1. OH NO!!! Quality Improvement

2. Objectives Define a Quality Improvement Program Identify how to get started Identify who should be involved Identify how to choose topics How many is enough. Become familiar with the 10 step process What do I do with the results?

3. How Many? Quality Improvement should be an on- going process throughout your term of accreditation. Do studies which mean something to the organization AAAHC does not have a specific number of studies which must be done.

4. QUALITY IMPROVEMENT PROGRAM The program is broad in scope to address clinical, administrative and cost of care issues as well as actual patient care outcomes. Program must be evaluated and approved annually Peer Review Quality Studies Benchmarking

5. Reasons we don’t like it Takes up too much time Can’t think of anything to study We are too good and we don’t need to improve. It’s just a paper pushing exercise Nobody cares about it! I will do a couple of studies just before our survey

6. Reasons we need to do it It will give us the opportunity to evaluate the service we provide to the patients, families, staff and physicians. It will give us the ability to improve the care we provide to the patients, families, staff and physicians.

7. Reasons we do it (cont) State Requires it CMS Requires it AAAHC, Joint and AAAASF require it.

8. Reasons we do it! CAUSE WE HAVE TO!!!!!

9. WHO SHOULD BE INVOLVED Don’t try to do it all yourself The Staff- (Is there anything they would like to work on?) The Physicians-(Any problems they see?) Patients- (Review Satisfaction Survey Results) QI Committee and Governing Body.

10. How to Choose Topics Does the study support the mission and goals of the organization? Talk to the staff about any concerns they may have. Take their suggestions. They are the ones who know if there is a problem. Talk to the Physicians about their concerns. Patients-Review results and identify areas where patients didn’t give you the best review Patient complaints

11. Topics (continued) Literature CMS requirements Results of Benchmarking Networking with other centers

12. Project Get By in from the people involved Develop parameters for the study Set a time limit for the study (How long?) Begin and be flexible!

13. Closing the Loop Statement of Purpose Why is this study being done? Is it any benefit to the center? Don’t do a study just because you need to do it for the accrediting body! There is no required number of studies that must be done.

14. Goals Identify the goal of the study. Give a specific goal (i.e. if you are studying medication errors, your goal is to have 0 medication errors. If you are studying cleaning of your OR, you want to have cleaning completed per policy 100% of the time. Give a specific example of the goal you want to achieve.

15. Data Description Describe what data you are going to review. What data do you need in order to verify: Whether a problem actually exists The Frequency, severity and source of the problem. How will you collect the data.

16. Evidence of Data Collection Describe the data you actually collected. How many records you reviewed or how many employees you observed performing a specific task. What are you looking at? What information are you reviewing? Don’t come to a conclusion at this point. Just gather the data!

17. Analysis of the Data Describe the findings What does the data tell you? Is there really a problem? If there is, determine what the data tells you. Determine the frequency, severity, and source of the problem If the data shows there is NO problem, YOU ARE DONE!!

18. STUDIES WHICH SHOW NO PROBLEM If after your analysis, you find there is no problem, that’s fine BUT: Please don’t present to surveyors only studies that show you have no problems. THEY WON’T BELIEVE YOU!!

19. IF YOUR ANALYSIS SHOWS A PROBLEM EXISTS Take the data you have analyzed and compare it to the goal you have set at the beginning of the study. If your goal is 95% compliance in a specific area and your data shows 60% compliance, a statement saying just that is fine.

20. Implementation of Corrective Action Gather stake holders for the study together and determine what corrective action should be taken to improve your performance. DON’T MAKE THIS DECISION YOURSELF! More heads will come up with better ideas!

21. Implementation of Corrective Action Decide when to implement the proposed action. Get support from the people who will need to implement the action. Determine how the action will be implemented. Educate everyone on what the corrective action is and how it should be implemented.

22. Re-measurement Determine how long you want to have the new process in place prior to re-measuring. Don’t make it years! About a month or two at the most will allow you to gather appropriate data to evaluate the effectiveness of the change.

23. Re-measurement Collect data on how the new process is working. Did it help? Was there any improvement or is there still a problem? Compare the results of the re- measurement to your original goal. Have you achieved the desired performance goal? If you have, move on to reporting.

24. Implementation of Additional Corrective Action If after comparing your re-measured data to your performance goal, you have not met your goal: START the Whole Process all over again.

25. Reporting Whether or not you have met the goal of the study, the results must be reported to the Governing Body. Ensure that this is documented in your GB minutes and as the tenth step of the QI study. Decide who else should be informed of the results of the study (staff, physicians) and document that as well.