1. Quality Improvement 101 Varsha Nimbal, Program Associate San Francisco Community Clinic Consortium November 5, 2010

2. Overview What is Quality Improvement? Principles of QI – Systems and processes Tools for QI – Flowcharts – Problem analysis Model for Improvement

3. How the Institute of Medicine Defines Quality: Institute of Medicine. Medicare: A Strategy for Quality Assurance. Vol. 1. (1990) “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. ” Defining Quality

4. Quality Improvement v. Quality Assurance Quality Improvement Focus on change at system level Multi-disciplinary Continuous and ongoing effort Regular assessment and measurement Reduction of variability Build an infrastructure to address system level problems California Improvement Network Quality Assurance “The planned and systematic activities put in place to ensure (quality) requirements for a product or service will be fulfilled.” Ensure that requirements/guidelines met Employs inspection (versus regular measurement) Also known as quality control

5. What is a system? INPUTS PROCESSESOUTCOMES

6. Understanding Processes Processes are the object of our quality effort Improving quality means improving processes Flowcharts National Quality Center

7. A Picture is Worth a Thousand Words Tools for Understanding Processes National Quality Center

8. Flowcharts to Understand Processes A flowchart is a picture of the steps of a process to: – Understand the process – Identify potential sources of problems – Outline the ideal process steps – Enable communications with others Flowcharts National Quality Center

9. Is This an Efficient Process? Patient arrives at front desk Patient in system? Staff asks patient to provide information Staff asks name, searches data- base for file Staff asks patient to be seated Patient waits Nurse takes patient to exam room Yes No Flowcharts National Quality Center

10. For the most part, errors are not the fault of individuals. The lessons that have been learned from industry are that most quality problems can be traced to: 1.Flawed systems 2.Lack of proper training 3.Misaligned incentives Where do Quality Problems Originate?

11. Supported by the C ALIFORNIA H EALTH C ARE F OUNDATION Identify the problem – this could come from a quality dashboard, an audit report, or peer review process Identify causes of the problem – include multiple perspectives Carry out an improvement strategy Problem Analysis

12. Identify a Problem

14. Use a Fishbone Diagram to explore potential root causes of a public health problem Conduct a Root Cause Analysis Use a Fishbone Diagram to explore potential root causes of a public health problem

15. Fishbone Diagram Example

16. What is the biggest contributor to the problem? What happens most frequently? What can be changed? Identifying Causes to Solve

17. Key Question Now that we’ve identified an area we want to improve and set up a team to work on it, what do we do next? Model for Improvement National Quality Center (NQC)

18. PDSA – Rapid Cycle Improvement What changes are to be made? Next cycle? Act Objective Questions & predictions (why?) Plan to carry out the cycle Plan Check/StudyDo Carry out the plan Document problems and observations Begin data analysis Complete data analysis Compare data to predictions Summarize what was learned

19. Principle: “ Achieve Continual Improvement Through Small, Incremental Changes ” Quality Principles National Quality Center

20. 1. QI Leadership 2. Quality Plan 3. QI Committee 4. Ongoing QI Activities 5. QI Training at All Levels of Staff 6. Clinical Information Systems for Data- Driven QI Core Components of QI Program

21. QIC Trivia In 1601, it was known that lemon juice prevented the disease scurvy, a Vitamin C deficiency. What year did the British Navy adopt this proven treatment – 1609 – 1811 – 1796 – 1602 National Quality Center

22. Key Points QI = efforts made by organization that lead to better patient health outcomes and better systems Focus needs to be on improving processes Change is incremental Key Points

23. Varsha Nimbal, Program Associate San Francisco Community Clinic Consortium vnimbal@sfccc.org National Quality Center - http://nationalqualitycenter.org/