Quality Improvement Timothy L. Ricks, D.M.D., M.P.H. Nashville Area Dental Officer Kristina Rogers, B.S. Nashville Area Statistician/Improvement Advisor 11/11/2018
Quality Components Risk Management Patient Safety Peer Review Quality Assurance Strategic Planning Quality Improvement 11/11/2018
What is Quality? It depends on the stakeholders’ perspectives From a provider view: Did the treatment I provided work? Are we using the best available equipment and procedures? From a health administrator’s view: Were the patients satisfied with the care they received? Was there a good cost-benefit ratio? From a patient’s view: Did my provider listen to my concerns? Did my provider spend enough time with me? From a tribal council’s view: Were all patients in need treated adequately? Is the clinic financially independent? 11/11/2018
Quality Components Risk Management Patient Safety Peer Review Quality Assurance Strategic Planning Quality Improvement 11/11/2018
Risk Management Risk management is all about mitigation of risk. Risk to Patients Patient Safety Activities Risk to Providers Malpractice - FTCA Risk to the Organization CMS Accreditation Organizations – AAAHC, JCAHO DEA www.ihs.gov/NonMedicalPrograms/NC4/Documents/RM2_a.pdf 11/11/2018
Risk Management Read the IHS Risk Management Manual: www.ihs.gov/NonMedicalPrograms/NC4/Documents/RM2_a.pdf The manual: Provides an overview of who is covered under FTCA & under what conditions Provides guidance on how to avoid malpractice issues (how to work with patients) 11/11/2018
Quality Components Risk Management Patient Safety Peer Review Quality Assurance Strategic Planning Quality Improvement 11/11/2018
Patient Safety “Patient safety is indistinguishable from the delivery of quality care.” IOM, 2004 To Err is Human - a landmark report by the Institute of Medicine in 1999 http://www.nap.edu/openbook.php?isbn=0309068371 National Patient Safety Goals 11/11/2018
Patient Safety Some possible dental patient safety issues: Sterilization Dental waterlines Disinfection of equipment/chairs Physical hazards Radiation Rubber dam use Medications/anesthesia Others? 11/11/2018
Quality Components Risk Management Patient Safety Peer Review Quality Assurance Strategic Planning Quality Improvement 11/11/2018
Peer Review Two types: How often should it be done? Ongoing Peer Review (routine) Focused Peer Review (for cause) How often should it be done? Ongoing – quarterly At least annually by external reviewer Who can do peer reviews? Dentists-dentists; DDS or RDH-RDH ADO can do them, but don’t just count on that. 11/11/2018
Peer Reviews in our Area 11/11/2018
Quality Components Risk Management Patient Safety Peer Review Quality Assurance Quality Improvement Strategic Planning 11/11/2018
What is Quality Assurance? Quality Assurance – evaluation of performance/quality of care that is reactive, retrospective, policing, and sometimes punitive. Quality Improvement – a formal approach at evaluating performance and systems that is proactive, both prospective and retrospective, non-punitive, and focused on improving care to patients. 11/11/2018
Which of the following has a QA focus? Which staff member failed to transfer the call to the correct extension? Are we creating an environment encouraging clinicians to report errors? How do we reduce production errors on the widget line? Patient had a bad outcome; were the doctors or nurses at fault? What could we do to increase the efficiency of chart filing? 11/11/2018
Quality Components Risk Management Patient Safety Peer Review Quality Assurance Strategic Planning Quality Improvement 11/11/2018
Strategic Planning Where are you going? What are your priorities? How are you going to get where you are going? 11/11/2018
Strategic Planning in Dental Written Quality Improvement/Performance Improvement Plan Written HP/DP Plan Written overall Strategic Plan (short-term and long-term goals) 11/11/2018
Quality Components Risk Management Patient Safety Peer Review Quality Assurance Strategic Planning Quality Improvement 11/11/2018
Quality Improvement Plan-Do-Study-Act (PDSA) Cycle Small scale tests and multiple cycles of testing should be used to build knowledge about needed changes. There is no wrong or right aspect to test. Initial testing sparks ideas that can lead to other tests. You should brainstorm ideas for change that might lead to an improvement with other clinic staff. Changes are tested by using Plan-Do-Study-Act (PDSA) cycles. This is essentially the scientific method. Each PDSA cycle will create information that can be used to determine how close you are to meeting your objectives. Rapid cycle PDSAs will allow you to obtain quick feedback and the opportunity to change testing components along the way. The Model for Improvement (shown below) is used to construct PDSA cycles. 11/11/2018
Quality 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? 11/11/2018
The “PDSA” Model PLAN: Plan a change or test of how something works. DO: Carry out the plan. STUDY: Look at the results. What did you find out? ACT: Decide what actions should be taken to improve. 11/11/2018
QI - PLAN State objective of the test Make predictions Develop plan to carry out the test… (who, what, where, when) 11/11/2018
QI - DO Carry out the test Document problems and unexpected observations Begin analysis of data 11/11/2018
QI - STUDY Complete the analysis of the data Compare test data to predictions Summarize what was learned 11/11/2018
QI - ACT What changes are to be made? What will be the objective of the next cycle? 11/11/2018
Important Aspects of the PDSA These are inherently done all of the time. Can you think of an example? Short-cycle (rapid) PDSAs allow for quick evaluations of minor changes made. A single QI project might involve multiple PDSAs. 11/11/2018
Quality Improvement is not a one-time process! The PDSA Cycle requires that the process be continued – the “Act” part of the cycle Continuous Quality Improvement helps: Maintain the positive steps you’ve already taken Continuously improve quality of care 11/11/2018