1. Quality Healthcare for Everyone
Albany Area Primary Health Care, Inc. Quality Department
Presenter: Joycelyn W. Yates, Chief Quality Officer

2. Overview QA Vs. QC Steps in Improving Processes Six Sigma (Quality)
PDSA
Key Functions of Quality Management within AAPHC
Continuous Improvement
Review and Summary

3. QA vs. QC: seeing the big picture
These are not new processes, and certainly not mine. These process improvement systems have been around for decades in manufacturing.
This presentation is a combining of these systems into the standpoint of ERM.

4. How we worked on improving processes
Key Performance Indicators (UDS Measures/ HEDIS)
Patient Satisfaction Surveys
Documentation of processes and work flows
Training
Employee Satisfaction Surveys
Follow up
Negotiate change
Create a plan to improve processes
Policies, practices and procedures commit the organization to implementing and performing consistently.

5. Identifying & Controlling
Risks

6. Six Sigma (Quality) Six Sigma focuses on: LEAN focuses on:
Identifying & removing the causes of defects (errors)
Minimizing variability of processes (Ensure consistency & predictability)
Defect/error metrics
LEAN focuses on:
Background - Started by Henry Ford in early 1900’s - Improved by Toyota in 1930’s – Continually improving ever since…
“Value Add” and “Non-Value Add” task steps
Operational “waste”
Optimizing processes
AAPHC Goals:
Identify, track, & trend defect (errors) metrics
Review metrics for cause & effect trends
Conduct PDSA cycles to evaluate root cause and improve process

7. Keeps Project On Target
Who owns the QI Process?
Quality Officer
Keeps Project On Target
Considers All Risk
Control Ideas
Owns Project Success
Removes Obstacles
Addresses Problems
Head On
Or Failure

8. Sustain & Continually Improve
Track & review metrics
Audit checks and balances
Report metrics to stakeholders
Re-evaluate if metrics are off.
Implement solutions
Work Flow process
Create checks and balances
PLAN DO
STUDY
ACT

9. Key Aspects & Functions of Quality Management within AAPHC
Quality Planning
Credentialing
Peer Review
Privileging
Compliance
Safety
Risk Management
Policies & Procedures
Medical Record
Clinical Protocols
Tracking Systems
Trend identification that impact systems and processes
So in terms of ERR, what does efficiency mean?

10. AAPHC Continuous Improvement

12. PDSA Cycle Colon Cancer
Monthly reports were run to verify accuracy.
Errors found were:
DI not marked correctly in ECW system
Incomplete reporting of test results
Evaluation during 4 month period in 2016
Daily/Intervention Reports
3 population managers hired to help find errors in systems
Correct way to document was
confirmed
Increase % of Colon Cancer Screening rate
Accurate reporting within ECW System
Establish Universe reporting
PLAN DO
STUDY
ACT

13. Where are we now?
We have improved our Colorectal Cancer Scrn. Score to 60.79% ( Compared to UDS National 39.90%; UDS State 30.60%; AAPHC %)
We have 3 projects in various stages of the process
* Initiative to Increase Pneumococcal Vaccination Rates in Rural GA
* CDC Georgia Breast & Cervical Cancer Program
* CDC Cancer Transformation Project
We have 3 projects that are ongoing – Customer Satisfaction, Peer Review, Charting/Billing/Coding (Timely Locking of Chart)
QI Sub-Committee: Sub group with multidisciplinary team of providers, DON and CQO working together to delve further into trends and issues from QI Committee and develop work flow process to assist in improvement/training needs.
Efficiency is how fast you can get something done, right?
Partially. Time to complete a task is very prominent and visible so it is often the main thing looked at. In reality, your efficiency is your “cost per unit – with a unit being whatever your measure of value is. Your measure of value is usually what you would be tracking to justify success.

14. Be willing to implement change Effective Meetings
The Steps to Success:
Empower Employees
Be willing to implement change
Effective Meetings
Continuous Process Improvement
Efficiency is how fast you can get something done, right?
Partially. Time to complete a task is very prominent and visible so it is often the main thing looked at. In reality, your efficiency is your “cost per unit – with a unit being whatever your measure of value is. Your measure of value is usually what you would be tracking to justify success.

15. Thank You