1. Continuous Quality Improvement (CQI)
Bethany Geldmaker PNP, PhD
Tracy Jebo MPH

2. Learning Objectives
Provide Infant Mental Health Advisory Board with foundational Continuous Quality Improvement knowledge and skills
Introduce the upcoming self-assessment survey

3. Performance Management and CQI
Two components:
Performance Management: Using data to improve performance
CQI (Continuous Quality Improvement): Involving all stakeholders to examine the performance of a process and address identified gaps
Performance Management and CQI are distinct processes. While some of the components may overlap, there are marked differences as well.

4. Four Parts of Performance Management
Performance Standards help agencies decide on the right path to take.
Performance Measures help agencies follow their path without getting off track.
Reporting of Progress helps agencies determine if they have made the right choices.
Quality Improvement helps agencies keep getting better.

5. Performance Standards
Objective standards or guidelines that are used to assess an organization's performance Identify relevant standards as described in your vision, mission, and strategic plan, and those supported by best practice policies . Select indicators of performance that align with each standard that can be tracked over time. Set targets for the performance of your agency related to each indicator. Communicate expectations for performance.
In the example to follow, we will be using an example based on weight loss.

6. Weight Loss Example
Performance Standards: Looking to the Body Mass Index chart for an ideal weight range (standards), and looking to lose two pounds per week (target) are based on standard recommendations for weight and weight loss.

7. Performance Measures
Defining measures for each standard so you know what data you need. Measures need to be clearly and logically related to each standard, feasible to collect over time, within your scope of influence and consistent (ECMH Data Indicators)
(e.g. % of live births that were preterm in 2013)
Developing data systems to make sure data are collected routinely and stored appropriately, and
Collecting data on a regular and ongoing basis.

8. Weight Loss Example
Performance Standards: Looking to the Body Mass Index chart for an ideal weight range , and looking to lose two pounds per week are based on standard recommendations for weight and weight loss.
Performance Measures: Recording (collecting data) weight, calories, and physical activity (defined measures) in a spreadsheet (data system) on a set schedule allows you to look at relevant data over time.

9. Reporting Progress Analyze data and compare with their target
Communicate results broadly to all stakeholders
Provide context and be targeted to the audience
Be routine – reports should be produced on a schedule to help ensure that results are utilized
Be created in a way that is straightforward, easy to produce, and easy to understand, and
Creates a system that is transparent, which helps drive monitoring and improvement.

10. Weight Loss Example
Performance Standards: Looking to the Body Mass Index chart for an ideal weight range, and looking to lose two pounds per week are based on standard recommendations for weight and weight loss.
Performance Measures: Recording weight, calories, and physical activity in a spreadsheet on a set schedule allows you to look at relevant data over time.
Reporting of Progress: Examining (analyzing) the data on a set schedule (routine) allows you to monitor the data and observe trends.

11. Quality Improvement
Uses data on how you are performing to drive activities which lead to true improvement.
Utilizes stakeholders to address identified gaps continually improve processes
Addresses the question: How do we get better?

12. Weight Loss Example
Performance Standards: Looking to the Body Mass Index chart for an ideal weight range and looking to lose two pounds per week are based on standard recommendations for weight and weight loss.
Performance Measures: Recording weight, calories, and physical activity a spreadsheet on a set schedule allows you to look at relevant data over time.
Reporting of Progress: Examining the data on a set schedule allows you to monitor the data and observe trends.
Quality Improvement: When the data showed (using data) that the targeted weight loss of two pounds per week wasn’t met, adding additional physical activity (improving process) was tested as an improvement strategy.

13. Performance Management, Evaluation, and Continuous Quality Improvement (CQI)
Determines current performance in relation to standards of performance
Determines whether your program is doing what it is intended to do
Determines whether adjustments to a process are improvements
Examines performance data and progress towards performance goals
Determines whether the effect is worth the resources needed to implement the program
Uses staff expertise to improve the processes by which the program is implemented
Occurs continuously
Occurs starting at program onset, continuing through program completion
Occurs at specific points in time when an improvement opportunity is identified
Examines performance across the organization
Examines the performance of a specific program
Examines the performance of a process
Conducted by all staff across the organization
Conducted by an outside, objective evaluator
Conducted by program/ process stakeholders
Identifies gaps between performance and standards
Identifies gaps between activities and goals
Addresses identified gaps

14. CQI: Four Principles
Continuous Quality Improvement is guided by four principles:
Focus on the individuals being served (in our case, individuals attending professional development trainings)
Continually improve all processes
Involve stakeholders (ECMHAB)
Mobilize both data and team knowledge to improve decision-making

15. CQI Process
The three key questions to keep front and center during all CQI work are:
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will results in improvement?
These questions can be addressed through the use of a deliberate and defined improvement process, such as the Plan-Do-Study-Act Cycle
In our weight loss example, CQI is looking analytically at the process to achieve weight loss. Performance Management is tracking performance.

16. PDSA Cycle
The PDSA cycle is used to improve existing processes, not to plan or implement new programs
Always relies on data to support its decisions
Both the DSS and ECCS grant are focusing on professional development. By using CQI, we can systematically look at how our professional development activities impact participants

17. PDSA Cycle: Nine Steps Plan-Do-Study-Act Cycle (Steps 1-5)
Step 1: Identifying a problem
Step 2: Assembling a CQI team that can address the problem (ECMHAB)
Step 3: Identify what the true cause(s) of the problem may be, map the process to understand the existing activities that lead to the problematic issue
Step 4: Brainstorming and conducting background research to look for possible solutions
Step 5: Working to develop a theory of improvement that can be tested
With the Board’s help and guidance, we will be conducting a survey (introduced later) that will look at areas in our implementation that may benefit from a closer look/improvement process.

18. What is a Process Map?
A process is a series of steps or actions performed to achieve a specific purpose.
Process map = Visual representation of steps in a process.
Describes the way things get done.

19. Process Mapping: Cooking Eggs
Write a narrative first of process (AS IT IS, NOT AS YOU WISH IT WAS). Then, using sticky notes, start to map out how the steps follow one another and flow. Think the process through step by step. There are specific symbols used in process mapping. Add dates/times where you can. Add in data points where available.
After you have the map completed, test the map using different scenarios to see if there are any breaks. You may find some examples of situations where the current system doesn’t work or where steps do not logically flow together. You may be able to identify duplicative effort or needless steps.

20. Plan-Do-Study-Act (Step 6)
Step 6: Test your theory of improvement
Implement a small-scale test of the change to your process.
Collect, chart, and display data to determine the effectiveness of the improvement.
Document problems, unexpected observations, and unintended side effects, because these occurrences will aid in the learning process.

21. Plan-Do-Study-Act (Step 7)
Step 7: Study the Results of your Test
Use data to determine if the test of your theory was successful
Compare the results of your test to the baseline data
Some questions to consider include:
Did your test work? What do the data show?
Did the results match your theory/prediction?
Are there trends in your data?
Did you have unintended side effects?
Is there improvement?
Do you need to test the improvement under other conditions?

22. Plan-Do-Study-Act (Steps 8 and 9)
Step 8: Either standardize your improvement (if test was successful) or develop a new theory for improvement (if test was unsuccessful)
Step 9: Establish Future Plans
Sustaining change or beginning PDSA again

23. The Self-Assessment Survey
The survey will be used to assess important components of the grant’s professional development activities:
Understanding consumer and capacity
Focus on providing high quality professional development
Using CQI principles and processes to optimize activities
Using data to drive decision making
The results of the survey will be used to identify potential areas that could benefit from a PDSA cycle