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QUALITY IMPROVEMENTWorking with your QI TeamValerie J. Vesich, RHIT, CTR
Onco, Inc.
Overall How QI Program is managedDefinitions, elementsStructure - ProcessesInitiation, Planning, Execution,
ClosureTribute to Those Studies that
Failed
BACKGROUND & SIGNIFICANCE
Efforts to EnsureQATQMQICQIQMPI
WHAT IS QUALITY – HEALTHCARE?
Requires Inspection***Tracking changes in
measures over time with Benchmarks
DocumentationJudgmentImprovement of Clinical
Performance
AN EFFECTIVE QUALITY QI TEAM & MANAGEMENT PROGRAM
Effective
Accountable
Responsible
WHY??
DEVELOP A QI PLAN
How are your qi project selected, managed and monitored
How are your staff trained in qi What methodology- six sigma, psda Describe your communication plan, updates,
who/when etc Description of measurement/analysis- How will your studies be evaluated
ELEMENTS OF A QUALITY DEPT.Proactive
Patient/Family Centered CareClinical InformaticsEducation
ReactivePeer ReviewRisk ManagementTJC, CMS, DOH Reviews/Visits
STRUCTURE - VARIESQuality functions – multiple depts.
Within Clinical Service Lines Half report to QI department Matrixes QI department - across depts. Larger Multi-hospital systems and Veterans
Affairs – corporate level quality staff Facilities have their own quality staff – reporting
to leadership Advisory Board – There is no one model that
performs better. Most Effective Model – Unique Dynamics to advance the culture and goals
STRUCTURE• Strategic Planning Process Outgrowth
SWOT – Strengths, Weaknesses, Opportunities and Threats Validates Mission, Provides Direction
• Knowing who is Responsible for PI/QI at Your Hospital is Important
WHAT PROBLEMS ARE YOU SOLVINGDefects---something that happens
that isn’t supposed to happenReducing healthcare-acquired
infectionsPerforming well in core measuresReducing re-admissions for the
same problem
TOP FOUR DEFECTSErrors in Communication (handoff
with patients and families) Issues related to Lack of LeadershipMedication ErrorsData Accuracy/Completeness
Reporting
Do
StudyAct
Plan
FOUR STEP PROCESS
PDSA Worksheet for Testing Change Aim: (overall goal you wish to achieve) Every goal will require multiple smaller tests of change
Describe your first (or next) test of change: Person responsible
When to be done
Where to be done
Plan List the tasks needed to set up this test of change Person
responsible
When to be done
Where to be done
.
Predict what will happen when the test is carried out
Measures to determine if prediction succeeds
Do Describe what actually happened when you ran the test Study Describe the measured results and how they compared to the predictions
http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx
FIVE STEP PROCESS
Identify Target Areas What
Processes Can be
Modified to
IMPROVEDevelop Effective
Strategies to
Improve Quality
Track Performan
ce and Outcomes
Disseminate Results
to Spur Broad
Spectrum Improvem
ent
TWO STEP PROCESS- TEXAS STYLE
PI PROCESSDefined differentlyShare one characteristic- cyclical in
natureMonitoring performance is DATA DRIVEN Data internal/external builds the
foundation Identifying issues that can be improvedTaking powerful steps—envision results
WHY DO STUDIES FAIL?Using Half-Baked IdeasUnrealistic Project DeadlinesAssigning jobs to those Who Might
Be Unable to HandleNo Monitoring of DataNo Comprehensive Project Portfolio
PI PROCESSES AND PHASES InitiationPlanningExecution (Implementation)Closure
PI PROCESSES Identify an improvement
opportunityResearch and DefineDesign and Re-Design
Process/EducationMeasure PerformanceDocument and Communicate
FindingsAnalyze and compare internal and
external data
INITIATION Input from Organization PI team
member importantDeveloping a Team – helps define
who is doing what and whenNeed a Team Lead or Facilitator – QI
Coordinator
CANCER PROGRAM – BUILDING A PI TEAM (S)Hospital PI member AdvisoryCancer Committee or serve as an
Ex-Officio or QI CoordinatorCancer Committee or Cancer
Program responsible for report to ??
Help build your QM Plan
PLANNING Identify ActivitiesDevelop system requirementsCriteria for standards for successDevelop a schedule/cost analysisPerform tasks and track progressDevelop the “plan” – how to
implement
DESIGN OF YOUR PLANRegistry Data ReviewCancer Program/Cancer Committee
Surgery Pathology Outpatient Therapies Support Services
Cause and Effect- Gantt Charts - PERT
Benchmarks, Guidelines, PathwaysDevelop In-House (ok per CoC)
ORGANIZE THE PLAN-Program Evaluation, Review,
Technique (PERT)Aka Critical Path Method (CPM)
Follow a path of arrows from start to finish
Adding duration time- total time to complete the project
QUALITY METRICS National Quality Forum (NQF)NCCN GuidelinesASCO/QOPICenters for Medicare Services-PQRSHospital Quality Alliance (HQA) Institute of Medicine (IOM)National Committee for Quality
Assurance (NCQA)
EFFECTIVE STRATEGIES TO IMPROVEAmerican Society of Breast
SurgeonsMastery of Breast Surgery℠ Program
https://www.breastsurgeons.org/new_layout/programs/mastery/
HHS- AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care National Quality Measures
Clearinghouse
Health Resources & Services Administration www.hrsa.gov/
Source: National Assoc of Community Health Ctrs
AAPPPPEENNDDII XX AA:: SSTTOORRYYBBOOAARRDD TTEEMMPPLLAATTEE LOCAL HEALTH DEPARTMENT NAME:
ADDRESS:
PHONE NUMBER:
SIZE:
POPULATION SERVED:
PROJECT TITLE:
PLAN Identify an opportunity and
Plan for Improvement 1. Getting Started Start typing here 2. Assemble the Team Start typing here 3. Examine the Current Approach Start typing here 4. Identify Potential Solutions Start typing here
5. Develop an Improvement Theory Start typing here
DO Test the Theory for Improvement
6. Test the Theory Start typing here
CHECK Use Data to Study Results
of the Test 7. Check the Results Start typing here
ACT Standardize the Improvement and
Establish Future Plans 8. Standardize the Improvement or Develop New Theory Start typing here 9. Establish Future Plans Start typing here
Jan-12
Feb-12
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Jul-12
Aug-12
Sep-12
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Jan-13
Feb-13
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Apr-13
May-13
Jun-13
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
84%87%
77%81% 79%
84%
60%65%
72% 72%77%
84%
92%90%94% 94% 96% 98%0.91 0.90.95
%
EXECUTIONPresent recommendations to leadershipExecute implementation plan - monthlyBegin TrainingTrack and Monitor ProgressRevise Project as Needed
CLOSURE
DISSEMINATE RESULTSPLAN SHIFTS TO BECOME AN INTEGRAL PART
CONTINUED FOLLOW-UP, MONITORING
EVALUATION/CONTROL TESTING LESSONS LEARNED
THANK YOU
VALERIE VESICH
Senior Sales ExecutiveOnco, Inc.
