Quality Management Branch Cady Clark, MSN, RN Branch Manager Claudia Himes-Crayton, BSN, RN Patricia...
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Transcript of Quality Management Branch Cady Clark, MSN, RN Branch Manager Claudia Himes-Crayton, BSN, RN Patricia...
Quality Management BranchQuality Management Branch
Cady Clark, MSN, RN
Branch Manager
Claudia Himes-Crayton, BSN, RN
Patricia Palm, MS, RNC
Nurse Consultants
ObjectivesObjectives
Describe the functions of the Quality Management Branch
Define “Quality” terminologyDescribe and discuss the Quality
Management Continuum
Branch PersonnelBranch Personnel
Quality Management Staff
Nurses
Nutritionists
Case ManagerWIC Fiscal Monitors
Quality Management TriangleQuality Management Triangle
Improving Quality
Measuring Quality
Defining Quality
QM
QualityQuality
Quality is the degree to which a service meets or exceeds established professional standards and user expectations.
Quality AssuranceQuality Assurance
Quality Assurance (QA) refers to a broad spectrum of evaluation activities aimed at insuring compliance with minimum quality standards.
Quality ImprovementQuality Improvement
Quality Improvement (QI) refers to activities aimed at improving performance and is an approach to the continuous study and improvement of processes of providing services to meet the needs of the individual or population.
Four Core Principles of Quality Four Core Principles of Quality Management (QM)Management (QM)
Focus on the clientFocus on systemsFocus on measurementFocus on teamwork
QUALITYQUALITY
Building It Into Your Agency
A Quality Management A Quality Management ProgramProgramIs organization-wide.Is designed to objectively,
systematically – evaluate the quality and appropriateness of
client care– identify and resolve problems in care and
performance– make changes to improve care and clinical
performance.
The Role of ManagementThe Role of Management
“The support of top management is not sufficient. They must get involved; they must act.” W.C. Deming
The Components of a Quality The Components of a Quality Management PlanManagement Plan
Mission Committee Roadmap (Work Plan)• Tools• Timeframe• Responsibility Process
The MissionThe Mission
An agency’s mission and philosophy must support quality management processes
Quality Management Quality Management CommitteeCommitteeThe role of the Quality Management
Committee is to monitor all aspects of service delivery.
A Quality Management A Quality Management CommitteeCommitteeAt a minimum, the QM Committee
should include:– The Executive Director or CEO– The Medical Director– The Director of Nursing or Clinical
Manager– Representatives of all functional areas,
such as medical records, clerical support, pharmacy and laboratory.
The Quality Management The Quality Management CommitteeCommitteeMust identify other members of the
agency that will be involved in quality assurance activities and how they will relate to the QM Committee.
The Quality Management The Quality Management CommitteeCommitteeMust determine the following:
– The scope of the QM Committee’s duties– The frequency of meetings– The responsibilities of the members– The purpose of the Committee, and– The processes that will be used to identify
opportunities for improvement.
The Quality Management The Quality Management CommitteeCommittee Meets periodically to discuss QM issues Records the minutes of QM all meetings Evaluates results of ongoing QM activities Recommends corrective actions or quality
improvement activities Ensures corrective actions are implemented Evaluates results of corrective action Assures evaluation of administration, clinical,
& facility
A Roadmap (Work Plan)A Roadmap (Work Plan)
The QM Plan must identify the areas of operation that will be reviewed.
The Plan must identify the frequency of reviews.
The Plan must identify what sources of information will be reviewed.
Measuring QualityMeasuring Quality
Methods which may be used to assess quality– Observation of service delivery– Audit of client records– Mystery client method– Clinic staff interviews– Data collection and analysis– Client satisfaction surveys
ToolsTools
Review tools must be developed and used:– To ensure the review process is
standardized– To document findings of the reviews – To assist in the identification of trends– To set acceptable thresholds
A TimeframeA Timeframe
Time periods, frequency of activities, and size of sample must be defined. Example:– Number of client records will be reviewed
quarterly.– 100% of staff will be observed for skill and
technical expertise annually.
ResponsibilityResponsibility
The individual(s) who will conduct activities should be identified. Examples:– The Laboratory Director will observe 100% of
laboratory staff every 6 months to ensure adherence to proper testing technique.
– The Director of Nurses will review a set percentage of all family planning client records each quarter.
The Quality Management The Quality Management ProcessProcessThe process by which findings and
results of activities will be communicated to and used by the QM Committee to identify problems and successes and to improve services must be clearly identified and defined.
The QM Process Must Include:The QM Process Must Include:
A method to identify, track and monitor outcome measures and indicators which includes:– How outcomes will be tracked– Who will track them– Who, how and how often they will be tracked– Who, how and how often they will be reported– The changes and trends that occur
The QM Process Must Include:The QM Process Must Include:
A standard for implementing corrective actions that ensures accountability for the implementation
A follow-up and review system that measures the effectiveness of the corrective actions
IdentifyValues
ChooseIndicators
Assess
EvaluateIdentify Problems
Propose Solutions
EnactSolutions
Reassess
QMB WebsiteQMB Website
http://www.dshs.state.tx.us/qmb
