1. National Quality Center Evaluating Your CQM Program and Improvement Efforts Kevin Garrett, MSW Lori DeLorenzo, RN, MSN May 19, 2016

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3. Agenda Discuss the core elements to review as part of the evaluation process Review tools and approaches to facilitate the evaluation of your quality management program Discuss use of evaluation results to plan for future QI activities

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6. Why?

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8. http://ngm.nationalgeographic.com/2013/10/changin g-faces/funderburg-text

9. National Quality Center Purpose Building in time to conduct evaluation provides valuable window for team to pause and assess functioning. Structured approach provides opportunity to understand what worked well and what needs improvement, thereby facilitating planning for the next year.

10. National Quality Center National Quality Center (NQC)10 Quality is Continuous

11. National Quality Center What?

12. National Quality Center Two Levels of Assessment

13. National Quality Center Infrastructure Core Components for Review

14. National Quality Center Infrastructure: Core Elements for Review

15. National Quality Center Infrastructure: Core Elements for Review Leadership Quality Management Committee Dedicated Staffing Dedicated Resources Quality Management Plan Annual Goals Consumer Involvement Stakeholder Involvement, esp. Subrecipients

16. National Quality Center National Quality Center (NQC)16

17. National Quality Center Performance Measurement: Core Elements for Review

18. National Quality Center Performance Measurement: Core Elements for Review Performance Measures Type & comprehensiveness Alignment with key priorities Data Results, trends & comparison Achievement of outcomes and goals Validity Display and dissemination Use of Data for Quality Purposes Identification of QI projects Incorporated into planning process

19. National Quality Center National Quality Center (NQC)19

20. National Quality Center Quality Improvement Projects: Core Elements for Review

21. National Quality Center Quality Improvement Projects: Core Elements for Review Number and Type Engagement of Staff Support and Resources Quality Committee Kept Informed Goals Realized Efforts Sustainable

22. National Quality Center Project Cycle

23. National Quality Center Quality Improvement Projects: Core Elements for Review

24. National Quality Center Quality Improvement Projects: Core Elements for Review Process How was the project selected? Was a goal clearly articulated? Was the scope of work and timeline realistic? Did you have senior leader support? Was the root cause determined before solutions were identified?

25. National Quality Center Quality Improvement Projects (cont.) QI Team Were the right members on the team? Were the team members actively engaged? Did the team members assume the necessary roles and share responsibilities? Were consumers involved? Were subrecipients involved?

26. National Quality Center Quality Improvement Projects (cont.) Measurement Was the appropriate goal set? Was the correct performance measure used? Were the results tracked for discrete PDSA cycles? Were improvements shown over time? Were the interventions effective?

27. National Quality Center Quality Improvement Projects (cont.) Documentation Were the change ideas tracked and documented? Was a summary of key change ideas compiled? Sustainability Were the change ideas spread beyond the implementation site? Were the processes institutionalized so the efforts can be sustained over time? Information Dissemination Were the results, successes and lessons learned shared with internal and external stakeholders?

28. National Quality Center Who?

29. National Quality Center Key Informants Clinical Quality Management Program Internal and External Stakeholders Quality Improvement Projects Team Members

30. National Quality Center When?

31. National Quality Center How?

32. National Quality Center Available at NQC website: http://www.nationalqualitycenter.org/r esources/organizational-assessment/

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37. Available at: http://www.nist.gov/baldrige/ Baldrige Excellence Framework

38. National Quality Center Baldrige Framework: Processes Approach: How systematic are your key processes? Deployment: How consistently are your key processes used throughout your organization? Learning: Have you evaluated and improved your key processes? Have improvements been shared within your organization? Integration: How do your processes address your current and future organizational needs?

39. National Quality Center Baldrige Framework: Results Levels: What is your current performance? Trends: Are the results improving, staying the same, or getting worse? Comparisons: How does your performance compare with that of other organizations or with benchmarks? Integration: Are you tracking results that are important to your organization? Are you using the results in organizational decision making?

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43. Lori DeLorenzo, RN, MSN NQC Coach 540-951-0576 loridelorenzo@comcast.net Kevin Garrett, MSW Senior Manager, NQC 212-417-4730 kevin.garrett@health.ny.gov

44. National Quality Center To access the recording… Go to: https://meetny.webex.com/meetny/lsr.php?RCID=be 6ced4c51e54b0b97784a4686d9dacf