Connie T. Chuang, MD, MPA, MPH
Spring 2014 (631) 756-2204 ext. 103
Wednesdays: 6:45 to 8:25pm
Location: Global Center for Academic &
Spiritual Life, 238 Thompson St, Room 269
Continuous Quality Improvement (CQI) HPAM-GP.2825
Introduction This course encourage students to think creatively about what it means for a healthcare organization to make quality the highest priority. We will
explore the current forces driving the push toward quality outcomes and accountability at all levels and settings of healthcare, while focusing on
the philosophy of continuous improvement through teamwork and statistical thinking. Students will use structural tools for analysis, decision
making and performance measurement.
Prerequisites:
CORE-GP.1011 Statistical Methods for Public, Nonprofit, and Health Management,
HPAM-GP.4833 Health Care Management I: Control and Organizational Design, and
Computer Proficiency.
Students lacking the prerequisites must obtain permission to enroll in the course.
Learning Outcomes At the successful completion of this course, students will be able to:
Appreciate the historical evolution of healthcare quality improvement,
Understand the current forces driving changes in healthcare quality,
Describe the major models for improvement that provide a framework for change,
Apply a systematic method of improving a process using a team approach,
Understand the use of structural, process, and outcome indicators for measuring quality,
Recognize the implications of organization-wide transformation to continuous systems improvement,
Appreciate the challenges facing leaders in sustainability and spread of improvement efforts, and
Determine skills in working collaboratively.
Learning Strategies This course is based on:
1. Discussion of current events and the common themes emerging that are affecting the delivery of healthcare services and
2. Learning by doing, i.e. applying methods learning in class to process improvement assignments.
3. Process analysis provides the student the opportunity to think, read, write and present ideas logically in an organized manner. Emphasis
will be placed on oral and written communication and working in teams.
In this course, students will take the role of a team in a specific department or service in a healthcare organization. Students will use
management tools and techniques, diagnose problems and develop innovative, practical and cost-effective solutions to address a process
needing improvement. Assignments are geared toward analyzing a specific process that is producing a less than optimum outcome, identifying
the data required to analyze the problem and using specific QI tools and techniques for innovative solutions.
This course will integrate with the IHI Open School for Health Professions, an online school for helping students learn about quality improvement
and patient safety competencies.
Course Expectations Attend every class on time,
Read all assigned materials prior to class,
Actively participate in-class discussions and exercises,
Work with team members to complete assignments, and
Complete online and written assignments on time.
Please discuss with me as soon as possible should you foresee difficulty in adhering to any course expectation. All class absences must be
excused in advance. Extensions for assignment completion are granted only in cases of emergency.
Expectations of The Instructor In-person meetings: please make prior arrangements with me.
Email: this is the best way to communicate with me. I will do my best to provide a timely response; however, please allow yourself 24 hours to
ensure responses to any pertinent questions related to an assignment.
Grading 1. Written assignments. Total 50 points.
This course relies heavily on teamwork and communication. Because written assignments represent a team effort, all team members
will receive the same written assignment grade, unless the team evaluation forms reflect a lack of involvement deemed unacceptable by
fellow team members.
All written assignments are submitted in-person on the due date in class.
2. IHI Open School course completion. Total 16 points.
Each IHI course (16 total) completed by the due date earns 1 point
IHI Open School Courses completed past the due date without approved extensions will not be credited.
3. Team charter and evaluations. Total 14 points.
Team charter completion earns 4 points.
Mid-semester and final team evaluation completions are each worth 5 points. Depending on your team members’ evaluation of you,
such an evaluation may affect your final course grade, e.g. your active participation in team meetings and completing assignments.
Team charter to be submitted with Assignment 1.
All team evaluations are to be handed to me in-person on the due date in class.
4. Final presentation. Total 10 points.
5. Class Participation/Attendance. Total 10 points.
A point will be deducted for any unexcused absence.
6. Each written assignment, including team charter and evaluations handed in late without approved extensions will be penalized 2 points per
day after the due date.
Wagner’s Academic Honesty and Grading Policy All students are expected to pursue and meet the highest standards of academic excellence and integrity. This course will abide by Wagner’s
general policy guidelines on grading and academic honesty, including plagiarism. It is the student’s responsibility to become familiar with these
policies.
Grading Guidelines: http://wagner.nyu.edu/students/policies/grading.php
Incomplete Grades: http://wagner.nyu.edu/students/policies/incompletes.php
Academic Honesty: http://wagner.nyu.edu/students/policies/
Proper citation of ideas, data and published work is expected in this course.
Writing references: http://wagner.nyu.edu/students/services/tutoring.php
Recommended References Scholtes , Peter R., Brian L. Joiner and Barbara J. Streibel. The Team Handbook. 3rd ed. Madison: Oriel Inc., 2003. Print.
Zelazny, Gene. The Say It with Charts Complete Toolkit. New York: McGraw-Hill, 2006. Print.
Executive Learning Inc. Handbook For Improvement: A Reference Guide for Tools and Concepts. 3rd ed. Nashville: Healthcare
Management Directions Inc., 2002. Print.
Required Articles Posted on NYU Classes under “Resources.”
Required Online Courses IHI Open School online courses are free to students and provide important lessons in patient safety, quality improvement and leadership.
Completion by the required date as noted in the syllabus is required. To receive credit for each completed course:
1. Generate the course completion certificate (you must complete the evaluation at the end of each course to generate the certificate)
2. Submitted the certificate through the NYU Classes site under “Assignments” as an attachment.
The IHI Open School offers a basic certificate of completion for the 16 “core courses.” An IHI Open School iPhone/iPad app is also available to
view and complete the courses.
Written Assignments
Team Charter (4 points)
Complete the provided charter template. Use this charter to set team expectations and roles, including acceptable forms of communication,
process used to complete assignments and process used if an expectation of a team member “does not meet team standards.” Be as clear and
detailed as possible. Feel free to revise the charter throughout the semester.
Grading 1. Description of team expectation and roles [1 point] 2. Description of process should an expectation is not met by a team member [2 points] 3. Grammar, formatting, spelling [1 point]
Mid-Semester and Final Team Evaluations (total 10 points)
Complete the provided evaluation forms. Use the mid-semester evaluations as a gauge of successfully meeting team expectations and if needed,
to alter team dynamics. Use the final team evaluations to learn and develop your “personal style” as a healthcare manager. I will be sharing
comments among appropriate team members for professional growth. To obtain your final course grade, you must submit your final team
evaluation form to me by the due date.
Grading (for each team evaluation) 1. Completion of team evaluation form [2 points] 2. Constructive criticism for improvement [3 points]
Process for Improvement Submission
In teams of 3-5, students will select an organization, to which at least one team member has access and investigate a process that needs
improvement. The process you choose should be meaningful to the organization so that recommended changes can be adapted. You must be
able to collect data (concurrently or retrospectively) about the process over time, so be sure to choose a process that is well-defined and lends
itself to measurement.
Note: Teams will be formed during the first and/or second class. Each team will submit its process for improvement to the instructor for approval
no later than the third class session.
Assignment #1: Flowchart (10 points)
The first step on the improvement journey is to select the process for improvement. Answer the 3 Model for Improvement (MFI) questions and diagram the process flow. When selecting the process to analyze, consider “measurability” since you will be collecting data on this process for your next assignments. Identify the process concretely and think about the type of information needed. Be sure your flowcharts are well-defined with beginning and end points. Label your flowchart to clearly state the process being mapped. Format
1. Cover page with team member names, organization and process being examined. 2. One-page description of process being analyzed, ending with MFI questions/answers. You can use the IHI Open School’s Charter Form as
a guide. a. What are we trying to accomplish?
b. How will we know that a change is an improvement?
c. What changes can we make that will result in improvement?
3. Flowcharts: each team creates a chart based on interviews of at least 2 key and relevant stakeholders (e.g. physician, health care provider, manager, and/or patient).
Grading
3. Flowchart: appearance and flow, including correct use of basic flow chart symbols [5 points] 4. Written description of process – start with why you picked this process [3 points] 5. MFI questions with answers – one sentence answers [1 point] 6. Grammar, formatting, spelling [1 point]
Assignment #2: Run/Control Chart (10 points)
Run charts are graphs of data taken over time. Control charts build on the run chart and are one of the key tools used to display variation in the process, and identify the presence or absence of special or common cause variation. The purpose is to determine the type and cause of variation so that appropriate actions can be taken. Gather data and prepare a run chart (≥ 25 data points). Add upper and lower control limits (ideally 3 standard deviations), to turn your run chart into a control chart, which will help you identify causes of variation. Label your chart to clearly state the content. Prepare a written summary of your analysis of the variation. Format
1. Cover page as in Assignment #1. 2. Run chart/control chart
3. Brief (1 page) written analysis of variation
Grading 1. Technical quality of run/control chart [5 points] 2. Analysis of variation: special and/or common cause [4 points] 3. Grammar, formatting, spelling [1 point]
Assignment #3: Cause and Effect Diagram (10 points)
A cause and effect diagram (also known as an Ishikawa or fishbone diagram) is a tool used to explore the relationship between causes and an effect. Brainstorm possible causes of process variation as identified in Assignment #2.
1. Use the problem as your effect (the head of the fish); 2. Brainstorm the causes using the categories discussed in class
a. Use a combination of 5M’s: man, machine, methods, materials, measurement, 4P’s: people, plant, policies and procedures and/or Vincent et al’s “Contributory Factors.”
b. Group individual causes them under the appropriate “main cause” category (the scales of the fish). c. Each cause should be clearly stated as to how/why it’s contributing to the effect. Identify the most significant root causes
contributing to the problem. You can use the IHI Open School’s Cause and Effect Diagram Form as a guide. Format
1. Cover page as in Assignment #1 2. Cause and Effect diagram 3. Brief description of root causes
Grading
1. Technical quality of cause and effect diagram [5 points] 2. Analysis of root causes [4 points] 3. Grammar, formatting, spelling [1 point]
Assignment #4: PDSA Cycle, Recommendations for Improvement, Measurement Plan (20 points)
Now that you have gathered the data and determined the main causes for the problem, recommend a change. Conduct a PDSA cycle and describe the results. If not possible to conduct a PDSA cycle at the organization, describe the anticipated results. Write an implementation plan for your recommended change. Be specific and include the who, what, where, when and how of implementation. To help the organization determine if the plan is successfully implemented and effective after you leave, develop a measurement tool and plan that you will leave with the organization for ongoing measurement. At a minimum, the plan should include the data that will be collected, who is accountable for collection and specific timeframes. You can use the IHI Open School’s PDSA Form as a guide.
Format 1. Cover page as in Assignment #1, report should not exceed 5 pages. 2. PDSA results or anticipated results 3. Implementation plan 4. Measurement plan
Grading
1. PDSA cycle [9 points] 2. Written implementation plan [5 points] 3. Written measurement plan and tool [5 points] 4. Grammar, formatting, spelling [1 point]
Final Presentation for Class (10 points) Provide a handout of the presentation by the due date. Do not submit the presentation through NYU Classes. Bring an electronic copy on the day you are presenting. Summarize your journey through the improvement process, including at a minimum:
1. Overview of the specific healthcare organization with which you were involved 2. What problem did you set out to solve 3. Obstacles encountered along the way 4. Significant findings (or anticipated findings) 5. Recommendations that you made 6. Response from organization at end of project 7. Lessons learned
Grading
1. Incorporated Assignments 1 through 4 [3 points] 2. Discussed the above points [3 points] 3. Used evidence-based information [3 points] 4. Made the “business case” [1 points]
Use visuals and make the business case! All team members should actively participate in a professional, engaging and compelling performance!
“Design is not just what it looks like and feels like. Design is how it works.” - Steve Jobs
Class Schedule (Subject to change during semester; Guest lecturers to be announced; last updated 1/3/14
Week/ Date
Topics/ Class Agenda
Required Readings/IHI Open School Courses Suggested Readings/Resources Assignments Due
Week 1 Jan 29
Quality Yesterday
and Today: An
Introduction to
CQI
Organize into
teams. Discuss
team charter and
evaluations.
NYSDOH Hospital Profile:
http://hospitals.nyhealth.gov/
Commonwealth Fund:
http://whynotthebest.org
HHS: http://hospitalcompare.hhs.gov
National Scorecard:
http://www.commonwealthfund.org/Pub
lications/Fund-Reports/2011/Oct/Why-
Not-the-Best-2011.aspx
1) Complete “Tell me
about yourself” document
posted on NYU Classes
and bring to first class.
2) Review instructions for
IHI Open School course
completion on NYU
Classes.
Week 2 Feb 5
Frameworks for
Improvement
Organize into
teams. Discuss
team charter and
evaluations.
IHI QI 101: Fundamentals of Improvement
IHI QI 102: The Model for Improvement
IOM (2001). Executive Summary. In
Crossing the Quality Chasm: A New
Health System for the 21st Century.
Retrieved from
http://www.iom.edu/Reports/2001/Cross
ing-the-Quality-Chasm-A-New-Health-
System-for-the-21st-Century.aspx
Week 3 Feb 12
Safety as Driving
Force
Discuss
Assignment 1.
IHI PS 100: Introduction to Patient Safety
IHI PS 101: Fundamentals of Patient Safety
IHI PS 102: Human Factors and Safety
National Health Policy Forum (1999,
May 14). Reducing Medical Error: Can
You Be As Safe In A Hospital As You
Are In A Jet? Issue Brief, No. 740.
Retrieved from http://www.nhpf.org/library/issue-
briefs/IB740_MedicalError_5-14-99.pdf
Submit Process for
Improvement and Team
Charter for instructor
approval.
Week 4 Feb 19
Leadership and
Teamwork
IHI L101: So You Want to Be a Leader in Health
Care
IHI PS 103: Teamwork and Communication
IHI PFC101: Dignity and Respect
NCHL Catalyst Framework: http://www.nchl.org/static.asp?path=28
52
Week 5 Feb 26
Measurement Part
I: Variation,
Statistical Process
Control (SPC)
and Monitoring
Discuss
Assignment 2.
IHI QI 103: Measuring for Improvement
IHI QI 104: Putting It All Together
IHI QI 106: Level 100 Tools
Nelson, E.C., Splaine, M.E., Batalden,
P.B. and Plume, S.K. (1998). Building
Measurement and Data Collection Into
Medical Practice. Ann Intern Med,
128(6), 460-466.
NHS Improvement-Statistical Process
Control:
http://www.improvement.nhs.uk/lung/S
erviceImprovementTools/StatisticalProc
essControl/tabid/96/Default.aspx
Assignment 1 due.
Week 6 Mar 5
NO CLASS
Week 7 Mar 12
Measurement Part
II: Root Cause
Analysis
Wu, A.W., Lipshutz, A.K. and Pronovost, P.J.
(2008). Effectiveness and Efficiency of Root
Cause Analysis in Medicine. JAMA, 299(6), 685-
687.
IHI PS 104: Root Cause, Systems Analysis
Joint Commission Framework for
Conducting A Root Cause Analysis and
Action Plan in Response to a Sentinel
Event:
http://www.jointcommission.org/Frame
work_for_Conducting_a_Root_Cause_
Analysis_and_Action_Plan/
Week 7 Mar 12
Measurement Part
III: Outcome
Evaluation
Models
Randolph, G. et al (2009). Model for
Improvement-Part Two: Measurement and
Feedback for Quality Improvement Efforts.
Pediatr Clin N Am, 56, 779-798.
W.K. Kellogg Foundation (2004). Logic Model
Development Guide. Retrieved from http://www.wkkf.org/knowledge-
center/resources/2006/02/WK-Kellogg-
Foundation-Logic-Model-Development-
Guide.aspx
Mid-Semester Team
Evaluation and Mid-
Semester Course
Evaluation Forms due.
Week 8 Mar 19
Spring Recess No Class
Week 9 Mar 26
Apply the Culture
of Safety to the
Workplace
IHI QI 105: The Human Side of Quality
Improvement
IHI PS 105: Communicating With Patients After
Adverse Events
IHI PS 106: Intro to Culture of Safety
Marx, D. (2001). Patient Safety and the
“Just Culture” [PowerPoint slides].
Retrieved from http://www.health.ny.gov/professionals/
patients/patient_safety/conference/2007/
docs/patient_safety_and_the_just_cultur
e.pdf
Wachter, R.M. and Pronovost, P.J.
(2009). Balancing “No Blame” With
Accountability in Patient Safety. N
Engl J Med, 361(14), 1401-1406.
Assignment 2 due.
Week 10 April 2
Regulation and
Accreditation
Review websites noted on the right-hand side.
OSHA Safety and Health Topics:
Healthcare:
http://www.osha.gov/SLTC/healthcarefa
cilities/index.html
Joint Commission National Patient
Safety Goals: http://www.jointcommission.org/standar
ds_information/npsgs.aspx
NCQA HEDIS Measures:
http://www.ncqa.org/HEDISQualityMea
surement/HEDISMeasures/HEDIS2014.
aspx
Week 11 April 9
Transforming
Healthcare
Quality
Discuss
Assignment 4 and
Final
Presentations.
IHI (2003). The Breakthrough Series: IHI’s
Collaborative Model for Achieving Breakthrough
Improvement. IHI Innovation Series White Paper.
Retrieved from http://www.ihi.org/knowledge/Pages/IHIWhitePap
ers/TheBreakthroughSeriesIHIsCollaborativeMode
lforAchievingBreakthroughImprovement.aspx
PCDC (2007). Factors Contributing to Sustaining
and Spreading Learning Collaborative
Improvements. Retrieved from
http://www.pcdc.org/assets/pdf/7515_commonwea
lth_study_-_sustainability_12-07.pdf
Chronic Care Model:
www.improvingchroniccare.org
NCQA’s Patient-Centered Medical
Home:
http://www.ncqa.org/Programs/Recognit
ion/PatientCenteredMedicalHomePCM
H.aspx
IHI QI 202: Quality Improvement in
Action: Stories from the Field
TA 101: Introduction to Population
Health
Week 12 April 16
Business Case for
QI
Forum on the Science of Health Care Quality
Improvement and Implementation, IOM (2008).
Communicating a Value Proposition. In Creating
a Business Case for Quality Improvement
Research: Expert Views, Workshop Summary.
Retrieved from
http://www.nap.edu/catalog.php?record_id=12137
Leatherman, S. et al (2003). The Business Case
for Quality: Case Studies And An Analysis.
Health Aff, 22(2), 17-30.
IHI QCV 101: Achieving Breakthrough Quality,
Access, and Affordability
Assignment 3 due.
Week 13 April 23
Role of Evidence-
Based, Health
Information
Technology in QI
AHRQ (2007). Health Information Technology
for Improving Quality Care in Primary Care
Settings. Retrieved from www.ahrq.gov
AHRQ (2009). Clinical Decision Support
Systems: State of the Art. Retrieved from http://healthit.ahrq.gov/images/jun09cdsreview/09
_0069_ef.html
Meaningful Use: http://www.healthit.gov/providers-
professionals/ehr-incentives-certification
AHRQ’s Transforming Healthcare
Quality Through IT (THQIT) program: http://healthit.ahrq.gov/portal/server.pt/c
ommunity/ahrq-
funded_projects/654/health_it_portfolio
_transforming_healthcare_quality_throu
gh_health_it_projects/21178
National Quality Forum Endorsed
Measures:
http://www.qualityforum.org/QPS/
Week 14 April 30
Final
Presentations
Assignment 4 and a
handout of final
presentations due.
Final team evaluation
forms due.
Week 15 May 7
Final
Presentations
Week 16 May 14
Final Exam
Period
Make up class, if needed.