1. Q UALITY I MPROVEMENT Working with your QI Team Valerie J. Vesich, RHIT, CTR Onco, Inc.

2. Overall How QI Program is managed Definitions, elements Structure - Processes Initiation, Planning, Execution, Closure Tribute to Those Studies that Failed

4. B ACKGROUND & S IGNIFICANCE Efforts to Ensure QA TQM QI CQI QM PI

5. W HAT IS Q UALITY – H EALTHCARE ? Requires Inspection ***Tracking changes in measures over time with Benchmarks Documentation Judgment Improvement of Clinical Performance

6. W HAT IS Q UALITY ? P ATIENTS Doing whatever needs to be done proactively rather than reactively My chart accurately reflects me The whole team knowing what is going on. Shouldn’t have to answer questions several times

7. A N E FFECTIVE Q UALITY QI T EAM & M ANAGEMENT P ROGRAM Effective Accountable Responsible

8. D EVELOP A QI PLAN How are your qi project selected, managed and monitored How are your staff trained in qi What methodology- six sigma, psda Describe your communication plan, updates, who/when etc Description of measurement/analysis- How will your studies be evaluated

9. E LEMENTS OF A Q UALITY D EPT. Proactive Patient/Family Centered Care Clinical Informatics Education Reactive Peer Review Risk Management TJC, CMS, DOH Reviews/Visits

10. S TRUCTURE - V ARIES Quality functions – multiple depts. Within Clinical Service Lines Half report to QI department Matrixes QI department - across depts. Larger Multi-hospital systems and Veterans Affairs – corporate level quality staff Facilities have their own quality staff – reporting to leadership Advisory Board – There is no one model that performs better. Most Effective Model – Unique Dynamics to advance the culture and goals

11. S TRUCTURE Strategic Planning Process Outgrowth SWOT – Strengths, Weaknesses, Opportunities and Threats Validates Mission, Provides Direction Knowing who is Responsible for PI/QI at Your Hospital is Important

12. W HAT P ROBLEMS ARE YOU S OLVING Defects---something that happens that isn’t supposed to happen Reducing healthcare-acquired infections Performing well in core measures Reducing re-admissions for the same problem

13. TOP FOUR DEFECTS Errors in Communication (handoff with patients and families) Issues related to Lack of Leadership Medication Errors Data Accuracy/Completeness Reporting

14. F OUR S TEP P ROCESS

15. http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx

16. F IVE S TEP P ROCESS Identify Target Areas What Processes Can be Modified to IMPROVE Develop Effective Strategies to Improve Quality Track Performance and Outcomes Disseminate Results to Spur Broad Spectrum Improvement

17. TWO S TEP P ROCESS - T EXAS S TYLE

18. PI P ROCESS Defined differently Share one characteristic- cyclical in nature Monitoring performance is DATA DRIVEN Data internal/external builds the foundation Identifying issues that can be improved Taking powerful steps—envision results

20. W HY D O S TUDIES F AIL ? Using Half-Baked Ideas Unrealistic Project Deadlines Assigning jobs to those Who Might Be Unable to Handle No Monitoring of Data No Comprehensive Project Portfolio

21. PI PROCESSES AND PHASES Initiation Planning Execution (Implementation) Closure

22. PI PROCESSES Identify an improvement opportunity Research and Define Design and Re-Design Process/Education Measure Performance Document and Communicate Findings Analyze and compare internal and external data

23. I NITIATION Input from Organization PI team member important Developing a Team – helps define who is doing what and when Need a Team Lead or Facilitator – QI Coordinator

24. C ANCER P ROGRAM – B UILDING A PI T EAM ( S ) Hospital PI member Advisory Cancer Committee or serve as an Ex- Officio or QI Coordinator Cancer Committee or Cancer Program responsible for report to ?? Help build your QM Plan

25. P LANNING Identify Activities Develop system requirements Criteria for standards for success Develop a schedule/cost analysis Perform tasks and track progress Develop the “plan” – how to implement

26. D ESIGN OF Y OUR P LAN Registry Data Review Cancer Program/Cancer Committee Surgery Pathology Outpatient Therapies Support Services Cause and Effect- Gantt Charts - PERT Benchmarks, Guidelines, Pathways Develop In-House (ok per CoC)

30. O RGANIZE THE P LAN - Program Evaluation, Review, Technique (PERT) Aka Critical Path Method (CPM) Follow a path of arrows from start to finish Adding duration time- total time to complete the project

32. Q UALITY M ETRICS National Quality Forum (NQF) NCCN Guidelines ASCO/QOPI Centers for Medicare Services-PQRS Hospital Quality Alliance (HQA) Institute of Medicine (IOM) National Committee for Quality Assurance (NCQA)

33. E FFECTIVE S TRATEGIES TO I MPROVE American Society of Breast Surgeons Mastery of Breast Surgery ℠ Program https://www.breastsurgeons.org/new_layout/program s/mastery/ https://www.breastsurgeons.org/new_layout/program s/mastery/ HHS- AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care National Quality Measures Clearinghouse

34. Health Resources & Services Administration www.hrsa.gov/

35. Source: National Assoc of Community Health Ctrs

38. E XECUTION Present recommendations to leadership Execute implementation plan - monthly Begin Training Track and Monitor Progress Revise Project as Needed

39. D RIVE C HANGE WITHIN D EPT. Quality Groups – Value Groups The culture of a system-wide QI department is fading away. Decentralization- more like manufacturing Engage each department or service line to apply PI methodologies

40. P ROCESS SUCCESS = A PPROACHES TO I MPROVEMENT Role of Front Line Workers Local Managers Financial Incentives Dashboards- achievement of goals Dissemination of Information Dashboards Newsletters Websites

41. C LOSURE D ISSEMINATE R ESULTS P LAN SHIFTS TO BECOME AN INTEGRAL PART C ONTINUED FOLLOW - UP, MONITORING E VALUATION /C ONTROL T ESTING L ESSONS LEARNED

42. THANK YOU VALERIE VESICH Valerie.Vesich@oncolog.com Senior Sales Executive Onco, Inc.