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Clinic Quality Improvement Initiative

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2 Clinic Quality Improvement Initiative
A Partnership Between Clinic Providers and OMH to Improve the Outcome of Our Services

3 As the first decades of the 21st Century unfold, what changes do you expect in the provision of mental health services?

4 Our Evolving Environment
We expect far more definitive research on what is effective in the treatment and rehabilitation of mental disorders Providers will need to be able to accomplish the transition from research to practice Providers will need to use objective tools to assess client needs as well as the process and outcome of care

5 OMH Vision: A Transformed System
Actively combats stigma Values quality Continuously improves Measures success by measuring individual recovery Adopts evidence based practices Tailors evidence based practice combinations to the needs of individual clients Stresses adequate housing, employment and social integration

6 An Overview of the Workshop
What is Quality Improvement Overview of the MOA Completion of the QI Plan Three Examples of Quality Improvement Initiatives

7 What is Quality Improvement

8 What is Continuous Quality Improvement?
A quality management model whereby healthcare is seen as a series of processes and a system leading to an outcome. QI strives to make changes in the structural and process components of care to achieve better outcomes. Talk about structure, process, outcomes

9 How Quality Improvement Began
Shewhart and Bell Labs Deming and the Japanese Auto Industry Industry in the 1980’s Healthcare in the 1990’s The Enduring Principles Method: Plan, Do, Check, Act Collaboration with those who do the work Focus on understanding our work Commitment to improvement Commitment to using objective data

10 Quality Improvement and Healthcare
Added element of the client Passive vs. active: Individuals are empowered Medical Errors Outcome of Care Basing Practice on Evidence Passive versus active patient: empowerment

11 Variations on the Approach
CQI Continuous Quality Improvement TQM Total Quality Management Six Sigma Engineering Origins PDCA Plan-Do-Check-Act cycle BSC Balanced Scorecard

12 The Shared Elements of Continuous Quality Improvement Approaches

13 Quality Improvement is an Orientation and Attitude
We understand our work as processes and systems. We are committed to continuous improvement of processes and systems

14 Core Principles of Continuous Quality Improvement
Customer Focus Recovery Oriented Employee Empowerment Leadership Involvement Data Informed Practice Using Statistical Tools Prevention over Correction Continuous Improvement Participation and Communication at all levels Customer Focus. High quality organizations focus on their internal and external customers and on meeting or exceeding customers’ needs. Employee Empowerment. Effective programs involve people at all levels of the organization in improving quality. Leadership Involvement. Strong leadership, direction and support of QI activities by the governing body and CEO are key to performance improvement. This involvement of organizational leadership assures that QI initiatives are consistent with provider mission and/or strategic plan. Data Informed Practice. Data is necessary to inform practice and measure results. Fact based decisions are likely to be correct decisions. Statistical Tools. Effective QI organizations use a defined set of analytic tools to turn data into information. Prevention over Correction. QI entities seek to design good processes to achieve excellent outcomes rather than fix processes after the fact. Continuous Improvement. Processes must be continually reviewed and improved. Small incremental changes do make an impact, and providers can almost always find an opportunity to make things better

15 Overview of a CQI Program
Essential Program Aspects Provide a structure through which the core organization functions are evaluated and improved Core functions will be defined by the Mission, Vision, and Values of the organization Examples of core functions Outcomes: client safety, clinical outcomes, client satisfaction Process: client flow, fiscal issues Core functions operationalized for data collection purposes Examples of operationalized functions Outcomes: med errors, suicide attempts, satisfaction survey data Process: wait list latency, no show rates, medication costs Evaluation of the functions achieved through analysis of collected data Improvements accomplished through projects/initiatives

16 Overview of a CQI Program
Where do projects and initiatives come from? Internal Unacceptable variation in key indicators Management initiatives Client complaints Incidents External Literature, e.g., Evidenced Based Practices Benchmarking – comparing organizations’ results to other, like organizations Regulatory agencies, changes in law/standards

17 Overview of a CQI Program
Internal and external factors will be reviewed by QI Committee (and others – Board of Directors, etc) Projects/initiatives will be started based on results of prioritization process

18 Setting Priorities Always more improvement opportunities than can be effectively addressed Set Priorities based on: Relevance to mission Clinical Importance: High volume, high risk, problem-prone Expected impact on outcome of care Available resources and cost

19 What is a Project or Initiative?
A planned activity, often involving a group of people, with a specific goal or expected outcome Quality improvement is about doing something based on our priorities Requires a planned and systematic approach

20 Shared Core Method of Quality Improvement Approaches
Plan Do Check Act Single approach employed throughout the facility.

21 Quality Improvement: Plan
Select the project Understand and clarify the process Data Flowcharting Brainstorming Fishbone Diagram Develop a Plan of Action

22 Quality Improvement: Plan
Plan the action Plan the pilot test of the action Include in the plan a measure of performance

23 What is a Performance Indicator?
A quantitative tool that provides information about the performance of a process Quantitative tool - means variable in relation to an outcome recognizing that some outcome measures relate to an entire host of processes? For example, recovery or symptom improvement or improvement in functional status.

24 Quality Improvement: Do
Collect data Analyze and prioritize Determine most likely solutions Test whether our action really works before we make it a routine part of our daily operations

25 Quality Improvement: Check
At the end of the pilot period, determine whether the action has had the desired effect. Is the modified process stable? Did the process improve?

26 Quality Improvement: Act
If the action works: Make it part of routine operations Continue to gather data to make sure you are holding the gains

27 Quality Improvement: Act
If the action does not work: Return to the Plan stage Use the test to plan a better action

28 PDCA is a Cycle It is not about one single dramatic action, but about trying things to see if they work. Remember, life is a series of experiments.

29 Evidence Based Practice
A special QI method: Systematically copying a process or system that works better Care of psychiatric disorders is an increasingly research based activity The Challenge: Transfer of knowledge A formal rather than informal activity Approach fidelity. Objective assessment.

30 Our Partnership for Quality
Memorandum of Agreement

31 Key Dates November 30, 2005: MOA due to OMH in order to receive increase retroactive to January 15, 2006: CQI Plan due to OMH February 1, 2007: First Annual Evaluation due to OMH February 1, 2008: Second Annual Evaluation due to OMH

32 Key Dates New York City November 30, 2005: MOA due to OMH in order to receive increase retroactive to January 15, 2006: CQI Plan due to OMH April 30, 2007: First annual evaluation due to OMH April 30, 2008: Second annual evaluation due to OMH

33 Highlights of MOA Does not require providers to adopt one particular framework Does require that certain key principles guide any QI effort Requires participation in the implementation of Child and Adult Integrated Reporting System (CAIRS) Creates measurement opportunities OMH’s Center for Information Technology and Evaluation Research (CITER) will be coordinating a statewide implementation of CAIRS for clinics in the next several months.

34 First Year Educate Leadership and Staff on principles of QI, Performance Measurement and Evidenced-Based Practices (EBP) Create an Administrative structure to perform QI activities through the designation of a Quality Improvement Committee Develop a Quality Improvement Plan Implement at least one measure of the process or outcome of care Handouts in the packet, on the CD enclosed and on the OMH and SAMHSA website re EBPs. Samhsa phone # re: EBP – 1(800) Tony Salerno – (518) Integrated treatment for co-occurring mental and substance use disorders Standardized pharmacological treatment Assertive Community Treatment (ACT) Illness management and recovery skills Family psychoeducation Supported employment

35 Second Year Include QI Plan in new employee orientation
Develop and use a second performance indicator Document use of data from indicators in decision-making Survey individuals served, families and staff about their perceptions of care Complete an annual QI Evaluation

36 Third Year Collaboration with OMH on an evidence-based practice in the area of medication therapy to be determined.

37 Practical Demonstration
Selecting potential indicators Brainstorming Nominal Voting Techniques

38 Time for a BREAK!!!

39 The Wide Variety of Possibilities (Three Examples)
Improving Engagement of Youth and Families Reducing the Wait List Integrated Treatment (An Evidence Based Practice)

40 Example 1: Relevance to Mission and Clinical Importance
Improving the Engagement of Youth and Families in Clinic Services Two thirds of children in need of mental health services do not receive services. (US Public Health Service, 1999, 2001) Only 20% of all children in a study sample of clinics in New York State completed the episode of care in which they were enrolled. (Lyons, 1999) No show rates can be as high as 50%. (Lerman and Pottick, 1995) What I would like to do now is walk you through a QI example using engagement. So where did they start? In the planning stage thinking about priorities they uncovered that: 2/3rds of children with mental health problems do not receive any type of mental health services. Furthermore, among those who receive some services, no-show rates for appointments may be as high as 50% and premature terminations are common. John Lyons found that in NY only 20% of all children in a sample of clinics completed care. No show rates can be extremely high. • From 2004 to 2005, OMH, the Citizens’ Committee for Children, the New York City Department of Health and Mental Hygiene (DOHMH), and the Mount Sinai School of Medicine implemented the 9-month quality improvement project the “Learning Collaborative to Improve Engagement and Retention of Children and Families in Treatment.” You are going to hear more about this tomorrow because Dr. McKay is on the agenda. The Collaborative, with input from a workgroup of local stakeholders (community providers, family and youth advocates, OMH staff, and DOHMH staff), found that evidence-based engagement interventions and quality improvement methods were effective in improving rates of initial engagement of children in outpatient mental health clinic services

41 What were the indicators ?
#1 The show rate for the first intake appointment for all new evaluations of children and adolescents: # who kept first intake appointments #scheduled appointments #2 Attendance at any scheduled clinic appointments subsequent to the first kept intake appointment for all new evaluations: # of attended clinic appointments (excluding first kept intake appt.) #scheduled clinic appt. (excluding the first kept intake appt)

42 North Shore Child and Family Guidance Center Baseline Data
91% of children and families keep intake appointments 66% of children and families attend clinic appointments subsequent to the first intake appointment

43 What was the desired result?
By implementing an evidence based training program related to improving the engagement rates for clients, the clinic would treat and retain more children for the duration of their episodes of care.

44 Objectives Improve the show rate for the first intake appointment for all new evaluations of children and adolescents Improve attendance at any scheduled clinic appointments subsequent to the first kept intake appointment for all new evaluations There were four indicators for this project, we will just focus on 2 for the purpose of this presentation.

45 What is Engagement? A process that begins with an individual being identified as experiencing mental health difficulties and ending with that individual receiving mental health care (Laitinen-Krispiijin et al, 1999, Zawaanswijk et al, 2003) Has been divided into 2 specific steps: initial attendance and ongoing engagement (McKay et al 1996, 1997, 1998). Rates of service engagement can differ at each and warrant specific consideration. References are from “Engagement of Youth and their Families in Child Mental Health Care Summary” Prepared by Mary McKay, Ph.D. and William Bannon, MSW Mt. Sinai School of Medicine and New York State Office of Mental Health. Not in packet, but available from Marcia Fazio and will send to them if they want.

46 Evidence Based Engagement Interventions
Reminders reduced missed appointments by as much as 32% (Kourany et al, 1990, McLean et al 1989, Shivack et al, 1989 and Sullivan) Intensive family-focused telephone engagement intervention associated with 50% increase in initial show rates and a 24% decrease in premature terminations (Szapocznik, 1988, 1997)

47 Empirically Supported Telephone Engagement Strategy
Focus during the initial telephone intake or appointment call Relies on an understanding of child, family, community and system level barriers to mental health care Family-Focused Telephone Engagement Intervention: 1. Clarify the need for mental health care 2. Increase caregiver investment and efficacy 3. Identify attitudes about previous experiences with mental health care and institutions 4. Problem Solve, Problem Solve, around concrete obstacles to care

48 How Was it Assessed? Staff received training in EBP engagement techniques Oct 04 In Nov 04, agency began collecting data on indicators 1 and 2 Data was tracked for 9 months Results compared pre (business as usual in Oct 04) and post (following the engagement intervention)

49 Plan Agency received training in the evidence based engagement intervention (Oct 04) Following the training, agency identified a quality improvement team, developed a plan to incorporate the EBP into their operations, and a plan to track the effectiveness of the intervention over nine months using the indicators agreed upon

50 Do In November 2004, agency implemented the engagement strategy and began collecting data Data was collected each month for nine months and analyzed for trends and patterns

51 Check Course corrections were made when it appeared that the results did not support the original intent North Shore reviewed data and discussed findings in monthly conference calls and quarterly meetings with other clinics participating

52 North Shore Child and Family Guidance Center Performance Indicator #1

53 North Shore Performance Indicator #2

54 North Shore’s Experience
Fewer issues with dropout (Indicator #1). They started high (91%) and maintained that rate over all The real success came with Indicator #2. They retained a significantly higher rate of clients after the collaborative than before Moved from 66 to 84 percent

55 Act Revised process was fully implemented
Data collection continues to ensure that the positive results are maintained over time Staff learned from each other

56 Lessons and Challenges
Collect only the data that is tied to the improvement you want to make. (example of what was collected for this in your packets) Keep it simple and Non-Burdensome. (Most clinics collected data by hand) Make sure the findings are communicated and that leadership knows about the QI project. It is part of the overall agency management framework. Don’t take shortcuts. Don’t skip the PDCA. Call your colleagues. Compare results across sites in an agency.

57 More Information Contact: Mary McKay, Ph.D. Professor of Social Work
Mt. Sinai School of Medicine, Dept. of Psychiatry Marcia Fazio, Director, External Review Unit New York State Office of Mental Health Office of Quality Management

58 More Contact Information North Shore Child and Family Guidance Center Regina Barros, Director of Clinical Services Andrew Malekoff, Associate Director 480 Old Westbury Rd. Roslyn Heights, NY 11577 ext. 330

59 Example 2: Mission Relevance and Clinical Importance
Reducing the Wait List Rensselaer County Mental Health Department determined that individuals were unable to access its clinic services in a timely manner. (Problem prone and high risk) There was no way to differentiate people who needed counseling from those who needed other types of services. (Mission relevance) Information gathered during the intake call was often inaccurate. (Problem prone) The result was that consumers were waiting 2-3 months for a clinic appointment. (Problem prone, high risk)

60 What were the indicators?
Number of calls received Number of appointments made Number of individuals who did not show for treatment Wait time Cost per appointment

61 Rensselaer County Baseline Data
760 calls received 760 appointments made 14 no shows each month 2-3 month wait time $133,000 cost for 760 appointments

62 What was the desired result?
The county wanted to reduce the wait list, improve the response time and provide services based on what its customers really needed.

63 What was the model? A team of senior clinicians was formed. They have the confidence to make decisions. Clinicians were trained to ask the right questions. Who is bothered? What is bothering them? How much and in what way? Client, Referral Source, Clinician? Individuals who called the clinic for help received a call back from a senior clinician immediately. Clinicians spent as much time as necessary over the telephone to determine what the caller needed. Clinicians were prepared to make multiple calls to referral sources if necessary. Clinicians were careful about the language that they used. Instead of saying “What do you expect to get out of treatment”? They asked “Why did you call?” Callers were called back in 2 weeks to ensure that the suggestions they were given were helpful.

64 Plan The county decided that the wait time for clinic services was not acceptable Senior staff implemented a model for answering the phone differently when consumers call for services that had proved successful in another part of the county’s organization The model developers were adamant that this model had been replicated from another part of the organization. The clinic did not invent it. so that’s what I was getting at above..

65 Do Senior Clinicians were trained in the model, assigned days of the week and answered all calls for their particular day Calls were tracked on a monthly basis and outcomes were monitored for the year to ensure that the intervention was having the desired effect

66 Data Before Calls received= 760 # Appts made= 760 (100%)
No-Show Rate= 14/mo Wait time to appt= 2-3 mo Cost 175. for 760 appts= $133,000. After Calls received= 760 #Appts made= 427 (56%) No-show Rate= 4/mo Wait time to appt= 0 creeping to 1.5 mo Cost $175. for 427 appts= $74,725. Savings to county= $58,275.

67 Examples of what services people received other than outpatient therapy
Transportation Respite services Parenting Classes Flexible Funds to pay for basic needs: clothing, phone Specialty Services: Bereavement, Sexual Offender Treatment Advice Education of the Referral Source (person doesn’t need therapy, they need some other service)

68 Check Course corrections were implemented when problems were identified. (e.g., Team members were replaced when it appeared their practices were inconsistent with the model.)

69 Act Successful strategies were reinforced during staff meetings
Adherence to new protocols monitored over time

70 Lessons Learned Not everyone who calls a clinic needs outpatient therapy. 43% of the callers in this county needed basic problems solved. Not all clinicians were cut out for this model and some were removed from the team. It was important to use Sr. Clinicians who were confident making decisions on the spot, speaking to judges, etc. Sr. Clinicians had a 30% appointment rate vs. 60% appointment rate for less experienced staff. Any person who really wanted to come in for therapy was provided an appointment even if the clinician had assessed that it was not necessary.

71 Contact Information Rensselaer County Department of Mental Health Katherine Maciol, Commissioner Aaron Hoorwitz, Ph.D. Chief Psychologist Ned Pattison Government Center Troy, NY 12180

72 Information on the Model
Developers: Rensselaer County Department of Mental Health Aaron Hoorowitz Chief Psychologist Donna Bradbury Principal Court Consultation Specialist Sara Thiell Court Consultation Specialist

73 Example 3: Mission Relevance and Clinical Importance
Integrated Dual Disorder Treatment: The Opportunity A clinic found that a significant percent of their clients were experiencing alcohol / substance use problems along with mental illness. (High volume/Problem prone) Among this group were the most difficult to treat effectively. (Problem Prone) Staff varied in their approach to these clients with no consensus on what was most effective. (High Risk) “Why is my client not getting better?” (Problem prone) OMH identified Integrated Treatment as an “evidence-based practice” with resources available. (Mission relevant) Back to our hypothetical illustration -

74 Indicators The number of dually diagnosed individuals assessed initially and at 6 and 12 month intervals The number of dually diagnosed individuals progressing through treatment

75 Desired Result A significantly improved treatment outcome for dual disorder (mental illness and substance use) clients as measured by changes in stage. Note this is an example of a project focusing on clinical outcome. A simple desired result but also an ambitious one. We must do some consistent measurement and assessment to determine whether we are reaching our desired result.

76 Plan: The Model Treatment is most effective if the same clinician or team helps the client with both substance abuse and mental illness People who recover from substance abuse disorder go through a stepwise process that can be described in stages At different stages, different types of treatment are helpful Let’s talk a little bit about the evidence based practice that the clinic is deciding to adopt. There is a very large research literature supporting this practice. A bibliography is available on the OMH web site. We will not make any attempt to summarize that research here. We will just provide enough information about IDDT so that it can be used as a hypothetical example. I am also not really an IDDT expert, so I will keep us focused on this as an example of adopting an EBP rather than on IDDT itself, its merits or shortcomings. But here are the core principles of IDDT. They are quite straight forward. (Read the principles)

77 Stages of Recovery Change Treatment Precontemplation Contemplation
Preparation Action Maintenance Treatment Engagement Persuasion Active Treatment Relapse Prevention This is a well developed practice with many training materials and other resources available to assist practitioners who want to adopt the practice. Here are the actual stages of change or recovery as defined within the IDDT approach. For each stage, there is a particular focus of treatment associated with specific therapeutic interventions and practitioner skills. In your handouts, is a brief chapter from the IDDT Workbook. Show them the notebook. This is one of the most useful basic resources for this approach. It is available from the Department of Health and Human Services. Briefly illustrate this slide with information from the handout about a particular stage (Chapter 6). There is a wide variety of other written resources available. OMH: Jeff Gleba, resource person in OMH. Willing to come out and consult. Variety of resources available regionally. Provide Field Office Resource person if there is one.

78 Substance Abuse Treatment Scale
Pre-Engagement Engagement Early Persuasion Late Persuasion Early Active Treatment Late Active Treatment Relapse Prevention In Remission or Recovery One of the things that makes this a particularly attractive EBP is that it comes with a very simple but effective assessment tool. It is an eight point rating scale based on the stages of recovery. A copy of the scale is in your handout. Each category on the scale is briefly described, for example… This scale has a number of real positives: Can be done instantly by clinicians who are knowledgeable of IDDT and who know their clients. It has a lot of what is called “face validity.” It has clear and obvious meaning in relation to the approach. Since it was developed directly in relationship with the IDDT approach, it has what is called “construct validity.” What it measures has real meaning in relation to how you understand you clients and what you are trying to accomplish with them. It gives you a single number that can readily be used in a number of ways to guide what you are doing and assess your success with this approach. We will be talking more about this.

79 Four Basic Skills of Clinicians
Knowledge of substances of abuse and how they affect mental illnesses Ability to assess substance abuse Motivational counseling for those not ready to acknowledge substance abuse Integrated substance abuse counseling for those motivated to address their problems As you can see in your handout, this is a highly prescriptive approach. At each stage, the therapist focuses on certain types of interventions. It requires a specific set of skills of practitioners. These are summarized on this slide.

80 Plan Commitment: We are serious about doing this and will stick with it Leadership and staff Learning, measuring and assessing Fidelity to the practice: We want to do this right Strategy A starting point and 12 month objectives Our hypothetical clinic has a close knit staff of a nurse, two social workers, a part time psychologist and a part time psychiatrist. One of the social workers also serves as the Director of the clinic. In their ongoing discussions, clinic staff have struggled with the issue of how to serve their clients with both mental illness and substance use disorders. Some members of the staff have been exposed to IDDT and have been favorably impressed. In their weekly staff meeting, the Director proposed that they consider adopting an integrated treatment approach. In their discussion, there was a discussion that a willy-nilly approach would not work. This will need to be a longer term commitment with a carefully planned and executed process, a strategy. Invited Jeff G. from OMH who shared the OMH perspective and other service providers. He also shared the idea of the stages of treatment as a practical starting point. Clinic staff met and decided to do it. All clinicians would make a commitment to learning and treating their clients with this approach. The Director developed a brief written strategy in close consultation with staff. Since this was to be a longer term project, they wanted to formulated some short term (12 month) objectives to focus their efforts. Note relevance to QI Plan. Director presented the strategy to the Board and they were highly supportive.

81 What is a Strategy? Avoiding the Britney Spears wedding
The larger picture A set of related and planned actions which make a coherent whole designed to accomplish a major goal Let’s talk a little bit about what it means to develop a strategy. It’s easy to fall in love and do something impulsive. Sometimes we regret this later. Often it does not work out. One benefit of making our strategy explicit is that it lets us know who, or in this case what, we are marrying. It is the rational basis for a long term commitment. A strategy is the larger picture. The term strategy comes from military parlance. It is the science of planning and directing large scale military operations. Read the definition.

82 The Clinic’s Strategy Obtain and maintain leadership and staff commitment All clinic staff will become competent in the skills of IDDT Clinical staff will carefully review all their clients, further assessing and making a substance use disorder diagnosis as appropriate Clinical staff will rate the stage of treatment of all clients with a substance diagnosis every six months Ratings will be used to assess individual progress and aggregated to guide staff training and assess outcome Staff will complete a self-rating of fidelity to the IDDT approach every six months So what does the clinic’s strategy look like. (Review) What do you think of this as a strategy? Note: The importance of leadership. This is an ongoing activity. How is commitment maintained. Deming – “constancy of purpose” This is the big picture, the major elements. In all cases there is another level of detail which may change over time. For example, in the are of staff training: Initially, staff committed themselves to use the IDDT Workbook and devote a hour of staff time each week to learning and practicing. The Board agreed to a budget for consultants to focus on specific learning issues and challenges. Fidelity rating scale is in the handout. Discuss the value of this. Note that this is a second measure and the OMH agreement requires only a single measure this year. Let’s look at the certain parts of this strategy in a little more detail.

83 Strategy: Learning and Practicing
Staff meet for an hour weekly using the “Integrated Dual Disorders Treatment Workbook” as a resource Focus on developing skills most relevant to the stage of recovery of most clients Later, as indicated by the data, focus on the most difficult stage transitions Bring in outside training resources to focus on treatment challenges This spells out the part of the strategy having to do with the development of staff competence in a little more detail. Note the relationship between the use of data and the staff training strategy.

84 Do Classify all clients who meet criteria for substance abuse or dependence on the Substance Abuse Treatment Scale Develop a profile of clients on the Scale Classify clients at the time of each treatment plan review Track and evaluate progress of individual clients and dual disorder clients as a group This is their strategy in the area of measurement of assessment and measurement. Understanding where their clients are in relation to the stages of treatment is also their critical starting point. It is an initial action which opens the door into the entire project.

85 Do: Starting Point: Assessment
Two Stages Identify clients who meet the criteria for substance abuse and dependence Classify clients on the Substance Abuse Treatment Scale

86 Do: Initial Rating Database
We are assuming a small clinic with a minimum of resources but plenty of motivation. Since we are assuming that most clinics have a copy of Microsoft Excel available to them, we will use that tool in our example. In this regard, we should mention a number of points. We will use Excel as an illustration, but we will not be training you how to use Excel for this purpose. Our illustration is a simple one, however, and should be well within the capabilities of anyone who has a modicum of ability in using computers and has had introductory training in Excel. This is a basic application. There are certainly many more sophisticated tools out there for this and similar purposes. If you are using one of these tools, we offer our encouragement to continue. We are not endorsing Excel as the optimal data analytic strategy. The data are made up, but the Excel application is real. We designed it to be as simple as possible. If you would like me to mail you a copy, give me your address after the session. Here is the really basic database. The fields are: Number: A unique number to identity the patient. Date: The date when the patient was assessed. Measure: This is interesting. This indicates the measurement point for the patient. 1 indicates the first time the patient was assess; two the second time, etc. According to our plan all of these measurement points will be six months apart. This illustrates the first point for all the patients. Rating: This is the actual rating for each patient on the 8 point scale.

87 Do: Initial Rating of Clinic Patients
This is the first thing the clinic did with their data. It is based on all clients first measurement point. They aggregated the initial ratings of clinic patients. What does this tell us? This revealed that most of their patients fell into the stages from engagement to early active treatment. This allowed them to focus their training efforts on the staff skills relevant to these stages.

88 Check Aggregate an initial, 6 month and 12 month rating of all IDDT clients Complete staff training using the IDDT Workbook Analyze stage of treatment of IDDT clients to help focus training needs and issues Analyze progress of IDDT clients as a group Analyze difficult stage transitions These are the 12 month objectives that are incorporated into the QI Plan. We will now look at some hypothetical data to illustrated how the data related objectives were met.

89 Check: Example of a Client’s Progress
Clinic staff continue to rate their patients every 6 months and put the numbers into their data base. This is an example of a specific patient’s progress over a year and a half. It could be made a part of the treatment plan review process for this group of patients.

90 Check: Progress of IDDT Clients
This graph depicts the average progress of all patients during their first 18 months of integrated treatment. Note that patients would start treatment as different points in time. It would be very difficult to aggregate this information using so many different dates. Putting in the numerical measurement points makes this analysis quite simple.

91 Check: Percent of Clients Progressing Through Each Stage
As the clinic gathered more data over time, they were able to do this interesting analysis. It asks the question: How successfully are clients moving through each stage of recovery. For each stage at each measurement point across clients, we calculated the percentage of clients who were at a higher stage at the time of the next measurement. Note: Stage 8 is not included because a client cannot progress any further. Let’s look at the data: Overall it looks like the program is pretty successful. Patients are progressing. Isn’t this helpful to know. Good success in moving clients on from the pre-engagement stage. But, note that we only counted two cases. We wouldn’t want to draw any conclusions from this. Look at stage 4. Our biggest barrier seems to be moving clients on from Late Persuasion to Early Active Treatment. This is where we want to focus our case review and staff development efforts. Perhaps consult an expert. To some extent, this also seems to be true of the movement from Relapse Prevention to the final stage, In Remission or Recovery, as well.

92 Act Actions were based on the initial assessment of clients
Since most of the patients fell into the stages from engagement to active treatment, training efforts focused on the staff skills relevant to these stages

93 The Quality Improvement Plan
Note required elements of the plan in the MOA.

94 Quality Improvement Plan Template
Meets the requirements of the MOA Optional Sections to be completed Mission, Vision and Scope of services Leadership and QI committee Goals and objectives Selection and description of indicator Assessment strategies Approach or model to be used Designed to meet the requirements of the MOA.

95 Mission/Vision: Scope of Services Section 1 of the Plan
Describe program philosophy Provide basic descriptive information including: Description of individuals served Catchment area Type of services Size of the organization

96 Leadership and QI Committee Section 2 of the Plan
The Quality Improvement Committee Membership issues Responsibilities Meeting frequency Critical role of leadership support Sharing of findings with stakeholders Suggested Materials for use in educating leaders:

97 Goals and Objectives Section 3 of the Plan
Long term core goals of any quality improvement program Objectives Related to selected goals Specific to the clinic Measurable Expected completion within 12 months A basis for the annual evaluation Objectives Do not need an objective under every goal Provide a couple of specific examples of objectives

98 Things to Consider in Selecting a Performance Indicator Section 4 of the Plan
Mission of the Clinic Clinical importance: High Volume, High Risk, Problem Prone Outcome Available resources and cost

99 Description of Performance Indicator Section 4 of the Plan
A quantitative tool that provides information about the performance of a clinic’s processes, services, functions or outcomes Data collection Assessment frequency

100 Assessment Strategies Section 4 of the Plan
Describe assessment methods and tools to turn data into information See Appendix A Memory Jogger in packet

101 Approach or Model Used Section 5 of the Plan
Various models exist PDCA is described

102 Contact Information Central and Western New York Thomas Cheney Long Island James Masterson New York City and Hudson River Alan McCollom and Ellen Smith

103 Time for Yoga

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