Quality Healthcare for Everyone Albany Area Primary Health Care, Inc. Quality Department Presenter: Joycelyn W. Yates, Chief Quality Officer

Overview QA Vs. QC Steps in Improving Processes Six Sigma (Quality) PDSA Key Functions of Quality Management within AAPHC Continuous Improvement Review and Summary

QA vs. QC: seeing the big picture These are not new processes, and certainly not mine. These process improvement systems have been around for decades in manufacturing. This presentation is a combining of these systems into the standpoint of ERM.

How we worked on improving processes Key Performance Indicators (UDS Measures/ HEDIS) Patient Satisfaction Surveys Documentation of processes and work flows Training Employee Satisfaction Surveys Follow up Negotiate change Create a plan to improve processes Policies, practices and procedures commit the organization to implementing and performing consistently.

Identifying & Controlling Risks

Six Sigma (Quality) Six Sigma focuses on: LEAN focuses on: Identifying & removing the causes of defects (errors) Minimizing variability of processes (Ensure consistency & predictability) Defect/error metrics LEAN focuses on: Background - Started by Henry Ford in early 1900’s - Improved by Toyota in 1930’s – Continually improving ever since… “Value Add” and “Non-Value Add” task steps Operational “waste” Optimizing processes AAPHC Goals: Identify, track, & trend defect (errors) metrics Review metrics for cause & effect trends Conduct PDSA cycles to evaluate root cause and improve process

Keeps Project On Target Who owns the QI Process? Quality Officer Keeps Project On Target Considers All Risk Control Ideas Owns Project Success Removes Obstacles Addresses Problems Head On Or Failure

Sustain & Continually Improve Track & review metrics Audit checks and balances Report metrics to stakeholders Re-evaluate if metrics are off. Implement solutions Work Flow process Create checks and balances PLAN DO STUDY ACT

Key Aspects & Functions of Quality Management within AAPHC Quality Planning Credentialing Peer Review Privileging Compliance Safety Risk Management Policies & Procedures Medical Record Clinical Protocols Tracking Systems Trend identification that impact systems and processes So in terms of ERR, what does efficiency mean?

AAPHC Continuous Improvement

PDSA Cycle Colon Cancer Monthly reports were run to verify accuracy. Errors found were: DI not marked correctly in ECW system Incomplete reporting of test results Evaluation during 4 month period in 2016 Daily/Intervention Reports 3 population managers hired to help find errors in systems Correct way to document was confirmed Increase % of Colon Cancer Screening rate Accurate reporting within ECW System Establish Universe reporting PLAN DO STUDY ACT

Where are we now? We have improved our Colorectal Cancer Scrn. Score to 60.79% ( Compared to UDS National 39.90%; UDS State 30.60%; AAPHC 2016 56.09%) We have 3 projects in various stages of the process * Initiative to Increase Pneumococcal Vaccination Rates in Rural GA * CDC Georgia Breast & Cervical Cancer Program * CDC Cancer Transformation Project We have 3 projects that are ongoing – Customer Satisfaction, Peer Review, Charting/Billing/Coding (Timely Locking of Chart) QI Sub-Committee: Sub group with multidisciplinary team of providers, DON and CQO working together to delve further into trends and issues from QI Committee and develop work flow process to assist in improvement/training needs. Efficiency is how fast you can get something done, right? Partially. Time to complete a task is very prominent and visible so it is often the main thing looked at. In reality, your efficiency is your “cost per unit – with a unit being whatever your measure of value is. Your measure of value is usually what you would be tracking to justify success.

Be willing to implement change Effective Meetings The Steps to Success: Empower Employees Be willing to implement change Effective Meetings Continuous Process Improvement Efficiency is how fast you can get something done, right? Partially. Time to complete a task is very prominent and visible so it is often the main thing looked at. In reality, your efficiency is your “cost per unit – with a unit being whatever your measure of value is. Your measure of value is usually what you would be tracking to justify success.

Thank You