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Implementing a Quality Improvement Plan Presented by Kathy Revell, RN MS NCAC II CPHQ and Roger A. Revell, MBA 2010 Kansas Addiction Summit II July 20, 2010 © 2010 REVELL INC. 1
The participants will know the basics of implementing a Quality Improvement(QI) Plan including: Reviewing the historical context of Quality Improvement Selecting staff to champion QI Selecting data sources to trend Establishing a facility/agency QI Committee Structuring a data analysis report (Aggregate Analysis) Understanding the process of moving from Quality Assurance compliance to Performance Improvement that measures outcomes 2 © 2010 REVELL INC.
Ѕ=α + ß(1-C) WHAT IS THIS? 3 © 2010 REVELL INC.
Ѕ=α + ß(1-C) Linear relationship between the rate of complaints (C) and the rate of satisfaction with services, S, is represented by this formula. In this formula, α and ß are constants calculated from the complaint and satisfaction rates of a large number of health care organizations. Empirical evidence supports the claim that complaints and satisfaction are related concepts. If you came here for math analysis, go get a cup of coffee now! 4 © 2010 REVELL INC.
QUALITY IMPROVEMENT IS THE PROCESS BY WHICH ORGANIZATIONS APPLY BEST PRACTICES OF CARE OPERATE EFFICIENTLY AND EFFECTIVELY OBTAIN BEST OUTCOMES FOR THEIR CLIENTS. Quality Improvement is defined as doing the right thing at the right time every time. 5 © 2010 REVELL INC.
Armand Feigenbaum: “ An effective system for integrating quality development, quality maintenance and quality improvement efforts of the various groups within an organization, so as to enable production and service at the most economical levels that allow full customer satisfaction”. 6 © 2010 REVELL INC.
Quality Improvement Two Domains Quality Assurance Performance Improvement ( Assure compliance to a standard) (Improve beyond the basic compliance such as improved processes) 7 © 2010 REVELL INC.
During the early days of manufacturing, the work of employee was inspected and a decision made whether to accept or reject it. This was QI focused to reduce $$$. In the 1920’s statistical theory began to be applied to quality control. In 1924, Shewhart made the first sketch of a chart to document and trend findings. In late 1940’s with its industries in ruins Japan became a “incubator of QI” with the help of some notable quality gurus – Juran, Deming and Feigenbaum. 8 © 2010 REVELL INC.
W. Edwards Deming while in Japan placed great importance and responsibility on management, at both the individual and company level, believing management to be responsible for 94% of quality problems. 9 © 2010 REVELL INC.
The quality revolution in the West was slow to follow, and did not begin until the early 1980’s, when companies introduced their own quality programs. In the 's American Western QI leaders, notably Philip Crosby and others, further extended the Quality Management concepts in the U.S. after the Japanese successes. 10 © 2010 REVELL INC.
This included the development and/or use of: Plan, Do, Check, Act (PDCA) cycle Pareto analysis 80/20 Cause and effect diagrams (Fishbone) Stratification Check-sheets Histograms Scatter-charts Process control chart Tolerance design ('Taguchi methodology) Quality Improvement Teams (QIT) Just In Time (JIT) manufacturing Management By Walking About (MBWA) 11 © 2010 REVELL INC.
The 80’s saw great strides applying Quality Improvement processes and concepts across all industries. FINALLY IT ARRIVES IN HEALTH CARE! QI in health care began with the Medicare Peer Review Organization (PRO) program in the mid 1980s. This was in response to concerns with medical necessity and quality of care of services delivered to the elderly and disabled, and paid for by the federal Medicare program. (C. Weinmann, 1998, Evaluations & the Health Professions Vol 21:4) © 2010 REVELL INC.
Today there are many types of QI processes including “SIX SIGMA” which is currently popular. Why "Sigma"? The word is a statistical term that measures how far a given process deviates from perfection. A six-sigma process is one in which % of the products manufactured are free of defects, compared to a one-sigma process in which only 31% are free of defects. Motorola (1981) set a goal of "six sigmas" for all of its manufacturing operations. The standards for Quality Improvement in health care nationwide (HEDIS) are set by the National Committee of Quality Assurance (NCQA). 13 © 2010 REVELL INC.
The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. (Access, Availability and Effectiveness) Over 70 measurements are all collected exactly the same way for all health plans including Commercial, Medicare and Medicaid. 14 © 2010 REVELL INC.
15 © 2010 REVELL INC.
16 © 2010 REVELL INC.
Initiation = Percentage of adolescents and adults aged 13 years and older diagnosed with AOD dependence and receiving a related service who initiate treatment Engagement = Assessment of the degree to which patients engage in treatment with two additional AOD treatments within 30 days after initiating treatment. 17 © 2010 REVELL INC.
QI is the responsibility of the CEO/Executive Director. The CEO is responsible to: Provide leadership for QI initiatives Ensure that resources are dedicated to QI Participate in the facility/agency QI committee Sponsor the recommendations of the QI committee It must permeate all levels of an organization and be supported and modeled by senior leadership. QI is about both Administrative and Clinical processes. QI can reduce administrative expenses by reducing re-work, work-arounds, and cost of responding to negative events. 18 © 2010 REVELL INC.
Employees are an Agency’s most valuable resource for successfully developing and growing the organization. All employees need to understand what the QI program is about and how it operates and fits into the Agency and it’s Mission. No quality management system works unless employees are committed and take responsibility for quality as a daily ongoing process. For it to be effective, quality concepts must become part of employees’ behavior and attitudes at all levels of the organization. 19 © 2010 REVELL INC.
“Key components of a positive patient safety climate include strong leadership, commitment to patient safety, open discussion of errors, and a habit of learning from mistakes.”(J.R. Reason, Human Error 1990) 20 © 2010 REVELL INC.
Regulatory guidelines/standards provide “minimum” measurement. An Agency having difficulty meeting the AAPS licensure standards most likely has QI issues/processes that need to be evaluated. Evidence-based practices help raise the bar above the minimum. SAMHSA’s National Registry of Evidence-based programs and practices has 164 mental health and substance abuse prevention and treatment Evidenced-based practices in the U.S. that you can view. 21 © 2010 REVELL INC.
22 © 2010 REVELL INC.
23 © 2010 REVELL INC.
Another Great Site The Treatment Improvement Exchange (TIE) is a resource sponsored by the Division of State and Community Assistance of the Center for Substance Abuse Treatment to provide information exchange between CSAT staff and State and local alcohol and substance abuse agencies. TIE is funded by the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. 24 © 2010 REVELL INC.
1) Be sure that CEO/Executive Director and the Governing Board are committed to “doing” QI well and “being” a QI driven organization. 2) The CEO/Executive Director has the responsibility to be the KEYSTONE for Agency QI. 3) In turn the Leaders and Managers set the direction for the front line staff to follow. They model that QI is very important and integral to the Agency. 4) Carefully choose a QI Lead/Manager who believes in QI and has the required attributes or potential for development. 25 © 2010 REVELL INC.
Be a linear thinker (“First, second, third, fourth, etc.”) with solid mathematical skills, and be able to SUSTAIN these skills. Demonstrate healthy curiosity (asks “Why?” frequently). Have analytical capacity. Data collection is only the first task of QI; analysis is essential. 26 © 2010 REVELL INC.
Be a good one-on-one communicator both verbal and written. Possess courage and persistence. Believe in the potential for both Administrative and Clinical QI to improve Agency outcomes, and reduce costs. _______________________________________________ The QI Lead/Manager is not the “QI COP” and is not responsible to give feedback to employees regarding non-compliance to QI processes. That responsibility remains with the employee’s direct supervisor. Avoid the counter-productive tendency to select an internal candidate who is your “least productive” clinician. An individual with the right basic QI potential can more easily learn what is required about the clinical arena than vice-versa. 27 © 2010 REVELL INC.
5) Ensure that the QI Lead/Manager has mentoring and opportunities to learn QI concepts and processes. 6) Form QA/PI Committee composed of members representing all Agency services. 7) Develop and approve the QA/PI Committee Charter that provides the Committee’s operational guidelines. 28 © 2010 REVELL INC.
Members of the QI Committee should have representation from all departments of the Agency including clinical, financial and operational representatives. Attendance becomes a job expectation. The role of QI Committee is to make recommendations on data presented and assign QI follow-up activities among themselves. Documentation includes written Agenda and formal MINUTES - crucial for follow through. 29 © 2010 REVELL INC.
8) Decide what data sets you are going to collect and from where. 9) Develop or decide what tools or forms you are going to use to collect data. 10) Develop, write and approve a QI Workplan once the data sets have been chosen. 30 © 2010 REVELL INC.
31 © 2010 REVELL INC.
11) Write specific Policies and Procedures that support the process and which can be used as accountability tools. 12) Internally “market” the Agency’s QI activities. Highlight QI activities on Employee bulletin boards. Post the QI Workplan. Be sure QI is part of all new employee orientation. Present/discuss data reports at staff meetings. Ask for input from staff. 32 © 2010 REVELL INC.
Information/Data that comes to the QI Committee includes but is not limited to: Data that has been analyzed and formally written into what is known as an Aggregate Analysis. Reports/outcomes of licensure visits Discussion of Serious Occurrences that need Committee input as to the potential root cause for each occurrence. Discussion of status of any CAPs the Agency is under with regulatory entities. Guest speakers on QI topics. 33 © 2010 REVELL INC.
Choose measurable data that you can collect and analyze over time. Must be able to be collected from the same source using the same method all year Some examples: Adverse Incidents, claims denials, client satisfaction, AMAs, number of admission, readmissions, ALOS, etc. Start with data you already are collecting. Document and maintain data in the same method and format across the Agency. Excel Access Create a form that all departments will be required to use, etc. 34 © 2010 REVELL INC.
We all get confused occasionally about the meanings of words. This is ever-so-true in the case of measurements. Let’s clear that up. Data refers to where we are gathering information from - the source documentation. Data are typically one- dimensional or single purpose. Data are often viewed as the lowest level of abstraction from which information and knowledge are derived. Examples: 21 families served 2,750 brochures distributed 31 AA meetings 980 clients admitted 35 © 2010 REVELL INC.
Measurement is the unit of “assigned value” that has the ability to show that there has been a change in data over time. What was true in one period (week, month, quarter, year, etc.) must be compared to what was true (for a corresponding event) in a later period using the “measurement” and the change in that measurement. Examples: 21.3% increase in admissions (Q1 to Q2) 5 % increase in private pay clients this quarter 11.2% reduction in expenses (April from March) 500 fewer brochures distributed in 2009 (over 2008) Note: percentages (%) and numerical brochure count (500) are the “assigned measurement values.” 36 © 2010 REVELL INC.
To capture measurement change requires a baseline to which another period is compared. Therefore, measurement change is at least two-dimensional (i.e., measurement of the activity and time). (Five family groups this month to six family groups next month. Thus, baseline is five family groups) Where no measurement change exits, gathering data in the first period (week, month, quarter, year, etc.) leads to a baseline, but there is no measurement change until data are available for a second period. 37 © 2010 REVELL INC.
Analyzing data refers to studying the measurement change for at least two time periods from the baseline to identify trending, interaction or cause and effect. One frequent mistake is not to gather and trend data for a sufficient time period before drawing a conclusion. The number (N = volume of the items/activities measured) is an important component of data validity. 38 © 2010 REVELL INC.
Validity = Does it measure what it is supposed to be measuring? Reliability = The extent to which a measurement gives consistent results. An example often used to illustrate the difference between reliability and validity in the experimental sciences involves a bathroom scale. If someone who is 200 pounds steps on a scale 10 times and gets readings of 15, 250, 95, 140, etc., the scale is not reliable. If the scale consistently reads "150", then it is reliable, but not valid. If it reads "200" each time, then the measurement is both reliable and valid. This is what is meant by the statement, "Reliability is necessary but not sufficient for validity." 39 © 2010 REVELL INC.
Adequate data analysis leads to questions regarding the data changes and potential factors contributing to these changes. What is the trend? What could be the cause(s) of this change? What needs to be done to reverse the trend, sustain the trend, or increase it? Interventions also called “Action Plans” are written plans created after the data are analyzed to plan interventions on the process(s) and facilitate favorable change. Interventions/Action Plans last for defined periods of time. The Action Plan includes a list of prioritized activities - what you are going to do, who is going to do it, and when each activity is to be completed. Evaluate the impact of the Action Plan. Did we get what we wanted? Was there a change in the data from impact of the intervention? Are there any surprises? What did we learn? 40 © 2010 REVELL INC.
A substance abuse treatment programs QI data showed that the majority of clients that left AMA where leaving on the weekends. The agency reviewed the charts of the clients for one quarter to see if there were any common trends. It was discovered that 75 % of them left on a shift that one particular counselor was on duty. It was the Agency’s policy to have a counselor talk to clients who were trying to leave. Upon further investigation it was found the counselor “believed” that if clients wanted to leave “Well, they have not hit bottom yet.” With focused in-service and assigned mentoring with another counselor, the rate dropped 30% for AMA’s in the next quarter when that counselor was on duty. WHAT BENEFITS CAME FROM THIS? 41 © 2010 REVELL INC.
42 © 2010 REVELL INC.
43 © 2010 REVELL INC.
44 © 2010 REVELL INC.
45 © 2010 REVELL INC.
46 © 2010 REVELL INC.
47 © 2010 REVELL INC.
48 © 2010 REVELL INC.
49 © 2010 REVELL INC.
50 © 2010 REVELL INC.
Focus on the client - we are here for them Secure leadership support Plan before you implement using the 12 steps in this handout Be process oriented Make business and clinical decisions that are driven by data FACTS ARE FRIENDLY! 51 © 2010 REVELL INC.
Thank you for your attention and best wishes in your QI journey Kathy Revell, RN MS NCAC II CPHQ Roger A. Revell, MBA REVELL, INC. 52 © 2010 REVELL INC.
© 2010 REVELL INC. 54
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