Presentation on theme: "Aug 26, 2008 Clemens Steinbock, MBA Director, National Quality Center"— Presentation transcript:
1 Aug 26, 2008 Clemens Steinbock, MBA Director, National Quality Center Quality Institute Session 1What is Quality Improvement? What are the Quality Expectations from HAB?Aug 26, 2008Clemens Steinbock, MBADirector, National Quality Center
2 Agenda - Opening Remarks - Overview and Introduction - Quiz – Group Activity- Principles of Quality Improvement- Scenario – Group Activity- HAB Expectations on Quality- QI Resources- Evaluations and Wrap-up
3 “How can you make this topic entertaining and keep everyone from falling asleep?”
8 1) What does CQI stand for? Community Quality InitiativeCase Management Quality IdeasContinuous Quality ImprovementCircular Quantum Invention
9 2) Why does Quality Improvement become increasingly important in health care? Quality Improvement has been proven to be successfulIncreasing requirements by regulatory agenciesIncreasing accountability by programs for the quality of servicesAll of the above
10 3) What is the main difference between Quality Assurance and Quality Improvement? Quality Assurance uses mainly a team approachQuality Improvement focuses on statistical outliers for improvementsQuality Assurance and Quality Improvement is practically the sameNone of the above
11 4) What is the most important principle for Quality Improvement 4) What is the most important principle for Quality Improvement? Quality Improvement focuses on…Individual performersRoutine measurement of performanceTraining of providersSystem’s issues
12 5) Which of the following statement by HAB is INCORRECT? QM programs need to look beyond clinical services to consider both supportive services and outcomesQM programs assess the extent to which HIV health services are consistent with the most recent Public Health Service guidelinesThe primary focus of the QM program is on performance measurement to assess clinical and non-clinical servicesQuality is the degree to which a health or social support service meets or exceeds established professional standards and user expectations
13 6) HAB describes the following characteristics of Quality Management Programs. Which ones are CORRECT?Be a systematic process with identified leadership, accountability and dedicated resourcesUse data and measurable outcomes to determine progress toward relevant, evidenced-based benchmarksFocus on linkages, efficiencies and client expectations in addressing outcome improvementEnsure that data are fed back into the quality improvement process to assure that goals are accomplishedAll of the aboveNone of the above
14 7) The following performance data report is presented: PPD 95%, GYN 85%, and PCP Prophylaxis 55%. You advise the program to continue to measure…only PCP ProphylaxisGYN and PCP ProphylaxisAll three indicators
15 8) The results of an adherence QI project are presented after 10 months of work, improving the rate to 98% and it was kept between 95%-100% for the last 4 months. You advise the program to…Discontinue routine measurementsSwitch to quarterly measurementsKeep monthly measurements
16 9) Due to the high rate of Mental Health screening (95%), the QI team stopped meeting but continued to measure the rate monthly. Recently the score declined. When should the MH QI team to re-start?90%80%70%
18 What is your professional background? Clinical Provider (MD, NP, PA)NurseCase Manager/Social WorkerAdministratorOther10
19 How do you rate your own quality improvement knowledge? NoviceBeginnerIntermediateProficientExpert10
20 How do you rate your HIV Quality Management Program? Not existingBeginningSufficientGoodExcellent10
21 Quality Improvement Principles Clemens Steinbock, MBANationalQualityCenter.org86,408 PLWA – reported in the 8 statesAt least 43,000 PLHIV – estimatedTOTAL POTENTIAL IMPACT:IMPROVING THE QUALITY OF CARE FOR 129,000 PLHIV/AIDS -- >10% of PLHIV/AIDS in United States
22 Success is achieved through meeting the needs of those we serve.
23 Most problems are found in processes, not in people.
24 Do not reinvent the wheel – Learn from best practices.
25 Learn through small, incremental changes to achieve continual improvements.
26 Actions are based upon accurate and measured data.
27 Infrastructure enhances systematic implementation of improvement activities.
29 Balance between Data Collection and Quality Improvement Activities Infrastructure
30 ‘QI is not QA’ Motivation Means Focus Responsibility Quality Assurance Quality ImprovementMotivationMeasuring compliance with standardsContinuously improving processes to meet standardsMeansInspectionPreventionFocusIndividuals, “bad apples”Processes and SystemsResponsibilityFewAll
31 Three Faces of Quality Improvement AspectImprovementAccountability(Accreditation)ClinicalResearchAimImprovement of careComparison, choice, reassurance, spur for changeNew knowledgeTest observabilityTest observableNo test, evaluate current performanceTest blindedSample size“Just enough” data, small sequential samplesObtain 100% of available, relevant, data“Just in case” dataTesting strategySequential testsNo testsOne large testSolberg, Mosser, and McDonald, Journal on Quality Improvement. March 1997, Vol.23, No. 3.
32 HAB’s Working Definition of Quality “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”Institute of Medicine. Medicare: A Strategy for Quality Assurance. Vol. 1. (1990)
33 In 1601, James Lancaster successfully conducted an experiment to illustrate the effectiveness of lemon juice to prevent scurvy. When did the British Navy adopt this treatment?16021689175717961865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later
34 Treatment of ScurvyStephen J. Bown - Scurvy: How a Surgeon, a Mariner, and a Gentleman Solved the Greatest Medical Mystery of the Age of Sail; St. Martin's Press, 2004In 1601 lemon juice, as a protective against scurvy, is recorded by James Lancaster.In 1612, Woodall recommended citrus fruit for protection against scurvy on sea voyages.In 1753 James Lind published A Treatise on the Scurvy which portrays his experiment on-board the ship Salisbury in 1747.From 1772 to 1775 sailors on historic voyages with Captain James Cook remained free from scurvy.In 1796 lemon juice was officially introduced in the British Navy as a prophylactic against scurvy.In 1865 British Board of Trade adopted the policy for the merchant marine.
35 How long did the NIH take to recommend the treatment of ulcer as suggested by Dr. Marshall in his 1984 Lancet Article?2 years5 years10 years20 years1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later
36 Treatment of Ulcer – Marshall Timetable:1979: Dr. Robin Warren, pathologist at Royal Perth Hospital, Australia found bacteria in stomach of patients1981: Dr. Barry Marshall starts residency1982: Marshall cultivates bacteria: Helicobacter pylori, 100% in Duodenal Ulcer and 77% in Gastric Ulcer1984: first publication in Lancet; presents treatment of ulcer with common antibioticum1994: National Institute of Health recommends treatment of ulcer as suggested by Dr. MarshallConclusio:Too long to adapt proven concept - how can we adapt existing knowledge faster in daily actvitiesNew ideas come from outsiders‘Early Adopter’ Diffusion of Innovation Everett RogersB) Neugeborenenstation in Honulu, Hawaii hat jährlich $120,000 Dollar für Schutzmasken, Plastik Handschuhe usw. ausgegeben. Nach 13 Studien wurde dort eine 14. Studie durchgeführt mit dem selben Ergebnis: es gibt keinen messbaren Unterschied der Ansteckungsrate zwischen der Vergabe von Schutzkleidern an Besuchern und der Nichtvergabe.C) CQI Team: billinf Team, six months still trying to find causes, did not start to change things around.HAND OUTS
37 In a recent article in the Journal of Quality Improvement 92 QI projects were compared. What was the timeframe from problem identification to completion of first pilot?23 days60 days397 days504 days1865 British Board of Trade adopted the policy for all ships in the merchant marine – 264 Years later
38 Survey of 92 Quality Improvement Projects in Journal of Quality Improvement Alemi F, Safaie F, Neuhauser D. “A Survey of 92 Quality Improvement Projects.” Journal of Quality Improvement 2001, 27(11):504 days from problem identification to completion of first pilot397 days from first team meeting to the end of first cycle75 days to describe current situation in flowchart62 days for data collection if change was improvement
39 How can we accelerate change and improvements in HIV programs? Model for ImprovementHow can we accelerate change and improvements in HIV programs?
40 Model 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
41 What 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 ..
42 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 ….
43 What change can we make that will result in 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?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..
44 The PDSA cycle for learning and improvement ActPlanObjectiveQuestions andpredictions (why)Plan to carry out the cycle(who, what, where, when)What changesare to be made?Next cycle?StudyDoComplete theanalysis of the dataCompare data topredictionsSummarize whatwas learnedCarry out the planDocument problemsand unexpectedobservationsBegin analysis ofthe data
45 PDSA Cycle to incorporate the use of a new CM form Improve Access to HIV Primary CareDSPADATAAPSDCycle 1E: Implement andmonitor the standardsDSPACycle 1D: Revise and test toolwith all clients for one weekAPSDCycle 1C: Present refined tool to all 3case managers and document feedbackAPSDIntroduce new CM Intake/ Assessment FormCycle 1B: Revise tool and test with Karl’sclients next MondayCycle 1A: Adapt new CM form and test with one of Joanne’s patients
46 Tips for PDSA Cycles“What change could you implement by next Tuesday?”Use the “Rule of 1”:1 facility1 office1 provider1 patientWe’ve learned:Keep the first test small. Remember Dr. Smith and her 35-minute screening tool. Give yourself a chance to even to fail in this first test. Sometimes you learn the most from trying something that really doesn’t work. A common question to those starting their first PDSA cycle is: what change can you implement by next Tuesday? This question forces you to think small by reducing the sample size (‘just a few records’) and decreasing the implementation timetable (‘within a few days’) to a minimum.One way to help you and your colleagues “keep it small” is to remember the Rule of 1. Design the first test for one facility, one office, one provider or one patient. See what happens, act on that knowledge, and then scale-up the test.
47 Useful, not perfect, data Use “huddles” to report Tips for PDSA CyclesVolunteers at firstUseful, not perfect, dataUse “huddles” to reportLearn from others (‘Steal shamelessly, Share senselessly’)Here are three more important pointers for success:Start out with your friends. Don’t try to convince the skeptics until you have proof. To get the proof, use volunteers – people who are interested in doing things differently.This isn’t a randomized clinical trial. It’s a test. You don’t need double-blind data, you need information about how to make things work. Whether Dr. Smith’s test took 34.3 minutes or minutes doesn’t matter. The point is that it took about 35 minutes, and that was way too long.Scheduling a formal meeting will take at least a week – pretty silly to do that to discuss the results of a one-day test. Grab people when you can, share information as it comes up. Dr. Smith could find Sally after the patient visit on Thursday morning and say, “Sally, that tool took 35 minutes, this will never work.” Sally might say, “Wow, you’re right. Joan and I found other tools, let me get her and we’ll come up with some others that might be better to try next.”The important thing is to keep moving forward, because…
48 ReferencesMoen, Ronald, Thomas Nolan; “Process Improvement” Quality Progress, 1987, p62Langley, Gerald, Kevin Nolan and Thomas Nolan; “The Foundation of Improvement,” Quality Progress, June 1994, p. 81Langley, Gerald, Kevin Nolan, Thomas Nolan, Cliff Norman, and Lloyd Provost; “The Improvement Guide” San Francisco, CA; Jossey-Bass, 1996Nolan, Kevin; “ASQs Accelerating Change Collaborative Series: A Challenge for Industry,” Quality Progress, Jan 1999, p55
49 HRSA’s 9-Step Model to Quality Goal of Manual:provide the tools to develop and implement a quality management programoutline a step-by-step process that can be applied in any care settingapplicable for both the experienced and non-experienced granteeDeveloped by HIV/AIDS Bureau Quality Institute
50 HRSA’s 9-Step Model to Quality Commit Leadership & Supportive Organizational StructureEstablish support of program leadership for Quality ManagementDelineate specific QM responsibilities of staffEstablish Quality Management PlanEstablish Quality Committee to oversee the QM programDevelop an organizational QM plan which delineates goals and objectives for the QM programDetermine Performance Measures & Collect DataBased on QM priorities, develop/adopt indicators to measure performanceDetermine method of data collection and collect data
51 HRSA’s 9-Step Model to Quality Analyze DataAnalyze data and review the resultsIdentify areas where additional data is requiredDevelop Project-Specific CQI PlanEstablish project-specific QM team to improve specific aspects of care/servicesDevelop timeline for reporting findings and improvementStudy and Understand the ProcessUtilize QI tools and techniques to understand the processReport progress to senior leadership and staff
52 HRSA’s 9-Step Model to Quality Develop and Implement an Improvement PlanIdentify potential solutions to make improvement to the systems of care.Try a small test of change and analyze results.Re-measurementRe-measure indicator after change has been implemented.Determine need for and/or level of re-measurement on an ongoing basis.Celebrate SuccessCommunicate results of the project to all levels of the organizationCongratulate team in public forum
53 ReferencesHAB Quality Management Manual, HRSA HIV/AIDS Bureau website; hab.hrsa.gov/tools/QM
54 Scenario – Group Exercise Clemens Steinbock, MBANationalQualityCenter.org86,408 PLWA – reported in the 8 statesAt least 43,000 PLHIV – estimatedTOTAL POTENTIAL IMPACT:IMPROVING THE QUALITY OF CARE FOR 129,000 PLHIV/AIDS -- >10% of PLHIV/AIDS in United States
55 HAB Quality Expectations Clemens Steinbock, MBANationalQualityCenter.org86,408 PLWA – reported in the 8 statesAt least 43,000 PLHIV – estimatedTOTAL POTENTIAL IMPACT:IMPROVING THE QUALITY OF CARE FOR 129,000 PLHIV/AIDS -- >10% of PLHIV/AIDS in United States
56 Update: Ryan White HIV/AIDS Treatment Modernization Act of 2006 – PL 109-415 Reauthorized for which sunsets 9/30/09Increased focus on living HIV and AIDS cases over the last calendar yearIncreased focus on expenditures for core medical servicesIncreased focus on coordination and integration of care and prevention at federal, state and local levelsSignificant changes include: Part A eligibility definition, funding formulas, hold harmless percentages, annual sample audits, biannual reports to congress on funds expended, consequences for failure to complySee a Side-by-side comparison at
57 Ryan White HIV/AIDS Treatment Modernization Act of 2006 “The chief elected official/ grantee… shall provide for the establishment of a clinical quality management program to assess the extent to which HIV health services provided to patients under the grant are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infection, and as applicable, to develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV health services”
58 Ryan White HIV/AIDS Treatment Modernization Act of 2006 “RWCA grantees are directed to establish clinical quality management programs to …”“assess the extent to which HIV health services are consistent with the most recent Public Health Service (PHS) guidelines…”“develop strategies for ensuring that such services are consistent with the guidelines for improvement in access to and quality of HIV health services”
59 Ryan White HIV/AIDS Treatment Modernization Act of 2006 “RWCA grantees are directed to establish clinical quality management programs..” which include:Development of a comprehensive clinical quality management infrastructure, including routine QM meetings with cross-functional representationDescription of QM program in a written quality plan, with a clear indication of responsibilities and responsible partiesInclusion and involvement of key stakeholders in your quality programDesignated leaders for quality improvement and accountability
60 Ryan White HIV/AIDS Treatment Modernization Act of 2006 “assess the extent to which HIV health services are consistent with the most recent Public Health Service (PHS) guidelines…” which includes:Development and/or adaptation of quality indicators for key clinical and service categoriesRoutine performance measurement of key care aspectsSharing of performance data with program staffUse of data to improve the organization’s performance on key services
61 Ryan White HIV/AIDS Treatment Modernization Act of 2006 “develop strategies for ensuring that such services are consistent with the guidelines for improvement in access to and quality of HIV service…” that include:Linking performance data results to quality improvement activitiesEstablishment of quality improvement teams with cross-functional representationIntegration of changes into routine program activities
62 Key Characteristics of a Quality Management Program Patient-centeredness is a fundamental focus of quality care and undergirds the 5 characteristics that follow.1. A systematic process with identified leadership, accountability, and dedicated resources available to the program2. Use data and measurable outcomes to determine progress toward relevant, evidenced-based benchmarks3. Focus on linkages, efficiencies and provider, and client expectation in addressing outcome improvement
63 Key Characteristics of a Quality Management Program (cont.) 4. A continuous process that is adaptive to change and that fits within the framework of other programmatic quality assurance and quality improvement activities5. Ensure that data collected are fed back into the quality improvement process to assure that goals are accomplished and that they are concurrent with improved outcomes
64 Quality Improvement Resources: Websites, Publications, Technical Assistance 86,408 PLWA – reported in the 8 statesAt least 43,000 PLHIV – estimatedTOTAL POTENTIAL IMPACT:IMPROVING THE QUALITY OF CARE FOR 129,000 PLHIV/AIDS -- >10% of PLHIV/AIDS in United States
65 Quality Improvement Websites NationalQualityCenter.orgHIV measuresChange ideasBest practicesTools/resourcesLiteratureFAQEach of these organizations has a web site, which we recommend you explore.First, NQC’s web site is at nationalqualitycenter.org. This web site is designed to provide cutting-edge information on measures of quality in HIV care, ideas for changes that will result in improvement, best practices in providing HIV care and services, tools and other resources to strengthen quality management programs and quality improvement work, recent literature and answers to frequently asked questions. More than 170 different tools are currently posted on the website.The NQC website contains links to the other sites mentioned in this Tutorial, so don’t worry if you don’t catch all the names.
66 Quality Improvement Websites HIV QI publicationsMeasuresHIVQUAL ProjectClinical guidelinesRecent news and eventsThe National HIVQUAL Project’s website is atManaged in concert with Johns Hopkins University, the website provides access to a wide range of publications about HIV care and quality improvement, information about measures of quality for HIV care, and more details about the HIVQUAL Project and how to become involved. The site also details clinical practice guidelines and links to articles about recent developments in the clinical care of people with HIV and AIDS.
67 Websites for Quality Improvement hab.hrsa.govHRSA QI expectationsQI ToolsTA Resources
68 QI Learning Resources Starting to Learn about Quality Improvement Measuring Quality of HIV Care MeasurementSetting up a QM InfrastructureWriting a Quality Management PlanConducting Quality Improvement Activities
70 Consumer Involvement Training Materials Soliciting Patient FeedbackEmpowering Patients to Partner with their Health Care ProvidersMaintaining a Patient Health RecordBest Practices for Consumer InvolvementTeaching Providers about Patient Self-Management
71 Quality Academy (Online Training Course) Online quality improvement training course – at no cost available 24/7 (also available on CD-Rom)Interactivity through test questions and online exercises20 QI topics from beginner (e.g., QI 101, PDSA) to advanced levels (e.g., dealing with resistance)NationalQualityCenter.org/QualityAcademy
72 Quality Improvement Publications There are many publications available to help your organization in its quality improvement work.“Measuring Clinical Performance: A Guide for HIV Health Care Providers” is a publication we will mention often during The Quality Academy. The New York State Department of Health AIDS Institute developed this guide that includes a step-by-step process for measuring clinical performance with the goal of improving quality of care. This guide, and other quality improvement resources can be downloaded when clicking on the documents on your screen.A second, valuable New York State Department of Health AIDS Institute publication is “Patient Satisfaction Survey for HIV Ambulatory Care.” Patient satisfaction is an important element of the quality of care, but good surveys are difficult to develop. This is believed to be the first HIV-specific validated satisfaction survey with 5 modules, including case management, women’s health, substance use, etc. This tool is also available in Spanish.
73 Quality Improvement Publications On your left you see the HIVQUAL Workbook, a comprehensive guide to quality improvement in HIV care developed in the 8 years of the HIVQUAL Project’s work. The guide covers both organizational infrastructure and specific quality activities, with many practical examples, tips, and tools for success. If you want to learn more about quality improvement in HIV care, study this detailed book and its chapters.On the right is a screenshot of the HIVQUAL data collection software, called HIVQUAL3. This software gives HIV programs and services an easy way to collect data on performance on the HIVQUAL quality-of-care indicators and to submit reports to the HIVQUAL staff to be aggregated into national program reports. It also includes adult, pediatric and case management indicators. While it is quite useful, please be reminded that it is not an electronic medical record.
74 Quality Improvement Publications Here are two resources for those who are training others on the topic of quality improvement in HIV care.The HIVQUAL Project’s Group Learning Guide contains instructions for 23 interactive exercises that teach the key points of quality improvement, gleaned from workshops held with HIV providers in the HIVQUAL Project. The Group Learning Guide includes facilitator notes, interactive group exercises, presentation slides and answer keys.The NQC Game Guide contains 20 creative, engaging and interactive exercises that teach the key principles of quality improvement in HIV care. Use these exercises to help create enthusiasm for quality improvement work in your organization. The Guide includes facilitator notes and practical tips on how to apply “lessons learned” in HIV care.
75 Quality Improvement Publications As we’ve mentioned in other Tutorials, it is vitally important to also involve consumers in your quality improvement work. Here are two resources for empowering consumers and involving them in quality improvement activities.On the left, you see “Making Sure Your HIV Care is the Best it Can Be,” a guide for facilitators to train consumers in how to understand HIV clinical care performance data and more importantly how consumers can become empowered to partner with health care providers.And on your right, ‘A Guide to Consumer Involvement’ details strategies and practices how to best solicit consumer feedback and involve consumers in quality improvement related activities. The Guide also includes lessons learned how to best identify and overcome barriers to consumer involvement.
76 Quality Improvement Publications As we’ve mentioned in other Tutorials, it is vitally important to also involve consumers in your quality improvement work. Here are two resources for empowering consumers and involving them in quality improvement activities.On the left, you see “Making Sure Your HIV Care is the Best it Can Be,” a guide for facilitators to train consumers in how to understand HIV clinical care performance data and more importantly how consumers can become empowered to partner with health care providers.And on your right, ‘A Guide to Consumer Involvement’ details strategies and practices how to best solicit consumer feedback and involve consumers in quality improvement related activities. The Guide also includes lessons learned how to best identify and overcome barriers to consumer involvement.
82 HIVQUAL Indicators – Case Management Complete psychosocial assessmentPatient Knowledge ScreeningTreatment Adherence AssessmentService Care Plan & Coordination of CareAccess and ContinuitySelf-Management: Client Participation in Care Planning
83 Technical Assistance Resources National Quality Center (NQC)NYSDOH AIDS Institute90 Church Street—13th FloorNew York, NY888-NQC-QI-TA
84 Technical Assistance Resources National HIVQUAL ProjectNYSDOH AIDS Institute90 Church Street—13th FloorNew York, NY