1. May 05

2. Quality Management Branch
Cady Clark, MSN, RN
Branch Manager
Claudia Himes-Crayton, BSN, RN
Patricia Palm, MS, RNC
Nurse Consultants
Good afternoon, during this portion of the Round Table agenda we will talk about Quality Management and how to build Quality Management principles into the day-to-day practices of your organization.

3. Objectives Describe the functions of the Quality Management Branch
Define “Quality” terminology
Describe and discuss the Quality Management Continuum
Learning objectives are:
Describe the functions of the DSHS Quality Management Branch
Define “Quality” terminology
Describe and discuss the Quality Management Continuum

4. Branch Personnel Quality Management Staff Nurses Nutritionists
Case Manager
WIC Fiscal Monitors
The Quality Management Branch (QMB) consists of nurses, nutritionists, a case manager along (who monitors case management activities for pregnant women and children), WIC Fiscal Monitors, and regional staff who evaluate the delivery of health care services provided with DSHS-funds.
Upon evaluation of health care activities, the Quality Improvement Team of the QMB may identify the need for improvement of systems of care for individuals and populations.
These activities make up a continuum that tie the activities of evaluation of services to the development of improved systems of care and services.

5. Quality Management Triangle
Defining Quality
We visualize this as the Quality Management Continuum. This Quality Management Continuum will be the focus of the Quality Management Branch.
Three distinct pieces make up this continuum: 1.) Defining Quality; 2.) Measuring Quality; and 3.) Improving Quality.
In defining “Quality” the QMB will work with policy staff and, various program staff and contractors to define the standards of care and program requirements-what is it we are trying to meet.
Measuring Quality- in the quality continuum Measuring Quality is inextricably linked to Defining Quality since the indicators for quality measurement are derived from the standards.
This means the QMB staff will work to assure that review tools clearly reflect identified health care standards and program requirements.
Improving Quality- Improving Quality involves applying appropriate methods to close the gap between current and expected levels of quality as defined by standards.
The QI activities use quality management tools and principles to understand and address systems deficiencies, enhance strengths and improve healthcare processes.
Quality Improvement recognizes that both the resources (inputs) and activities carried out (processes) must be addressed together to ensure improvement in the quality of care. QM
Improving
Quality
Measuring Quality

6. Quality
Quality is the degree to which a service meets or exceeds established professional standards and user expectations.
To best understand QM it is important to understand “Quality” terminology and the Four Core Principles of Quality Management.
Quality as defined by Webster’s Dictionary is a “degree of excellence.” In evaluating health care services one should consider the following:
1. The quality of the inputs- which are resources that are necessary to carry out a process (e.g., staffing, technology).
2. The quality of the service delivery process- steps that come together to transform inputs into outcomes ( e.g., eligibility, billing, hours of operations, satisfaction, both staff and clients).
3. The quality of outcomes- what outcome are you looking to achieve to assure you have the right inputs and outcome, in order to continuously improve systems of care for individuals and populations (e.g., decrease in teen pregnancy, decrease in STD transmission).

7. Quality Assurance
Quality Assurance (QA) refers to a broad spectrum of evaluation activities aimed at insuring compliance with minimum quality standards.
Webster’s Dictionary defines quality assurance as an “aggregate of activities designed to ensure adequate quality.”
Quality Assurance is both an internal and external process to evaluate many different aspects of care.
Quality Assurance is that set of activities that are carried out to monitor performance so that the care provided is as effective and as safe as possible; and it may also involve a method to measure the anticipated outcomes of service based on standards of good practice.

8. Quality Improvement
Quality Improvement (QI) refers to activities aimed at improving performance and is an approach to the continuous study and improvement of processes of providing services to meet the needs of the individual or population.
Quality Improvement builds upon quality assurance methods by emphasizing the organization and systems-focusing on “process rather than the individual; recognizing both internal and external “customers” and promotes the need for objective data to analyze and improve processes.
Quality Improvement is based on four key steps:
you must identify- determine what to improve;
analyze- understand the problem;
develop- hypothesize about what changes will resolve the problem and develop solution strategies; and
test and implement- test the hypothesized solutions (what is the sustainability etc.)

9. Four Core Principles of Quality Management (QM)
Focus on the client
Focus on systems
Focus on measurement
Focus on teamwork
We have talked about quality terminology, now let’s look at the four core principles of QM. The four core principles of QM are:
Focus on the client- services should be designed to meet the needs and expectations of clients and communities.
Focus on systems and processes- providers must understand the service delivery system and its key service processes in order to improve them (e.g., program requirements; billing and eligibility).
Focus on measurement- data are needed to analyze processes, identify problems, and measure performance (correctly measure what you want to evaluate).
Focus on teamwork- quality is best achieved through a team approach to problem solving and quality improvement (getting input from stakeholders- community, clients, staff both clinical and non-clinical).

10. Building It Into Your Agency
QUALITY
Building It Into Your Agency
Now that we have talked about QM and the Quality Management Continuum and how QMB staff uses the concepts to evaluate quality- let’s talk about the importance of a Quality Management Plan in the agency setting.
Why Assure Quality?
To:
identify and reduce risk to agency and clients;
evaluate performance;
measure progress towards goals;
improve client outcome; and it is
required by funding agencies.

11. A Quality Management Program
Is organization-wide.
Is designed to objectively, systematically
evaluate the quality and appropriateness of client care
identify and resolve problems in care and performance
make changes to improve care and clinical performance.
Incorporating a Quality Management Program within an organization is an ongoing process in which a set of activities, structures, and values becomes an integral and sustainable part of an organization. To develop a successful QM system there must be:
buy-in from the agency and staff;
an active internal process;
standardized system; and
implementation
Quality Management will be institutionalized when it is formally and philosophically incorporated into the structure and functioning of an organization, consistently implemented, and supported by a culture of quality, as reflected in organizational values and policies that advocate quality care.

12. The Role of Management
“The support of top management is not sufficient. They must get involved; they must act.” W.C. Deming
Management has a key role, top management must be actively involved to ensure oversight, coordination, delegation of roles and responsibilities, and accountability.
This includes leadership being involved in developing strategies, setting priorities, being involved in follow-up and monitoring of progress.

13. The Components of a Quality Management Plan
Mission
Committee
Roadmap (Work Plan)
Tools
Timeframe
Responsibility
Process
Here are the essential components of a Quality Management Plan: 1.)A mission that supports quality management processes; 2.) A committee to monitor QM activities; 3.) A roadmap, that will serve as a work plan, with tools, timeframes and responsibility, to identify how often and what sources of data will be used for QM activities; and 4.) A process.
To incorporate quality management into the fabric/structure of an organization, it is important that an environment exists that enables the initiation, growth, and continuity of quality activities.
The continuity of QM activities must also incorporate supportive policies, effective leadership, structures that support the performance of quality activities, and adequate resource allocation that emphasizes the importance of quality and encourages people to practice QM activities as part of their daily work. It is important that quality is a part of everybody’s job. Make everybody feel that they are a part of the process, because they are, and their roles and responsibilities are equally important to the QM process.
So let’s look at the components of a well-developed QA/QI Plan. Each component plays an important role in building the overall framework of quality.

14. The Mission
An agency’s mission and philosophy must support quality management processes
The mission and philosophy of an agency must support quality.
The agency's mission statement and philosophy should demonstrate to staff and clients the investment the agency has made in the quality process.

15. Quality Management Committee
The role of the Quality Management Committee is to monitor all aspects of service delivery.
The Quality Management Committee. This component is very important. The most effective of measurement systems will be of little value if no one is responsible for evaluating and using the information to make improvements.
The Quality Management program needs a home, it needs to be managed and overseen--and that is the function of the Quality Management Committee.
The role of the QM Committee is to monitor all aspects of service delivery including administrative processes and facilities, and to use the QM process to improve performance through the coordination of the QM activities.

16. A Quality Management Committee
At a minimum, the QM Committee should include:
The Executive Director or CEO
The Medical Director
The Director of Nursing or Clinical Manager
Representatives of all functional areas, such as medical records, clerical support, pharmacy and laboratory.
The Quality Management Committee at a minimum should consist of: the Executive Director or CEO; the Medical Director; and the Director of Nursing or Clinical Manager.
The Committee should also include members of management and representatives of all functional areas of activity to ensure a comprehensive internal review process.
If you are a small agency, perhaps your Committee will be very small. The goal is to ensure QM activities are implemented and that corrections are being made and services improved when necessary.

17. The Quality Management Committee
Must identify other members of the agency that will be involved in quality assurance activities and how they will relate to the QM Committee.
In a quality-oriented agency, quality becomes the business of everyone.
Employees begin to look at ways to do what they do better, more efficiently and more cost-effectively. But this activity needs to be focused and guided.
The QM Committee should describe the roles and functions of all members involved in quality activities.
The Committee should ensure that all persons involved know how to effectively communicate suggestions and needs to the Committee.
All involved should know that their activities will receive the serious consideration of the Committee.

18. The Quality Management Committee
Must determine the following:
The scope of the QM Committee’s duties
The frequency of meetings
The responsibilities of the members
The purpose of the Committee, and
The processes that will be used to identify opportunities for improvement.
The QM Committee must define its scope of duties and how and by whom the duties will be fulfilled.
In the early stages of QM development, it may be useful to clearly outline the specific duties, lines of reporting, and accountability for results, to ensure that QM activities are duly implemented and that there is necessary time allocated for staff participation. Staff must be allocated time to monitor; analyze the data; and look at outcomes.
Clearly defining the structure, responsibilities, purpose and scope of work of the Committee and its members provides a framework to guide the Committee's activities and progress.

19. The Quality Management Committee
Meets periodically to discuss QM issues
Records the minutes of QM all meetings
Evaluates results of ongoing QM activities
Recommends corrective actions or quality improvement activities
Ensures corrective actions are implemented
Evaluates results of corrective action
Assures evaluation of administration, clinical, & facility
The QM Committee should meet regularly to discuss quality issues, and minutes of all such meetings should be kept.
Ongoing reviews, observations and other types of quality activities should be discussed and evaluated at the meetings and recommendations for corrective actions should be made.
The QM committee should then define corrective actions to be implemented, and define timelines for monitoring the results of the QI activities. The results of the QI activities should be evaluated and reported to the committee.

20. A Roadmap (Work Plan)
The QM Plan must identify the areas of operation that will be reviewed.
The Plan must identify the frequency of reviews.
The Plan must identify what sources of information will be reviewed.
To ensure that the QM Committee and the agency gets where it wants to go, the route to quality should be plotted. The Committee should have a roadmap to know where it is going- a work plan must be developed.
The Committee should identify which areas of activity will be reviewed, how often and what sources of data will be used.
Identification of these elements guides the Committee's activity in an organized and standardized manner.
Because quality management is not limited to a few areas of the agency, all functional areas should be included in quality management activities.

21. Measuring Quality Methods which may be used to assess quality
Observation of service delivery
Audit of client records
Mystery client method
Clinic staff interviews
Data collection and analysis
Client satisfaction surveys
A quality assessment frequently combines various data collection methods.
These methods typically involve either some form of direct observation or indirect assessment of performance. Examples of such methods are:
Observation of service delivery
Audit of client records
Mystery client method
Clinic staff interviews
Data analysis
Client satisfaction surveys

22. Tools Review tools must be developed and used:
To ensure the review process is standardized
To document findings of the reviews
To assist in the identification of trends
To set acceptable thresholds
The QM Plan should include the tools necessary to do the job. For the data collected to be reliable it must be collected in a standardized manner, and documented in a way that allows comparison over time and among programs.
The tools should allow the reviewers and the QM Committee to identify trends and an acceptable threshold of quality so that improvement activities can be implemented.

23. A Timeframe
Time periods, frequency of activities, and size of sample must be defined. Example:
Number of client records will be reviewed quarterly.
100% of staff will be observed for skill and technical expertise annually.
All monitoring activities should occur within a specified period of time at a specified frequency to provide the agency and the Committee with a timetable for QM activity and milestones by which to measure progress.

24. Responsibility
The individual(s) who will conduct activities should be identified. Examples:
The Laboratory Director will observe 100% of laboratory staff every 6 months to ensure adherence to proper testing technique.
The Director of Nurses will review a set percentage of all family planning client records each quarter.
The individuals who are responsible for completing an activity should be designated and be held accountable for the activity. In order for the process to be on-going, people need to know what they are responsible for.

25. The Quality Management Process
The process by which findings and results of activities will be communicated to and used by the QM Committee to identify problems and successes and to improve services must be clearly identified and defined.
A well-defined process promotes successful quality implementation by providing direction and a system for conducting QM activities.

26. The QM Process Must Include:
A method to identify, track and monitor outcome measures and indicators which includes:
How outcomes will be tracked
Who will track them
Who, how and how often they will be tracked
Who, how and how often they will be reported
The changes and trends that occur
Finally the QM process must assist the agency in measuring the outcome of service delivery. The end result is to ensure that outcome of service delivery, meet the standard of care.

27. The QM Process Must Include:
A standard for implementing corrective actions that ensures accountability for the implementation
A follow-up and review system that measures the effectiveness of the corrective actions
A follow-up and review system is essential to determining if the quality improvement activities are having the desired effect.

28. Identify Values Reassess Choose Indicators Enact Solutions Assess
Propose
Solutions
In summary, Quality Management requires more than a technical approach of tools and methods.
Sustained improvements often require a change of attitude and sense of ownership for the quality of services provided by an organization.
The Quality Management process is not a linear process, but rather, a circular process.
Each step in the process is influenced by the step which preceded it and by the step which follows it.
The results of this continual circular process is a quality organization and that is definitely worth the effort.
Evaluate
Identify
Problems

29. QMB Website

30. Who to Contact Cady Clark Cady.Clark@dshs.state.tx.us
(888) ext. 2187
If you have any questions, you can contact Cady Clark at this address or phone number.