2WHY DO WE NEED TO KNOW ABOUT CQI? Provision of Quality CareCQI tools and techniques work in healthcare. Bureau of Primary Health Care requires quality improvementNew process relates health care plan, QI, UDS info, needs assessmentFocus on Core Clinical Measures
3A Few Questions to Ask… Services provided in timely manner? Was necessary care provided?Efficient provision of care?Was the expected outcome achieved?Are patients, clients and customers satisfied with provided services?
4Success is achieved through meeting the needs of those we serve.
5Quality Assurance vs. Quality Control Quality assurance and quality control are often used interchangeably to refer to ways of ensuring the quality of a service or product.The terms, however, have different meanings.
6Quality Assurance“The planned and systematic activities implemented in a quality system so that quality requirements for a product or service will be fulfilled.”American Society for Quality
7Examples of Quality Assurance Activities Activities that are based on public health standards, licensing standards, institutional policies, etc.Annual infection control and safety trainingReview medication closet for outdated medsReview emergency chart once a week for supplies and outdated medsCan help identify a problem, but are more often used to comply with the standards.
8Quality Control“The observation techniques and activities used to fulfill requirements for quality.”American Society for Quality
9Examples of Quality Control Infection control training sign-in sheets cross-referenced with staff rosterReview sheet of emergency cartDirect observation of counseling session
10Quality Improvement“Continuous improvement is an ongoing effort to improve products, services or processes. These efforts can seek “incremental” improvement over time or “breakthrough” improvement all at once.”American Society for Quality
11Philosophy of CQIBased on concept of balance between quality improvement & performance measurementQI programs are built upon foundation of program support & infrastructureEmphasizes development of systems & processes to support QI
12Guiding Principles Ongoing QI activities improve patient care Performance measurement lays foundation for QIInfrastructure supports systematic implementation of QIIndicators are based on clinical guidelines & formal group-decision making
13Core Clinical Measures for Health Care Plan DiabetesCardiovascular DiseasePrenatal CarePerinatal CareChild healthBehavioral HealthOral HealthOther x2
14Goals of Quality Improvement The goals of QIto understand process, reduce unintended variation in care, eliminate errors, remove unnecessary steps, and improve communication and accountability.process is designed toward outcomes.Quality improvement depends on measurement.
15Core Concepts of CQIQuality defined as meeting and/or exceeding expectations of customers.Success is achieved through meeting the needs of those we serve.Most problems are found in processes, not in people. CQI does not seek to blame, but rather to improve processes.
16CORE CONCEPTS OF CQIUnintended variation in processes can lead to unwanted variation in outcomesPossible to achieve continual improvement through small, incremental changes using the scientific method. CQI most effective when it becomes natural part of way everyday work is done.
17Comparison of QA & QI QA QI Motivation Measuring compliance with standardsContinuously improving processes to meet standardsMeansInspectionPrevention, monitor over timeAttitudeRequired, defensiveChosen, proactiveFocusOutliers or “bad apples”, individualsProcesses, systems, majorityPlayersSelected departmentsOrganization wide, benchmarkingDisciplinesWithin professionMultidisciplinary approachScopeMedical profession focusedPatient care focusedResponsibilityFewAll
19What is the benefit for: Exercise on QualityWhat is the benefit for:PatientsStaffOrganization
20Putting It All Together QA + CQI + Peer Review + Consumer Satisfaction = QM
21Are we doing what we said we’d do? Process Indicator:Are we doing what we said we’d do?Outcome:Is it working for the clients?
22GUIDING VALUES of CQIMost problems are found in processes, not in people. If you “focus” on everything, you can’t focus on anything.The best solutions are staff designed.
23Roles and Responsibilities Leadership/Board/Consumers: Oversight and resources. Help set priorities.QI Committee: Review data, pick projects and goals, review results of tests.Project Team: Brainstorm ideas and design tests.All Staff: Help perform tests and collect data.
26PITFALLS OF CQIStaff view it as a ball and chain, hindering their daily work
27PITFALLS OF CQIThe Process can tie you up in knots
28Lessons Learned“The shorter the timeframes between test cycles, the more tests can be conducted and therefore, more opportunities for learning will emerge.” - HIVQUAL Workbook“Let’s be as opportunistic as a virus!” - Anonymous
29Common Themes among QI Models Improvement is about learningtrial and error (scientific method)improvements requires change, however not all changes are an improvementMeasure your progressonly data can tell you whether improvements are madeintegrate measurement into the daily routineImprovements thru continuous cycles of changesPlan-Do-Study-Act approachchanges are initiated on a small scale to test them before implementationLeadership is neededestablish organizational commitment and support staff and activities
30One MODEL FOR IMPROVEMENT Model consists of:three questions (aim, measure, change) to form context for improvementPlan-Do-Study-Act (PDSA) Cycle to structure tests
31Model for Improvement Act Plan Study Do Model for Improvement What are we trying to accomplish?How will we know that a change is an improvement?What change can we make that will result in improvement?ModelforImprovementActPlanStudyDoMFI model for ImprovementHow many have heard?Elegantly simple model that is useful …3 questions plus the PDSA cycleGo over 3 questions and plan do study act ; pdsa
32What are we trying to accomplish? Model for ImprovementWhat are we trying to accomplish?How will we knowthat a change is an improvement?What change can we make that will result in improvement?Why this question is important … highly corelated with success of a team ..
33What are we trying to accomplish? that a change is an improvement? Model for ImprovementWhat are we trying to accomplish?How will we knowthat a change is an improvement?What change can we make that will result in improvement?What is the second question … how will we know?Why is this important ….
34Model for Improvement What are we trying to accomplish? How will we knowthat a change is an improvement?What change can we make that will result in improvement?So what is the third question?The changes that you make should align with your aim and measures…Where do they come from ? IHI change packages… chanes with a pedigree… have a high degree of belief they willwork .. Have worked .. Ideas in the op doc.. Op Doc.. Each other..
35PDSA CYCLE Plan - Plan a change Do - Try it out on a small-scale Study - Observe the resultsAdopt, adapt, or abandon -Refine the change as necessary
36PRINCIPLES OF PDSA CYCLES Short cycles of changes to accelerate rate of improvementsmall scale tests (“What can you test till next Tuesday”)collect just enough informationCreate flow of ideas, then emphasize implementationincrease frequency of testsbuild knowledge sequentially - use multiple cycles to adapt a change to your systemAdopt existing knowledge (‘not more research but more application of existing knowledge’)‘Steal shamelessly, Share senselessly’Promote peer learning
37Tips for PDSA Cycles - formulate question and predict results - test first in ‘safe zones’ (with team members, volunteers)- ‘Just-do-it’ mentalitycollect useful just enough data, not perfect datathink a couple of cycles aheadscale down size of test (# of patients, clinics)be innovative to make test feasibleExample: Improve decision support by using a standard based flowsheet- adapt flowsheet with one pt- revise flowsheet and test with Dr. 1 pts on Monday- present flowsheet to all MDs- revise and test for one week- implement and monitor standards
38PDSA Cycles: Testing a pap Cuing Plan Improved Decision SupportDSPADATACycle 1D: Implement thruout clinic andmonitor the impact.DSPAAPSDCycle 1C: Test with all patients for a full week, document feedback and time required.APSDCycle 1B: Debrief staff; did it help, how long did it take? Test with Dr. Strange’s patients for a full week.Use of flowsheet will improve care to known standardsCycle 1A: On Mon., prescreen Fred’s Tues. pts, mark appointment sheet for those who are due for paps.
39Smaller Scale Tests: Scale Down Timeframe YearsQuartersMonthsWeeksDaysHoursMinutesReduce your timeframe to plan Test Cycle!When you’re in your meeting, listen for a time frame. Move down two levels to do a test. This formula helps people rethink the time frame.If you hear quarters…Ask what test can we do by the end of next week?If you hear weeks, what can do in the next hours. You won’t get the change all tested but gets people moving.
40Analysis Tools: Flowcharts Flowchart is picture of any process,Flowcharts help visualize processEasier to understand and easier to improve.Identifies potential sources of problems and solutions
41FLOWCHART Flowchart symbols Oval: shows beginning or ending step in a processRectangle depicts particular step or taskArrow: shows direction of process flowDiamond: indicates a decision point
42FLOWCHART EXAMPLE NO Patient arrives at front desk Receptionist asks for patient’s name & searches database for his/her fileReceptionist asks patientto complete paperwork for new clientsand return it to front deskPatient in system?NOYESAsk patient to be seated in theWaiting roomETC.Medical assistanttakes patient intoexam room
43CAUSE-AND-EFFECT DIAGRAM Used to map variables that may influence a problem, outcome, or effectAlso called:Ishikawa diagramFishbone diagram
44CAUSE-AND-EFFECT DIAGRAM CAUSES The four M’sMethods, Materials, Machines, ManpowerThe four P’sPlace, Procedures, Policies, PeopleThe four S’sSurroundings, Suppliers, Systems, Skills
48Why Measure?Separates what you think is happening from what is really happeningEstablishes a baselineHelps to avoid putting ineffective solutions in placeTo monitor improvements and prevent slippage
49What is a good indicator? Relevance. Does the indicator relate to a condition that occurs frequently or have a great impact on the patients at your facility?Measurability. Can the indicator realistically and efficiently be measured given the facility’s finite resources?Accuracy. Is the indicator based on accepted guidelines or developed through formal group-decision making methods?Improvability. Can the performance rate associated with the indicator realistically be improved given the limitations of your clinical services and patient population?