Quality ImprovementQuality Improvement

What is QI?What is QI?

Quality Improvement is a formal approach to Quality Improvement is a formal approach to the analysis of performance and systematic the analysis of performance and systematic efforts to improve it. There are numerous efforts to improve it. There are numerous models used. models used.

These models are all means to get at the same These models are all means to get at the same thing: Improvement. They are forms of thing: Improvement. They are forms of ongoing effort to make performance better. ongoing effort to make performance better.

Why QIWhy QI

To improve outcomes!!!!!To improve outcomes!!!!! In industry, quality efforts focus on topics like In industry, quality efforts focus on topics like

product failures or work-related injuries. product failures or work-related injuries. In administration, one can think of increasing In administration, one can think of increasing

efficiency or reducing re-work. efficiency or reducing re-work. In medical practice, the focus is on reducing In medical practice, the focus is on reducing

medical errors and needless morbidity and medical errors and needless morbidity and mortality.mortality.

Who is Responsible for QI?Who is Responsible for QI?

Everyone!!!!Everyone!!!!NursesNursesDoctorsDoctorsAssisstantsAssisstantsEveryone in the buildingEveryone in the building

How Do You Define Quality?How Do You Define Quality?

The definition of quality often depends on the The definition of quality often depends on the stakeholders. Stakeholders are, as the name stakeholders. Stakeholders are, as the name implies, people with some stake or concern in implies, people with some stake or concern in the process.the process.

In Healthcare, the definition of quality can be In Healthcare, the definition of quality can be complex and controversial because of the complex and controversial because of the different views of people with a stake in good different views of people with a stake in good Healthcare. Let’s look at a few different Healthcare. Let’s look at a few different stakeholders. What does each of these stakeholders. What does each of these stakeholders want? stakeholders want?

ProvidersProviders

Providers:Providers: Tend to view quality in a technical sense – Tend to view quality in a technical sense –

accuracy of diagnosis, appropriateness of accuracy of diagnosis, appropriateness of therapy, resulting health outcometherapy, resulting health outcome

PayersPayers

Payers:Payers:Focus on cost-effectiveness.Focus on cost-effectiveness.

EmployersEmployers

Want both to keep their costs down, and to get Want both to keep their costs down, and to get their employees back to work quickly.their employees back to work quickly.

PatientsPatients

Want compassion as well as skill with clear Want compassion as well as skill with clear communication. communication.

Can you see any conflicts between what these Can you see any conflicts between what these stakeholders want? The decisions around the stakeholders want? The decisions around the conflicts often determine if a QI project will be conflicts often determine if a QI project will be a success.a success.

Quality in Healthcare Quality in Healthcare

If you wanted to get a sense of the quality of If you wanted to get a sense of the quality of healthcare delivery, how would you go about it?healthcare delivery, how would you go about it?

You could ask each of the providers if they were You could ask each of the providers if they were following the guidelines for a specific disease following the guidelines for a specific disease

You could ask providers to keep track of their errors You could ask providers to keep track of their errors or “near misses”or “near misses”

Can you imagine any reason these methods may not Can you imagine any reason these methods may not work?work?

Can you imagine any reason these Can you imagine any reason these methods may not work?methods may not work?

Earnest InterviewerEarnest Interviewer: Have any of your patients : Have any of your patients gotten worse because of treatment you provided?gotten worse because of treatment you provided?Reluctant ProviderReluctant Provider: Er, um… No, never, of course : Er, um… No, never, of course not.not.EIEI: Do you use the approved guidelines for this : Do you use the approved guidelines for this condition?condition?RP: RP: Of course—every time!Of course—every time!EI: EI: What about the time . . . ?What about the time . . . ?RP:RP: (interrupting) Well, that was a special case. (interrupting) Well, that was a special case.

These methods would be fraught with These methods would be fraught with problems of validity and reliability. Self-report problems of validity and reliability. Self-report of errors is shown to be low and, particularly if of errors is shown to be low and, particularly if there is a potential punitive response, reporting there is a potential punitive response, reporting would be infrequent and inaccurate. would be infrequent and inaccurate.

This leaves us with a deficit in how we can This leaves us with a deficit in how we can assess quality.assess quality.

QI in a HealthcareQI in a Healthcare SettingSetting

One means of getting around the problems with self-One means of getting around the problems with self-report is to use more objective data. report is to use more objective data. You start with a small problem. Perhaps you want to see You start with a small problem. Perhaps you want to see

how well your group is doing with patients with a chronic how well your group is doing with patients with a chronic disease, such as diabetes, asthma, or hypertension. From disease, such as diabetes, asthma, or hypertension. From that point you can narrow your focus even further. that point you can narrow your focus even further.

Decide what aspect of care you think might be a problem. Decide what aspect of care you think might be a problem. How about assessment of how well the condition is being How about assessment of how well the condition is being

controlled? controlled? Within an office visit what measurements would be useful?Within an office visit what measurements would be useful?

Measurement: Process and Outcome Measurement: Process and Outcome IndicatorsIndicators

MeasuresMeasuresThere are 3 types of measures used in quality work:There are 3 types of measures used in quality work:

StructureStructure: Physical equipment and facilities : Physical equipment and facilities ProcessProcess: How the system works : How the system works OutcomeOutcome: The final product, results: The final product, results Structure and process are easier to measure; outcome Structure and process are easier to measure; outcome

is more important.is more important.

Can you think of an example in Can you think of an example in Healthcare?Healthcare?

If you were concerned about reducing prenatal If you were concerned about reducing prenatal mortality, you might look at mortality, you might look at StructureStructure

Availability of physicians and/or midwives providing obstetrical Availability of physicians and/or midwives providing obstetrical care.care.

ProcessProcess Percent of mothers receiving prenatal care prior to 12 weeks Percent of mothers receiving prenatal care prior to 12 weeks

gestation. gestation. Percent of mothers taking prenatal vitamins. Percent of mothers taking prenatal vitamins. Percent of smoking mothers counseled to quit. Percent of smoking mothers counseled to quit.

OutcomeOutcome Neonatal mortality rate Neonatal mortality rate Pre-maturity rate. Pre-maturity rate.

Methods of Quality ImprovementMethods of Quality Improvement

FADE FADE PDSAPDSA DMAICDMAIC DMADVDMADV

Things Quality Improvement is NOTThings Quality Improvement is NOT

Performance ImprovementPerformance Improvement The terms quality improvement and performance The terms quality improvement and performance

improvement are sometimes used interchangeably. improvement are sometimes used interchangeably. Performance Improvement means a change in the system Performance Improvement means a change in the system performance. In Healthcare, this is often used to refer to performance. In Healthcare, this is often used to refer to administrative systems, as contrasted to QI as impacting administrative systems, as contrasted to QI as impacting the actual quality of healthcare.the actual quality of healthcare.

ResearchResearch

The distinction between QI and research is an The distinction between QI and research is an important one. There is a spectrum, and it can be important one. There is a spectrum, and it can be blurry sometimes, but there are some key points (with blurry sometimes, but there are some key points (with legal implications!).legal implications!).

QI: QI: Intent is to improve current practice. For internal use only. Intent is to improve current practice. For internal use only. By definition, the data is confidential. By definition, the data is confidential. Action is within existing standards of care. Action is within existing standards of care. Institutional Review Board (IRB) approval is not necessary.Institutional Review Board (IRB) approval is not necessary. Research: Research: Intended to create generalized knowledge. Intended to create generalized knowledge. Desire to publish or present. Desire to publish or present. Testing new methods. Testing new methods. Needs approval!Needs approval!

Summary Summary

Key points to remember.Key points to remember. Improving Healthcare quality is our Improving Healthcare quality is our

responsibility. responsibility. Measurement and improvement are possible. Measurement and improvement are possible. Identify the root cause before making changes. Identify the root cause before making changes. Be creative in developing solutions.Be creative in developing solutions. THINK OUTSIDE THE BOX!THINK OUTSIDE THE BOX!

Any Questions??Any Questions?? http://patientsafetyed.duhs.duke.edu/module_a/module_overview.htmlhttp://patientsafetyed.duhs.duke.edu/module_a/module_overview.html