1. Introduction to main quality improvement concepts HAIVN 2011

2. Objectives Upon completion of this presentation, participants will: Understand concepts of quality and quality of care Understand how to start to improve quality of care

3. Outline Quality Quality of care Why should we care about quality of care Key principles of quality improvement

4. What is quality improvement all about? 4 Defining Quality Knowing what is supposed to be done Measuring quality Knowing if it is being done Quality Improvement Figuring out what changes are needed if a problem is found, doing it, and checking to see if it worked Team based and focused on systems

5. Quality – Many definitions Being free from defects and deficiencies The degree to which one thing is better or worse than another – a way to compare. – “Farmer Nguyen’s peaches are of higher quality than farmer Thao” A measure of excellence compared to an accepted standard – “Toyota cars are considered high quality” Customer view of quality - Something that meets or exceeds customer expectations

6. How do we define quality in health care?

7. Quality of care The degree to which health services for individuals and populations 1.increase the likelihood of desired health outcomes and 2.are consistent with current professional knowledge. Lohr K, Committee to Design a Strategy for Quality Review and Assurance in Medicare, eds. Medicare: a strategy for quality assurance, Vol. 1. Washington, DC: National Academy Press; 1990.

8. 5 minute exercise Turn to your neighbor What are one or two examples of desired health outcomes? Write them down and be ready to share with the group.

9. Quality of HIV care Examples of desired health outcomes – Long life – Stable health – Ability to work, play, contribute to their families and their community Adapted from National Quality Center

10. How do we decide what is quality of care in HIV? Based on evidence based recommendations or guidelines (MOH, WHO, international, etc) that communicate how care is supposed to be delivered Example – – Patients with CD4 < 350 should be given cotrimoxazole.

11. Why do we care about quality? Gaps in quality lead to: – bad health outcomes – wasted resources The health care system wishes to provide high quality of care but it is not always achieved

12. In HIV care, quality predicts outcomes Starting ART at higher baseline CD4 prevents OI and deaths Better adherence reduces treatment failure Early and correct management of treatment failure prevents resistance Correct PMTCT reduces HIV transmission

13. Case study XYZ district is 120 km from the provincial hospital in a province with 10,000 PLWHA OPC opened 2 years ago – 265 patients registered, but only 40 on ART – 22 patients died in the previous year PAC remarks: Low quality OPC Head of the OPC: Good quality OPC, but there are still problems because the clinic is at the district level A patient: Many patients died here and I don’t want to continue my treatment

14. Questions What do you think about the OPC and its quality of care? What other information might you need to know if there is a problem?

15. So how do you know where your clinic has gaps in quality of care? Measure

16. Quality improvement starts with measurement Identify where there are gaps in quality that need to be addressed Helps you to know where to focus your efforts Helps you follow progress over time Re-measurement lets you know if you made things better (or worse) with quality improvement

17. Measuring Quality (Performance Measurement) Looks for differences between expected and actual performance to identify gaps and opportunities for quality improvement. Example: All patients with CD4 < 350 should be started on ART within 30 days However in clinic XYZ only 40% of patients with CD4 < 350 are on ART and only 10% are starting within 30 days

18. Case study (cont.) A measurement of many aspects of XYZ OPC revealed: – Appropriate CTX prophylaxis 87% – Routine TB screening 90% – Mean CD4 at ART start was 20 cells/ml. – 20/22 mortalities had penicilliosis – Itraconazole stock out for one year due to issues with the supplier.

19. Case study (cont.) Treating doctors and nurses complained of high workload and low income Some patients on ART wanted to transfer to the OPC in provincial hospital You are the Vice Director of the hospital. What would you do?

20. Case study (cont.) After being aware of high number of deaths, the Vice director of hospital asked the Head of the OPC to list who was in charge of the patients that died to cut down their salary as means of punishment. What do you think? Is this the right answer to solve the problem?

21. Principles of QI Most Problems are Found in Processes and Systems, Not in People To fix a problem we must first understand why it exists Turn to your neighbor and come up with 2 or 3 reasons why the death rate is so high. Be ready to share. Adapted in part from National Quality Center

22. Linking Measurement to QI Measure quality Work to address the gap: QI Identify a gap Understand why gap exists

23. Identify a gap The clinic team discusses together and decides that patient deaths and late start on ART are the biggest problems to address first. As a first step they want to try to start patients on ART sooner.

24. Understand why the gap exists This clinic team then sits together to understand all the possible reasons for the gap and come up with three top causes No system to keep track of CD4 counts. No regular counseling schedule. Many patients live very far away.

25. Work to address the gap They assign one of the nurses to make a list of all patients with CD4 less than 250 to keep better track of who needs to start ART and start ART faster.

26. Measure quality (again) One month later: – 2 patients died – 50 patients on ART – 300 patients registered

27. Principles of QI Achieve Continual Improvement Through Small, Incremental Changes From National Quality Center

28. Understand why the there is still a problem Plan has been easy to implement Nurse developed list of patients with CD4 < 250 and keeps it updated However, patients live very far away and find it hard to return for repeated adherence counseling required to start ART.

29. Work to address the gap After a meeting again with the clinic team, and understanding long distance between hamlets and the OPC, the Vice director of the hospital decided to use two rooms with 12 beds for outpatients staying overnight.

30. Measure quality (again) Six months later there were 650 patients registered, of which 210 on ART and no patient died. What do you think?

31. Principles of QI QI is a journey of many small steps From National Quality Center

32. Summary – A practical view of Quality Improvement Quality – what are we supposed to be doing to improve health outcomes? Measurement – Are we doing it? QI – If not, why not and how do we make it better?

33. Summary – A practical view of Quality Improvement Quality – what are we supposed to be doing to improve health outcomes? Measurement – Are we doing it? QI – If not, why not? How do we make it better? Measure quality Work to address the gap: QI Identify a gap Understand why gap exists

34. Thank you! Questions?

35. Extra slides

36. Some difference between QI and Quality assurance Quality AssuranceQuality Improvement MotivationMeasuring compliance with standards Continuously improving processes AttitudeRequired, defensiveChosen, proactive FocusOutliers: “bad apples” Individuals Processes Systems ResponsibilityFewAll From National Quality Center

37. Differences between QI and Clinical Research Quality Improvement Clinical Research AimImprovement of careNew knowledge Test observabilityTest observableTest blinded Sample size“Just enough” data, small sequential samples “Just in case” data Testing strategySequential testsOne large test Solberg, Mosser, and McDonald, Journal on Quality Improvement. March 1997, Vol.23, No. 3. From National Quality Center