Post on 07-Feb-2017
Continuous Quality Continuous Quality Improvement 101Improvement 101Amelia Broussard, PhD, RN, Amelia Broussard, PhD, RN,
MPHMPHbroussardco1@msn.combroussardco1@msn.com
WHY DO WE NEED TO KNOW WHY DO WE NEED TO KNOW ABOUT CQI?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…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 Success is achieved through meeting the needs of those we meeting the needs of those we
serveserve..
Quality Assurance vs. Quality Quality Assurance vs. Quality ControlControl
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 AssuranceQuality 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 Examples of Quality Assurance ActivitiesActivities
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• Annual infection control and safety training• Review medication closet for outdated meds• Review emergency chart once a week for supplies
and outdated meds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 ControlQuality Control“The observation techniques and activities used to fulfill requirements for quality.”
American Society for Quality
Examples of Quality ControlExamples of Quality Control• Infection control training
sign-in sheets cross-referenced with staff roster
• Review sheet of emergency cart
• Direct observation of counseling session
Quality ImprovementQuality 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 CQIPhilosophy 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 PrinciplesGuiding 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 Core Clinical Measures for Health Care PlanHealth Care Plan
• Diabetes• Cardiovascular
Disease• Prenatal Care• Perinatal Care
• Child health• Behavioral Health• Oral Health• Other x2
Goals of Quality Goals of Quality ImprovementImprovement
• 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 CQICore 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 CQICORE 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 & QIComparison of QA & QIQA QI
Motivation Measuring compliance with standards
Continuously improving processes to meet standards
Means Inspection Prevention, monitor over time
Attitude Required, defensive Chosen, proactiveFocus Outliers or “bad
apples”, individualsProcesses, systems, majority
Players Selected departments
Organization wide, benchmarking
Disciplines Within profession Multidisciplinary approachScope Medical profession
focusedPatient care focused
Responsibility
Few All
QA versus QIQA versus QI
Exercise on QualityExercise on Quality
• What is the benefit for:– Patients– Staff– Organization
Putting It All TogetherPutting 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 CQIGUIDING 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 ResponsibilitiesRoles 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 CQIPITFALLS OF CQI
• The paperwork can bury you
SET PRIORITIESSET PRIORITIES
PITFALLS OF CQIPITFALLS OF CQI
• Staff view it as a ball and chain, hindering their daily work
PITFALLS OF CQIPITFALLS OF CQI
• The Process can tie you up in knots
Lessons LearnedLessons 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
• 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
Common Themes among QI Common Themes among QI ModelsModels
One MODEL FOR One MODEL FOR IMPROVEMENTIMPROVEMENT• Model consists
of:– three questions
(aim, measure, change) to form context for improvement
– Plan-Do-Study-Act (PDSA) Cycle to structure tests
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?
Act Plan
Study Do
Model for ImprovementModel for 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 ImprovementModel 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 ImprovementModel 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 ImprovementModel for Improvement
PDSA CYCLEPDSA 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 PRINCIPLES OF PDSA CYCLESCYCLES
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 CyclesTips 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 PDSA Cycles: Testing a pap Cuing PlanCuing Plan
Use of flowsheet
will improve care to known
standards
Improved Decision Support
A PS D
A PS D
D SP A
DATAD SP A
Cycle 1A: On Mon., prescreen Fred’s Tues. pts, mark appointment sheet for those who are due for paps.
Cycle 1B: Debrief staff; did it help, how long did it take? Test with Dr. Strange’s patients for a full week.
Cycle 1C: Test with all patients for a full week, document feedback and time required.
Cycle 1D: Implement thruout clinic and monitor the impact.
Smaller Scale Tests: Smaller Scale Tests: Scale Down TimeframeScale Down Timeframe
• Years• Quarters• Months• Weeks• Days• Hours• Minutes
Reduce your timeframe to plan Test Cycle!
Analysis Tools: FlowchartsAnalysis 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
FLOWCHARTFLOWCHART• 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 EXAMPLEFLOWCHART EXAMPLE
Patient arrives at front desk
Receptionist asks for patient’s name & searches database for his/her file
Patient in system?
Receptionist asks patient to complete paperwork for new clients
and return it to front deskNO
Ask patient to be seated in the Waiting room
YES
Medical assistanttakes patient into
exam room
ETC.
CAUSE-AND-EFFECT CAUSE-AND-EFFECT DIAGRAMDIAGRAM
• Used to map variables that may influence a problem, outcome, or effect
• Also called:– Ishikawa diagram– Fishbone diagram
CAUSE-AND-EFFECT CAUSE-AND-EFFECT DIAGRAMDIAGRAMCAUSESCAUSES
• 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 CAUSE-AND-EFFECT DIAGRAMDIAGRAMSAMPLESAMPLE
Low show ratefor appointments
Procedures People
Patients
Patient unawareof appointment
Computer
System downfor routinemaintenance
Skeleton
EquipmentEnvironme
nt
ExerciseExercise• Construct Cause and Effect Diagram
with staff
Performance Performance Measurement and Measurement and
DataData
Why Measure?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?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?