sustained leadership
 staff training and support
 time for teams to meet
 data systems for tracking outcomes
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National Quality Center (NQC)
Quality Management Program Assessments
• The Baldridge Performance Excellence Program
• NYS DOH AIDS Institute HIVQUAL Organizational
Assessment
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National Quality Center (NQC)
Creating Sustainable Organizations
The Baldrige Performance
Excellence Program
Sherry Martin
All Grantee Meeting
November, 2012
Funded by HRSA
HIV/AIDS Bureau
Improving Quality in the Face of Change
• Is change real; is health reform real?
• Why consider using the Baldrige
approach?
• What are the key success factors
leading to high performance?
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National Quality Center (NQC)
National Health Expenditure
2011
2020
NHE: $ 2.7 Trillion
NHE: $4.6 Trillion
Per capita:
$8,650
Per capita:
$13,708
GPD
GPD
17.7%
19.8%
CMS, Office of the Actuary, July, 2011
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National Quality Center (NQC)
Health Affairs, September 3, 2012
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National Quality Center (NQC)
Baldrige Performance Excellence Program
WHAT IS IT?
• Formal recognition of US organizations from the
President
• Established to promote performance excellence and
sharing of successful practices
• Administered by National Institute of Standards and
Technology
• Formerly, the Baldrige National Quality Program
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National Quality Center (NQC)
What is Performance Excellence?
Integrated management approach that results in:
• Delivery of continually improving value to the patient,
including effective health care outcomes
• Improved delivery processes, more efficient and timely
• Organizational learning
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National Quality Center (NQC)
The Baldrige Program
HOW DOES IT WORK?
• Structured self assessment tool, that enables an
organization to:
 Identify challenges and barriers to achieving their
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mission/vision
Develop strategies and action plans to overcome
Determine whether their approaches used to run the
organization are achieving results
Collect, analyze and use data effectively
Align the organization to achieve sustained results
National Quality Center (NQC)
The Self Assessment Core THE CRITERIA
• Structured questions that enable you to analyze how
you manage your work processes and the associated
results
• Applicable to any size or type of healthcare facility
• Non-prescriptive – they don’t tell you how to establish
your infrastructure or processes
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National Quality Center (NQC)
Baldrige 2011-2012 Criteria Categories
•
•
•
•
•
•
•
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Leadership
Strategic Planning
Customer Focus
Measurement, Analysis and Knowledge Management
Workforce Focus
Process Management
Results
National Quality Center (NQC)
Criteria Example
LEADERSHIP
• How do senior leaders create an environment for
organizational performance improvement, the
accomplishment of your mission and strategic
objectives, innovation, and organizational agility?
• How do senior leaders take an active role in reward and
recognition programs to reinforce high performance
and a customer and business focus?
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National Quality Center (NQC)
Criteria Example
STRATEGIC PLANNING
• What are your key strategic objectives and the timetable
for accomplishing them?
• How do your strategic objectives achieve the following?
 Address your strategic challenges and strategic advantages
 Capitalize on your core competencies and address the need
for new core competencies
 Enhance your agility to adapt to sudden shifts in your market
or regulatory conditions
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National Quality Center (NQC)
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National Quality Center (NQC)
How Sharp Aligned the Organization
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Sharp
Health Care – 2007 Baldrige Winner
National Quality Center (NQC)
Criteria Example
CUSTOMER FOCUS
• How do you listen to patients and families and other
customers to obtain actionable information? How do
your listening methods vary for different customers.
• How do you determine patient satisfaction and
engagement? How do your measurements capture
actionable information for use in exceeding your
patients’ expectations?
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National Quality Center (NQC)
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National Quality Center (NQC)
Criteria Example
MEASUREMENT, ANALYSIS AND KNOWLEDGE
• How do you select, collect, align and integrate data and
information for tracking daily operations and overall
organizational performance, including progress relative
to strategic objectives and action plans? How do you
use this data to support organizational decision making
( at the front line)
• How do you use organizational performance review
findings to develop priorities for continuous
improvement and opportunities for innovation
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National Quality Center (NQC)
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National Quality Center (NQC)
Criteria Example
Workforce Focus
• How do you assess your workforce capacity and
capability needs, including skills, experience and staffing
levels?
• How do you recruit, hire and retain new members of
your workforce?
• How do you determine the key elements that affect
workforce engagement and satisfaction”
• How do you transfer knowledge from departing and
retiring employees?
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National Quality Center (NQC)
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National Quality Center (NQC)
Criteria Example
Operations Focus
• What are your work systems and processes? How do
you manage and improve them to deliver customer
value and achieve organizational success and
sustainability?
• How do you control costs of your work systems? How
do you incorporate ( measure) cycle time, productivity
and other efficiency and effectiveness factors into these
processes?
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National Quality Center (NQC)
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National Quality Center (NQC)
Sharp Health Care – 2007 Baldrige Winner
RESULTS
•
•
•
•
•
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Healthcare - outcomes related to core business
Customer focused – satisfaction
Workforce-focused – engagement
Process management – efficiency, cycle time
Leadership – accomplishment of strategic plans to
achieve mission
National Quality Center (NQC)
Criteria Examples
RESULTS
• What are your current levels and trends in key measures or
indicators of health care outcomes that are important to
and directly serve your patients and stakeholders?
• How do these results compare with the performance of
other organizations with similar offerings
• What are your current levels and trends in key measures of
operational performance of your work processes, including
productivity and cycle time…
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National Quality Center (NQC)
Levels and Trends
• LEVEL – your current level of performance – enables
you to compare performance with benchmarks and
establish targets to achieve
• TREND – the rate of your performance improvement
- enables you to determine whether your interventions
are working
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National Quality Center (NQC)
Southcentral Foundation – 2011 Baldrige Winner
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National Quality Center (NQC)
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National Quality Center (NQC)
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National Quality Center (NQC)
Baldrige Self Assessment
SUCCESS FACTORS
• Comprehensive – evaluates all aspects of an
organization
• Fact-based – objective assessment
• Systematic – evaluates approach, deployment and
effectiveness ( results)
• Identifies key opportunities on which to focus to
achieve the mission
• Operates in the organizational background
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National Quality Center (NQC)
Baldrige Assessment
IS IT A TOOL FOR US?
• Requires:
 Data and information to answer the criteria questions
 Consensus around key identified opportunities on which to
focus
 Improvement initiative cycles
The Result
Improved Quality in a Changing Environment
SUSTAINABILITY
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National Quality Center (NQC)
NYSDOH AIDS Institute HIVQUAL
Organizational Assessment (OA)
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National Quality Center (NQC)
Overview of Quality Management Organizational
Assessment (OA)
• Purpose
 Build grantee technical capacity in and knowledge of QM
program key components
 Provide a time-tested tool to measure progress in key QM
program components
 Highlight opportunities for improvement at the QM program
level
 Focus on progress over time and inform annual QM planning
activities
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National Quality Center (NQC)
Overview of Quality Management Organizational
Assessment (OA)
• History
 Version 1 initiated by HIVQUAL to assess Ryan White
grantee Quality Management (QM) Programs
 Conducted primarily by QI consultants but used as a self
assessment by some grantees
 Aligned with HAB QM program guidance
 Provided a baseline to inform HIVQUAL and HAB technical
assistance planning
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National Quality Center (NQC)
Overview of Quality Management Organizational
Assessment (OA)
• Scoring
 Provides a metric to assess progress along a continuum for
each component
 Scoring from 0 to 5
 Focus on progress over time
 Provides method to identify QM program priorities
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National Quality Center (NQC)
Overview of Quality Management Organizational
Assessment (OA)
• Version 2
 Improve consistency of scoring across multiple reviewers
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and self evaluators
Reflect increased sophistication and knowledge of grantees
Reflect advances in QI science and methodology
Promotes “high performance” vs. minimum standards
Provide better definitions and purpose of each component
for education and implementation
National Quality Center (NQC)
Alignment…..
• With Baldridge
• With HAB guidelines
• With Medical Homes
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National Quality Center (NQC)
Overview of Quality Management Organizational
Assessment (OA)
• Version 2 OA New Sections
 Achievement of Outcomes
 Reduction of Disparities
 Staff Satisfaction
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National Quality Center (NQC)
OA Components
• Quality Management
 Leadership
 Quality Committee
 Quality Plan
• Workforce Engagement in the HIV Quality
Management Program
• Measurement, Analysis and Use of Data to Improve
Program Performance
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National Quality Center (NQC)
OA Components
• Quality Program Evaluation
• Achievement of Outcomes
• Disparities in Care
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National Quality Center (NQC)
Implementation Guidelines
• Conducted by an expert QI coach or as a self
evaluation.
• Results used for work-plan development and to
guide planning process and priorities
• Key leadership and staff should be involved in the
assessment process
• Results of the OA should be communicated to
internal key stakeholders, leadership and staff
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National Quality Center (NQC)
Example: Quality Improvement Initiatives
D. Quality Improvement Initiatives
GOAL: To evaluate how the HIV program applies robust process improvement
methodology* to achieve program goals and maintain high levels of performance over
long periods of time.
The Quality Improvement Initiatives section examines how leadership and workforce use
these methods and tools to conduct improvement initiatives with emphasis on identification
of the exact causes of problems and designing effective solutions; determining program
specific best practices and sustaining improvement over long periods of time. In high
reliability organizations robust process improvement methodology is routinely utilized for all
identified problems and improvement opportunities to assure consistency in approach by all
staff members.
*Robust process improvement includes reliably measuring the magnitude of a problem,
identifying the root causes of the problem and measuring the importance of each cause,
finding solutions for the most important causes, proving the effectiveness of those solutions,
and deploying programs to ensure sustained improvements over time
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National Quality Center (NQC)
Example: Quality Improvement Initiatives
D.1. To what extent does the HIV program identify and conduct quality improvement initiatives using robust process improvement methodology to assure high levels
of performance over long periods of time?
Getting Started
0
 Formal quality improvement projects have not yet been initiated in the program.
Planning and
QI initiatives: (No assessment of organizational performance or system level analysis of data performed; are not team-based and do not use
initiation
specific tools or methodology.
1
 Focus on individual cases only.
 Reviews are primarily used for inspection.
Beginning
QI initiatives:
Implementation
 Are prioritized by the quality committee based on program goals, objectives and analysis of performance measurement data.
2
 Involve team leaders and team members who are assigned by the quality committee or other leadership.
 Begin to use specific tools or methodology to understand causes and make effective changes.
Implementation
QI initiatives:
 Are ongoing based on analysis of performance data and other program information, including external reviews and assessments.
3
 Focus on processes of care in which QI methodology is routinely utilized.
 Are regularly documented and provided to Quality Improvement Committee.
 Involve staff on QI teams. Cross departmental/cross functional teams are developed depending on specific project needs.
Progress toward
QI initiatives:
systematic
 Are ongoing based on analysis of performance data and other program information, including external agency reviews and assessments.
approach to
 Can be identified by any member of the program team through direct communication with program leadership.
quality
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 Routinely and consistently reinforce and promote a culture of quality improvement throughout the program through shared accountability and
responsibility of identified improvement priorities.
 Are supported with appropriate resources to achieve effective and sustainable results.
 Involve support of data collection with results routinely reported to QI project teams.
Full systematic
QI initiatives:
approach to
 Are ongoing in every service category.
quality
 Correspond with a structured process for prioritization based on analysis of performance data and other factors.
management in
 Are implemented by project teams. Further, physicians and staff can identify an improvement opportunity at any point in time and suggest a QI
place
team be initiated.
 Consistently and routinely utilizes robust process improvement and multidisciplinary teams to identify actual causes of variation and apply
effective sustainable solutions.
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 Are guided by a team leader or sponsor, and include all relevant staff depending on specific project needs.
 Are regularly communicated to the Quality Committee, staff and patients.
 Routinely involve consumers on QI project teams.
 Are presented in storyboard context or other formats and reported to larger organization and/or placed in public areas for staff and patients (if
relevant).
 Involve recognition of successful teamwork by senior leadership.
 Are supported by development of sustainability plans.
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National Quality Center (NQC)
Example: Achievement of Outcomes
G. ACHEIVEMENT OF OUTCOMES
GOAL: To assess HIV program capability for achieving excellent results and outcomes in areas
that are central to providing high quality HIV care.
In order to determine whether a program is achieving excellence in HIV care, a system for
monitoring and assessing clinical outcomes should be in place. This system should include analysis
of an appropriate set of measures; trending results over time; stratifying data by high-prevalence
populations (see G2) and comparison of results to a larger aggregate data set*used for
programmatic target setting. A set of appropriate measures may be externally developed (i.e. HAB,
HIVQUAL) and/or internally developed based on program goals. Viral Load Suppression and
Retention in Care are two essential measures of outcome that should be incorporated into the
program’s set of clinical measures.
*Possible data sets for comparison include HIVQUAL, HAB, In+Care Campaign, Regional groups,
RSR, VA, Kaiser, HIVRAD
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National Quality Center (NQC)
Example: Achievement of Outcomes
G.1. To what extent does the HIV program monitor patient outcomes and utilize data to improve patient care?
Getting Started
0  No clinical performance results are routinely reviewed or used to guide improvement activities.
Planning &
Initiation
1
Beginning
Implementation
2
Implementation
3
Progress toward
systematic
approach to
quality
Full systematic
approach to
quality
management in
place
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4
5
Data:
 For some measures are routinely reviewed and used to guide improvement activities.
 Trends for some measures are reported to determine improvement over time.
Data:
 Results for most measures are routinely reviewed and used to guide improvement activities.
 Trends for most measures are reported and many show improving trends over time.
Data:
 Results for all measures are routinely reviewed and used to guide improvement activities, including Viral Load Suppression and
Retention in Care.
 Trends for all measures are reported and many show improving trends over time.
 Results are compared to a larger aggregate data set for at least 2 outcome measures: Viral Load suppression and Retention in care.
 Comparison to larger aggregate data set is used to set programmatic targets.
Data:
 Results for all measures are routinely reviewed and used to guide improvement activities, including Viral Load Suppression and
Retention in Care.
 Trends are reported for all measures and most show improving trends over time.
 Results are compared to a larger aggregate data set for 2 outcome measures: Viral Load suppression and Retention in Care.
 Comparison to larger aggregate data set are used to set programmatic targets and targets are met for at least 50% of measures.
 Results for Viral Load Suppression and Retention in Care scores are equal to or greater than the 75th percentile of comparative data
set.
Data:
 Results for all measures are routinely reviewed and used to guide improvement activities, including Viral Load Suppression and
Retention in Care.
 Trends are reported for all measures and most show sustained improvement over time in areas of importance aligned with
organizational goals.
Results are compared to a larger aggregate data set for 2 outcome measures: Viral Load suppression and Retention in care.
 Comparison to larger aggregate data set are used to set programmatic targets and targets are met for at least 75% of measures.
 Results for Viral Load Suppression and Retention in Care scores are above the 75th percentile of comparative data set.
National Quality Center (NQC)
Implementation: University of Pittsburgh Medical
Center
• What does a mature sustainable Quality Management
Program look like?
• How can you use the OA tool to develop your
program?
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National Quality Center (NQC)
University of Pittsburgh
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National Quality Center (NQC)
Group Work
• Score your program on one component of the OA – these
will be assigned by table (5 min) (supplies – paper tool
provided)
• Engage in discussion of your scores including what has
worked for you and what challenges you have faced reaching
high performance (15 min)
• As a group determine 2 strategies to improve performance
for this component – your 2 best ideas (10 min)
• Report back to the larger group (10 min)
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National Quality Center (NQC)
NQC Offerings
NQC Website
HIVQUAL
Regional Groups
in+care Campaign
Quality Academy
On-Site TA
NQC Trainings
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NQC Resources
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Margaret Palumbo, MPH
Deputy Program Director
HEALTHQUAL International
[email protected]
National Quality Center
212-417-4730
NationalQualityCenter.org
[email protected]