1. Establishing an Effective CQI Program By: Shannon Bentley, RN,c And Lois Sacher, RN

2. Welcome CQI Team!

3. Each team member will: 1. Help establish the project objective 2. Listen to each other’s ideas and acknowledge their point of view 3. Define project roles and responsibilities together 3. Define project roles and responsibilities together 4. Promote responsibility

4. CQI Meeting Agenda Monday, June 22, 2009 Introduction Julie (0:00-5:00) Introduction Julie (0:00-5:00) Participant Introductions All (5:00-10:00) Participant Introductions All (5:00-10:00) Brief Overview Lois (10:00-15:00) Brief Overview Lois (10:00-15:00) Creating the CQI Program All (15:00-35:00) Creating the CQI Program All (15:00-35:00) Center Success Stories Loydene and Brenda (35:00-55:00) Center Success Stories Loydene and Brenda (35:00-55:00) Wrap-Up Shannon (55:00-1 hour) Wrap-Up Shannon (55:00-1 hour)

5. Introductions Hello my name is. Hello my name is. My position on center is. My position on center is. The thing I dislike the most about the service I receive at my personal doctor’s office is. The thing I dislike the most about the service I receive at my personal doctor’s office is.

6. CQI Improves organization and systems Improves organization and systems Most things can be improved! Most things can be improved! This philosophy does not subscribe to the theory that “If it ain’t broke, don’t fix it." This philosophy does not subscribe to the theory that “If it ain’t broke, don’t fix it."

7. CQI or QA? 1. 1. Focus is on human error and eliminating poor performers 2. 2. Ensure that policies, procedures and protocols make sense 3. 3. Monitors compliance through periodic audits and inspections 4. 4. Relies on teamwork and incorporates evidence-based care Source: The NYC Division of Mental Hygiene. Quality IMPACT Basic CQI Course. http://www.nyc.gov/html/doh/downloads/pdf/qi/qi-training.pdf http://www.nyc.gov/html/doh/downloads/pdf/qi/qi-training.pdf

8. What are you doing—CQI or QA? 1. Corrective Action Plans (CAPS) 2. Surveying students on the service they receive in the HWC 3. Tracking Chlamydia test positives and experimenting with different sex education initiatives

9. Steps in CQI Plan DoStudy Act

10. Tools Brainstorming Brainstorming Purpose Purpose Time limit Time limit Note taker Note taker Multivoting Multivoting Relies on popular opinion Relies on popular opinion Prioritizing projects or elements of projects Prioritizing projects or elements of projects Please be creative! There are no bad ideas!

11. Plan Step 1

12. Data Collection Methods: Surveys of staff and students Observation Chart audits Review of current protocols Focus groups Student suggestion boxes Individual discussion Use of the SGA/or Wellness Committees

14. Survey Results Nursing staff’s skills and ability = 3.2 Nursing staff’s skills and ability = 3.2 How well the nursing staff listened to you = 3.0 How well the nursing staff listened to you = 3.0 Extent to which the nursing staff involved you in decisions about your care = 2.5 Extent to which the nursing staff involved you in decisions about your care = 2.5

15. Target Identification: Wellness Center Complaints

17. Do Step 2

18. What cause are we going to tackle?

20. Possible Interventions Possible Interventions Writing or revising formal policies and procedures Writing or revising formal policies and procedures Obtaining new equipment Obtaining new equipment Create or revise educational materials for students or staff Create or revise educational materials for students or staff Student/staff training Student/staff training

21. Study Step 3

22. What does this tell us? Intervention

23. Interpreting Data Pilot test the system and make necessary revisions Establish a schedule for follow- up data collection Analyze and present findings to health and wellness team or supervisor, as appropriate Identify and implement corrective actions

24. Act Step 4

25. Where should we go with this? Brainstorm Brainstorm

26. CQI is a never-ending process! Re-evaluate for: Results Results Changes needed in process Changes needed in process New or different goals New or different goals

27. Policy PRH and Desk Reference

28. PRH Requirements R15. Continuous Quality Improvement Center health staff shall seek feedback Quality of care provided, and document quality improvement activities

29. Desk Reference Seek feedback from students through surveys and utilize the SGA and health and wellness committees to develop a quality management system that works for your center Seek feedback from students through surveys and utilize the SGA and health and wellness committees to develop a quality management system that works for your center

30. Center Success Stories Loydene and Brenda

31. Gary Job Corps Wellness Committee Wellness Committee “Top 3” students “Top 3” students Panther Club Staff leader Panther Club Staff leader Student satisfaction surveys Student satisfaction surveys Confidential way in which the students may lodge a complaint Confidential way in which the students may lodge a complaint Development of a quality improvement plan annually Development of a quality improvement plan annually

32. Weekly Meetings Starting a MAR Updating the Infection Control Plan Starting weekly power meetings for the nurses Noting medication orders Staffing issues

33. Guthrie Job Corps Center Continuous Quality Improvement (Performance improvement) CQI/PI Plan contains: PAT (Performance Action Teams) PAT (Performance Action Teams) Trial period or pilot testing period Trial period or pilot testing period Performance measures Performance measures Follow up Follow up

34. Performance Examples of data the Wellness Center may choose for monitoring its performance include the following: Risk Management Risk Management Quality control Quality control Patient safety Patient safety Medical Records CQI Medical Records CQI Performance measurement data on the needs, expectations, and satisfaction of the individuals it serves Performance measurement data on the needs, expectations, and satisfaction of the individuals it serves

35. Guthrie Collection of performance measurement data by asking Wellness customers (both internal and external) it serves the following: Collection of performance measurement data by asking Wellness customers (both internal and external) it serves the following: How the Wellness Center can improve its service How the Wellness Center can improve its service How the Wellness Center can improve patient safety How the Wellness Center can improve patient safety Patient surveys, student satisfaction surveys, Health Services Committee, other Department concerns/complaints Patient surveys, student satisfaction surveys, Health Services Committee, other Department concerns/complaints Performance measures that are related to the following processes: Performance measures that are related to the following processes: Significant medication errors Significant medication errors Emergency Protocols Emergency Protocols Lab Testing Protocols Lab Testing Protocols State Mandated STD/Communicable disease reporting State Mandated STD/Communicable disease reporting Undesirable patterns or trends in performance are extensively analyzed and addressed. Undesirable patterns or trends in performance are extensively analyzed and addressed.

36. Resources

37. Resources Institute for Healthcare Improvement—This program provides the user with the ability to set up and document individual or team improvement projects, including collection of data, and track/trend changes over time http://www.ihi.org/IHI/Topics/Improve ment/ImprovementMethods Institute for Healthcare Improvement—This program provides the user with the ability to set up and document individual or team improvement projects, including collection of data, and track/trend changes over time http://www.ihi.org/IHI/Topics/Improve ment/ImprovementMethods http://www.ihi.org/IHI/Topics/Improve ment/ImprovementMethods http://www.ihi.org/IHI/Topics/Improve ment/ImprovementMethods

38. Resources Center for Evidence-Based Medicine— This website provides the user with tools to implement a project that evaluates practice against evidence-based medicine. http://www.cebm.net/ Center for Evidence-Based Medicine— This website provides the user with tools to implement a project that evaluates practice against evidence-based medicine. http://www.cebm.net/ http://www.cebm.net/ Agency for Healthcare Research and Quality provides several resources for tools to help design and support quality improvement programs and projects. http://www.ahrq.gov/qual/pstools.htm Agency for Healthcare Research and Quality provides several resources for tools to help design and support quality improvement programs and projects. http://www.ahrq.gov/qual/pstools.htm http://www.ahrq.gov/qual/pstools.htm Quality Tools http://www.syque.com/quality_tools/tools/T ools_usage.htm#col Quality Tools http://www.syque.com/quality_tools/tools/T ools_usage.htm#col