1. Cindy Tumbarello, RN, MSN, DHA September 22, 2011

2. PI Process improvement Continuous quality improvement Performance improvement PIP CQI Quality Assurance  Lean Six Sigma QAPI

3.  Measuring the output of a process or procedure modifying process/procedure to increase the output (success) increased efficiency or effectiveness of the process/ procedure.  Quality assurance is not performance improvement ◦ QA is a system for evaluating performance (ex. daily temperature logs or glucometer checks)

4.  Improves care or operations, which ultimately leads to greater patient, staff and physician satisfaction  Systematic approach toward improvements  Required by regulatory agencies ◦ CMS, Accrediting bodies

5.  Identify a problem  Define the problem  Define the goal  Steps to attain goal ◦ Rapid cycle change  Evaluate performance  Reassess compliance at a later time DOCUMENT, DOCUMENT, DOCUMENT

6.  Evaluate current practices for a process that is not meeting standards ◦ Methods to identify processes requiring improvement- surveys, input from physician, clinical staff or clients (ex. wait times). ◦ Process should be something that can be measured  Once the problem areas are identified, a brainstorming session should occur with a variety of people who are involved with the processes.

7.  The target problems are decided upon and a list of possible causes is identified.  Collect baseline  data- this does  not need to be extensive or elaborate

8.  After possible problems are noted, the next step is to prioritize  The problems that are having the greatest effect are the highest priority items. Focus on high risk, high volume and problem prone areas (CMS)

9.  It has been “discovered” time and again that a great percentage of the trouble in nearly all processes is caused by a small percentage of the total factors involved. ◦ 5% of the problems are taking over 80% of the time

10.  Problem must be clearly identified ◦ Without a clear identification of the problem there is no way to know if it is resolved (if you don’t know what “it” is, you can’t fix “it”)  In order to maximize effectiveness, identify the key opportunities for improvement, those items that will provide the most benefit to your organization.

11.  Lack of a clear goal has more than one impact ◦ May not “fix” the right problem ◦ Staff do not know what you are trying to achieve ◦ A goal should include what, when, and how  Write it down!

12.  Identify who is responsible for an activity – Don’t forget to set a due date and hold individuals responsible  Small tests of change may be a strategy to “trial” an intervention  Document the steps took and the effectiveness ◦ It’s ok if a step is not effective. Write it down, including reasons why the action was ineffective

13.  Monitor the process. Make sure to use data to demonstrate effectiveness ◦ Chart review ◦ Survey related to satisfaction ◦ Decrease in costs  If ineffective, return to implementation phase and try something else  Conduct an evaluation in the future to ensure change is sustained

14. Plan  Collect data and establish a baseline – what is the current process doing now?  Identify the problem and the possible causes. Do  Make changes designed to correct or improve the situation. Study  Study the effect of these changes on the situation.  Collect data on the new process and compare to the baseline.  Evaluate the results and then replicate the change or abandon it and try something different. Act  If the result is successful, standardize the changes and then work on further improvements or the next prioritized problem.  If the outcome is not yet successful, look for other ways to change the process or identify different causes for the problem.

15.  An organization develops and implements a quality improvement program that is broad in scope to address clinical, administrative, and cost- of care performance issues, as well as actual patient outcomes

16.  The quality program (performance improvement) is integrated, organized, and peer based  Size and complexity of an organization will guide how extensive the program will be

17.  Someone must “own” the PI program ◦ Support for the person with oversight for PI program  Multidisciplinary involvement leads to robust solutions and varied perspectives

18.  Mean- A measure of the center of data, also called the average. The mean is calculated by summing all of the observations and dividing by the number of observations. 150- 10-10-15-10-15-20-25-0 =28.3  Median- The “middle” value of a group of observations, or the average of the two middle values. 150- 10-10-15-10-15-20-25-0 =15  Mode- The observation that occurs most frequently in a sample. 150- 10-10-15-10-15-20-25-0 =10

20.  Statistical significance- 3 or more data point below the mean (94.5)

21.  Benchmarks can be local, state, or national standards ◦ Possible to benchmarks against historical data if unable to obtain state/national benchmarks  Benchmark can serve as a goal ◦ Exceeding benchmark can indicate “better” than the average ◦ Below a benchmark may be perceived as poor performance

22.  Choose a benchmark that is appropriate ◦ Comparing procedure time for a GI case to an orthopedic procedure is not valid  Benchmarking sources ◦ MGMA- Medical Group Management Associates ◦ ASCA- Ambulatory Surgery Center Association ◦ Intellimarker

23.  Staff involvement ◦ Enhanced when they are involved and know the results  Performance improvement activities must be reported to the governing body and throughout the organization  Patients know what kind of care you provide ◦ Lack of transparency can result in mistrust

24.  Use of graphs, charts, etc  Use of storyboards  All information should be available in one location (quality binder, computer disk) ◦ Show how data impacted care

26.  Get people involved  Address problems that are meaningful  Collect data on a routine basis  Hold individuals accountable  Let staff know it’s acceptable to make mistakes

27.  Consider validating findings (inter-rater reliability)  Share results- transparency  Report findings to governing body  Evaluate effectiveness of program at least annually- be honest