1. Action Planning for Quality Improvement
May 14, 2009
Kathy Reims, M.D.
NQC Consultant
Analee Beck
Early Intervention Services - Program Coordinator
Pueblo Community Health Center

2. Poll
How satisfied are you with how your Quality Management Plan is implemented in your organization?
Very satisfied
We do well all things considered
We could do better
We struggle

3. Implementing the QM Plan

4. Call Objectives Understand the purpose of a QM action plan
Learn about key components of good action planning
Understand a best practice: translating your QM plan into action

5. Key Components of Action Plans
A statement of what must be achieved. Align with the goals of a strategic, business, operational or quality management plan.
Detailed steps of what must be done
A schedule and timeline for each step
Indication of who will be responsible for making sure each step is completed.
Clarification of the resources needed.

6. Prerequisites for a Successful Action Plan
√ Resources align with scope.
√ Time allowance adequate for success.
√ Clear goals and objectives.
√ Alignment of stakeholder expectations.
√ Realistic planning process.

7. Action Planning Steps 1. Assess key tasks 2. Confirm skills required
3. Build your team
4. Define the tasks in more detail
5. Establish the interrelationships among the tasks

8. Action Planning Steps (continued)
6. Identify the milestones 7. Communicate the draft plan 8. Evaluate the draft plan against the resources you have 9. Get your entire action plan approved In reality, many of these steps are iterative, not strictly sequential.

9. You have thought about all the pieces….
View One using the puzzle as a model
…time to execute!

10. Executing your Plan Create the infrastructure to get the job done
Adjust meetings, reports and attend to the “culture” as needed

11. Monitor as you go Monitor Communicate progress Messaging important
Standardize

12. Reflect and Celebrate Use the milestones Public forums
Lessons learned, reflection, celebration

13. NQC Resources Action Planning Guide
Strategies for Implementing your Quality Improvement Activities |

14. Early Intervention Services

15. About Pueblo Community Health Center
Mission: To provide primary health care to those in need
Vision: To be the primary health care provider of choice in Pueblo County by providing top quality care through accessibility, leadership and financial independence

16. Key Components of EIS Work Plan
EIS Team
providers, managers, and supportive staff
Annual Work Plan - Framework
RW Part C Funding Guidelines
HIV/AIDS
Chronic Care Model
HIV/QUAL Project Core Indicators
Annual Work Plan – Quality Monitoring
HRSA Quarterly progress reports
Clinical Audits and Financial Reports
Quality Improvement Projects

17. WHO writes the action plan?
Multi-disciplinary team
Collaborative process begins half-way into a program year
Progress to date is reviewed
Team prepares to write new action plan

18. WHAT goes in the action plan?
EIS Team
providers, managers, and supportive staff
Annual Work Plan - Framework
RW Part C Funding Guidelines
HIV/AIDS
Chronic Care Model
HIV/QUAL Project Core Indicators
Annual Work Plan – Quality Monitoring
Team defines:
Goals and objectives
Detailed clinical and non-clinical action steps
Person responsible for each step
Projected timeline for completion of each step

19. Portion of the EIS Workplan

20. WHEN are the action steps implemented?
Team follows the timelines they have outlined
Annual
On-going
Time-specific
Start date and end date

21. HOW do we put “action” into our action plan?
Team completes the action steps
Continuous monitoring
HRSA progress reports
Clinical audits
Financial reports
Quality improvement projects

22. FOCUS-PDSA Quality Improvement Process
Find a process or project for improvement
Organize a team
Clarify your current knowledge of the process
Understand variations – current process
Select an improvement
Plan improvement
Do the Improvement
Study the results
Act or Adjust to hold the gain

23. Find a process or project for improvement
Improve access to patient information

24. ORGANIZE A TEAM
EIS Clinic Staff, IT Specialists and Operations Department

25. CLARIFY YOUR CURRENT KNOWLEDGE OF THE PROCESS
EIS Program does not have access to an Electronic Medical Records system

26. UNDERSTAND VARIATIONS – CURRENT PROCESS
Patient information must be accessed from a variety of sources
Recording patient information required double data entry

27. SELECT AN IMPROVEMENT
QI project selected: create a unique multi-functional database

28. PLAN IMPROVEMENT
Researched and collected all data sources and documents that supported patient care.

29. Acuity Worksheet

30. Clinical Care Flow Sheet

31. Intake Questionnaire

32. DO THE IMPROVEMENT Created database system
Able to customize to better meet needs
Data entry work flows designed

33. STUDY THE RESULTS Studied work flows Monitored data accuracy
Monitored database changes

35. ACT OR ADJUST TO HOLD THE GAIN
Assure all data entered for essential reports
Formatting of reports for HRSA, HIV/QUAL and financial

36. Wrap Up Focused on a meaningful project
impacted the infrastructure supporting the QM Plan as well as daily work
Put together a multidisciplinary team and called in others as needed
Identified key milestones, monitored progress
Culture of accountability, flexibility, “can do”
Communication and celebration

37. Questions or reflections?

38. Poll
I learned at least one idea to improve the ability to translate my Quality Plan into action:
Strongly Agree
Agree
Neutral
Disagree

39. Contact Information
Kathy Reims, M.D.
Chief Medical Officer
CSI Solutions, LLC
Analee Beck
Early Intervention Services - Program Coordinator
Pueblo Community Health Center

40. National Quality Center (NQC)
NationalQualityCenter.org