Quality Improvement

Justine Strand, MPH, PA-C

Patricia Castillo, MS, PA-C

Victoria Kaprielian, MD

Goal:

Apply principles and practices of Quality Improvement.

What is QI?

QI Opportunities and Benefits

QI can give you the opportunity to …..

• Look at things differently• Come up with new options and solutions• Eliminate things that make you crazy

QI: A Historical Perspective

• based on the theories of Deming and Juran

• 1980s – Japanese auto industry

• 1990s – American manufacturers and health care industry

Health Care: Cost and Access

• Improvements in technology

• Higher prices

• Greater demand

• Integrated medical delivery systems

Perspectives on Quality

• Providers

• Payers

• Employers

• Consumers

QI is a “Hot Topic”

• “…The quality of health care received by the people of the United States falls short of what it should be.”

IOM, 2001

US Health System Rankings

• 37th place overall (out of 191) because of significant health disparities

• Tied for 82nd place (out of 171) on polio vaccination rate

• Number 1 on both dollars spent per capita, and proportion of GDP spend on health care

Medical Errors

• How extensive is the problem of medical errors?

• More people die in a year from medical errors than from motor vehicle accidents, breast cancer, or AIDS

“Crossing the Quality Chasm” IOM 2001

• Under use – helpful services not delivered

• Overuse – useless interventions

• Mistakes – inevitable human error

Medical Errors

• Not the fault of individuals

• Lessons from industry

QI in Health Care

• How can you measure quality in health care?

• What do you want to measure?• How can you do it?• What are the challenges?

Issues in Measurement

• Structure

• Process

• Outcome

Process vs. Outcome

• Process:– How health care is provided– How the system works

• Outcome:– Health status– Does it make a difference?

Proxy Measures

• Used when you can’t exactly measure what you want or need

• Measure something that is close enough to reflect similarly

Information Systems

• Can be a valuable tool

• Can facilitate quality efforts

• Examples:– Databases– Disease registries

Convenience Samples

• Takes a limited number

• Extrapolates to the whole population

• Not necessarily randomized

QI: Issues in Measurement

• Process vs. Outcome

• Proxy measures

• Information systems

• Convenience samples

“FADE” Methodology

u FOCUSu ANALYZEu DEVELOPu EXECUTE/EVALUATE

The FADE model

GenerateGeneratea list ofa list of

problemsproblems

SelectSelectoneone

problemproblemVerify/Verify/definedefine

problemproblem

FOCUSFOCUS

Written statement of problemWritten statement of problem

DecideDecidewhat youwhat youneed toneed toknowknow

List ofList ofmostmost

influentialinfluentialfactorsfactors

BaselineBaselinedatadata

CollectCollectdatadata

baselines/baselines/patternspatterns

AANNAALLYYZZEE

DEVELOPDEVELOP

Solution forSolution forproblemproblem

DevelopDevelopimplementationimplementation

planplan SelectSelectsolutionsolution

GenerateGeneratepromisingpromisingsolutionssolutions

A plan forA plan forimplementationimplementation

EXECUTE

Organizationalcommitment

Gaincommitment

Executeplan

Executeplan

Monitorimpact

Recordof

impact

F A D E

DetermineDetermineinfluentialinfluential

factorsfactors

Example 1

The state child health report indicates no well child care is being done in your primary care clinic.

What do you do?

Quality Improvement vs. Performance Improvement

• Quality Improvement focuses on quality of care

• Performance Improvement focuses on administrative systems

• The goal is improvement in quality

The Diagnostic Process

Example 2

An audit shows your immunization rate for well children to be 45%

What do you do?

Evaluation results

About 18 months later, your immunization rate is now 82%

What would you do now?

Is 82% good enough?

QI: Rapid Cycle Improvement

• EVALUATE• FOCUS• ANALYZE• DEVELOP• EXECUTE• EVALUATE

“PDSA” Methodology

• PLAN

• DO

• STUDY

• ACT

“PDSA” Methodology

• PLAN

• DO

• STUDY

• ACT

Example 3

Improving a phone message system

PLAN

DO

STUDY

ACT

QI vs. Research

QI:• Confidential• Existing standard of

care• Improving care

• No IRB approval needed

Research:• Publish/present• Tests new methods• Creating new

generalizable knowledge

• Needs IRB approval

Summary

• Improving health care quality is our responsibility

• Identify the cause before making changes

• Be creative in developing solutions

THINK OUTSIDE THE BOX!