1. Quality Improvement/ Quality Assurance Amelia Broussard, PhD, RN, MPH Christopher Gibbs, JD, MPH

2. Understanding Quality Improvement and Quality Assurance Quality Assurance and Quality Improvement are often confused as the same process Terms used interchangeably but not the same One is focused on observations only and one time opportunity Other is continuous process documenting improvement Both based on standards for performance Both important to organization Both focus on quality services to patients 2

3. Definition of Quality Assurance Planned systematic activities implemented in quality system Quality requirements for product or service fulfilled Activities typically based on standards of practice Can help identify problem but no solution Compliance with standards goal 3

4. Definition of Quality Improvement QI is continuous ongoing process designed to improve patient outcomes, services or process Focus is ongoing rather than one time review Team is multidisciplinary with representatives from all departments Focus on process or service not individual Proactive rather than reactive 4

5. Goals of QI Goals of Quality Improvement Understand process Reduce & eliminate errors Improve efficiency Improve communication Requires measurement Focuses on outcomes 5

6. Core Concepts of Quality Improvement Exceed expectations of patients or clients Process usually problem not people Does not seek to blame but to improve process Most effective when part of everyday work Focus on everything, you can not focus on anything 6

7. Quality Improvement and FTCA QI plan integrates all departments in activities One QI plan for organization Minutes document QI activities Plan should have certain components outlining process of committee 7

8. Quality Improvement Plan Components Statement of Purpose or Intent of Plan Scope of Plan Administrative Responsibility Risk Management Systems (some make this separate plan) Role of Peer Review in QI Committee Composition Committee Accountability Methods for conducting QI activities Tracking of QI Activities Approval and Review 8

9. Statement of Purpose Plan includes statement of purpose or intent Example –The purpose of the Quality Improvement Program is to support improved health care delivery and outcomes for the patient population receiving care. Objective is to promote continuous Quality Improvement within the organization and support the objectives and scope of Quality Improvement Program. 9

10. Scope of Plan Scope refers to what the QI committee will do Includes monitoring of select measures, evaluation of performance and improvement in organizational performance Discusses which activities are applicable to QI Includes risk management tracking as reported to QI, results of peer review and measures to be followed during year Areas of consideration include medical/clinical, operational/administrative, governance and finance Resources available in notes section 10

11. Administrative Responsibility Health center identifies by title individual with overall responsibility for QI program Approval requirements are stated (who must approve plan) Individual consulted in development of QI/QA Plan and activities Identification of who will receive information about decisions and activities of QI/QA program 11

12. Risk Management Systems Health center identifies the following: –Policies/procedures regarding appropriate supervision of clinical and non-clinical staff –Policies/procedures to identify and document system process or breakdown –Policies/procedures for addressing and investigating medical malpractice claims Resources available in Notes section of slides 12

13. Role of Peer Review Peer review is the process of all providers reviewing a peer’s medical records Specific time frame for review is defined (i.e. quarterly, monthly, bi-monthly) Results of peer review should be communicated in aggregate form to QI committee for possible QI projects to improve patient care Review should consist of two parts –Medical care review –Review for completion and documentation –Resources in Notes section 13

14. Committee Composition Establishes QI committee Membership is defined Multidisciplinary membership Committee chairperson & vice chair person identified Committee must have defined meeting frequency. Meeting 6 times per year strongly encouraged* Agendas and minutes for committee meetings maintained * Application requires 6 sets of minutes within past year. 14

15. QI Committee Accountability Short statement that defines accountability of QI committee Defines frequency of reports to Board of Directors Defines time frame for updating QI plan and schedule 15

16. QI Committee for Multiple Sites Still one QI committee for organization Site QI committees may be established and described in overall QI plan Site QI plans must mirror overall plan and report on a regular basis to overall QI committee Main QI plan sets agenda for organization –Additional QI projects may be done at satellites based on center needs in addition to main QI program Reporting from each site is very important in the overall QI committee 16

17. Methods for QI Activities QI plan should include methods used to conduct QI projects Includes process for collecting data and sources Allocation of resources defined Process most common: Improvement Model and use of PDSA Process Schedule of activities for monitoring measures Defines QI activities based on subcommittees 17

18. Tracking of QI Activities Defines reports to be given by subcommittees to overall organizational QI committee QI activities reported by subcommittees to overall QI committee –Report baseline on project, interventions attempted, results of interventions and continued monitoring Committee members track measures over time for QI activity impact 18

19. Approval and Review Identifies individuals who must approve QI plan Signature page in place with dates Appropriate signatures in place on review page Frequency of review and updates for individuals who are responsible for approval 19

20. QI/QA Committee Meeting Minutes FTCA weighs minutes very heavily Should be enough information for reviewer to verify successful implementation of QI program Provide written documentation of QI activities Must include information on monitoring activities for measures listed in QI plan Must document multidisciplinary team by name and title during attendance Must report on QI activities conducted during meeting interval Data used to measure objectives of QI plan and track improvement activities 20

21. Sample QI Meeting Minutes Include: Attendees Agenda items Discussion topics Recommendations Action items Clearly label with consistent titles Provide sufficient detail 21

22. Conducting the QI Meeting Agenda should always be set –Review QI data/progress toward goals –Analyze trends and identify problem areas –Brainstorm for improvement strategies –Develop improvement plans Develop, revise and implement QI plans Document meeting minutes and keep on file 22

23. QI/QA Reports to Board QI/QA information reported at least 6 times Board meeting minutes reflect: –QI committee findings and activities o Short summary of QI projects conducted by staff –Objectives, data, improvement goals –Board review of QI plan on a regular basis (usually annually) –Board is also responsible for reviewing and approving credentialing/privileges of all medical providers 23

24. Submission of Information for FTCA Submit QI plan as developed by organization with appropriate signatures and approval Must also indicate board review during last three years Meeting minutes: –6 months of QI meeting minutes –6 months of Board meeting minutes with reports from QI program –Multiple site minutes 24