Continuous Quality Improvement 101 Amelia Broussard, PhD, RN, MPH broussardco1@msn.com

WHY DO WE NEED TO KNOW 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… 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 meeting the needs of those we serve.

Quality Assurance vs. Quality Control 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 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 Activities 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 Annual infection control and safety training Review medication closet for outdated meds Review emergency chart once a week for supplies and outdated meds Can help identify a problem, but are more often used to comply with the standards.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 Control “The observation techniques and activities used to fulfill requirements for quality.” American Society for Quality

Examples 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 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 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 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 Health Care Plan Diabetes Cardiovascular Disease Prenatal Care Perinatal Care Child health Behavioral Health Oral Health Other x2

Goals of Quality Improvement 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 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 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 & QI QA QI Motivation Measuring compliance with standards Continuously improving processes to meet standards Means Inspection Prevention, monitor over time Attitude Required, defensive Chosen, proactive Focus Outliers or “bad apples”, individuals Processes, systems, majority Players Selected departments Organization wide, benchmarking Disciplines Within profession Multidisciplinary approach Scope Medical profession focused Patient care focused Responsibility Few All

QA versus QI

What is the benefit for: Exercise on Quality What is the benefit for: Patients Staff Organization

Putting It All Together QA + CQI + Peer Review + Consumer Satisfaction = QM

Are we doing what we said we’d do? Process Indicator: Are we doing what we said we’d do? Outcome: Is it working for the clients?

GUIDING 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 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 CQI The paperwork can bury you

SET PRIORITIES

PITFALLS OF CQI Staff view it as a ball and chain, hindering their daily work

PITFALLS OF CQI The Process can tie you up in knots

Lessons 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

Common Themes among QI Models 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

One MODEL FOR IMPROVEMENT Model consists of: three questions (aim, measure, change) to form context for improvement Plan-Do-Study-Act (PDSA) Cycle to structure tests

Model for Improvement Act Plan Study Do 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 Improvement Act Plan Study Do MFI model for Improvement How many have heard? Elegantly simple model that is useful … 3 questions plus the PDSA cycle Go over 3 questions and plan do study act ; pdsa

What are we trying to accomplish? 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? Why this question is important … highly corelated with success of a team ..

What are we trying to accomplish? that a change is an 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? What is the second question … how will we know? Why is this important ….

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? So what is the third question? The changes that you make should align with your aim and measures… Where do they come from ? IHI change packages… chanes with a pedigree… have a high degree of belief they willwork .. Have worked .. Ideas in the op doc.. Op Doc.. Each other..

PDSA 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 CYCLES 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 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 Example: Improve decision support by using a standard based flowsheet - adapt flowsheet with one pt - revise flowsheet and test with Dr. 1 pts on Monday - present flowsheet to all MDs - revise and test for one week - implement and monitor standards

PDSA Cycles: Testing a pap Cuing Plan Improved Decision Support D S P A DATA Cycle 1D: Implement thruout clinic and monitor the impact. D S P A A P S D Cycle 1C: Test with all patients for a full week, document feedback and time required. A P S D Cycle 1B: Debrief staff; did it help, how long did it take? Test with Dr. Strange’s patients for a full week. Use of flowsheet will improve care to known standards Cycle 1A: On Mon., prescreen Fred’s Tues. pts, mark appointment sheet for those who are due for paps.

Smaller Scale Tests: Scale Down Timeframe Years Quarters Months Weeks Days Hours Minutes Reduce your timeframe to plan Test Cycle! When you’re in your meeting, listen for a time frame. Move down two levels to do a test. This formula helps people rethink the time frame. If you hear quarters…Ask what test can we do by the end of next week? If you hear weeks, what can do in the next hours. You won’t get the change all tested but gets people moving.

Analysis 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

FLOWCHART 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 EXAMPLE NO Patient arrives at front desk Receptionist asks for patient’s name & searches database for his/her file Receptionist asks patient to complete paperwork for new clients and return it to front desk Patient in system? NO YES Ask patient to be seated in the Waiting room ETC. Medical assistant takes patient into exam room

CAUSE-AND-EFFECT DIAGRAM Used to map variables that may influence a problem, outcome, or effect Also called: Ishikawa diagram Fishbone diagram

CAUSE-AND-EFFECT DIAGRAM CAUSES 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 DIAGRAM SAMPLE Skeleton Equipment Environment Computer System down for routine maintenance Low show rate for appointments Patients Patient unaware of appointment Procedures People

Exercise Construct Cause and Effect Diagram with staff

Performance Measurement and Data

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? 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?