Sandy Smith, Consultant

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QUALITY ASSURANCE/PERFORMANCE IMPROVEMENT

• A TEAM PROCESS

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OBJECTIVES

• The participants will be able to
• Describe basic performance improvement concepts
  (includes statistical analysis)
• List 4 critical components to ensure effective
  teams
• List 5 methods for displaying data
• Describe 5 important components for effective
  data management

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Critical Access HospitalRegulations

• C195 Each CAH shall have an agreement with
  respect to quality assurance with at least
• (i) One hospital that is a member of the network
• (ii) One PRO or
• (iii) One other qualified entity

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Regulations

• C330 Periodic evaluation and quality assurance
  review (annual evaluation of the total program)
• C336 The CAH has an effective quality assurance
  program to evaluate the quality and
  appropriateness of the diagnosis and treatment
  furnished in the CAH and of the treatment outcomes

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Requirements of the Quality Assurance Program

• Evaluation of all services affecting patient
  health and safety
• Nosocomial infections
• Medication therapy
• Quality and appropriateness of the diagnosis and
  treatment furnished by physicians

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Components

• Collect data
• Analyze data
• Remedial action
• Evaluate actions

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What is Quality?

• What one defines it to be

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Leadership Responsibility

• Mission
• Vision
• Values

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Quality Control

• The performance of processes through which
  actual performance is measured and compared with
  goals, and the difference is acted on.
• JCAHO

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Quality Assurance/Improvement

• An approach to the continuous study and
  improvement of the processes of providing health
  care services to meet the needs of individuals
  and others.
• Synonyms include continuous quality improvement,
  performance improvement, and total quality
  management.
• JCAHO

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Performance Improvement

• The continuous study and adaptation of a health
  care organizations functions and processes to
  increase the probability of achieving desired
  outcomes This is the third segment of a
  performance measurement, assessment, and
  improvement system.
• JCAHO

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Key to Effective Teams

• Define the Quality/Performance Model
• Provide Team Training
• Define Team Expectations
• Provide Resources to the Team (Time, space,
  leadership support)

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Stages of Team Development

• Forming
• Storming
• Norming
• Performing
• Source The Team Handbook

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Performance Improvement Model (FOCUS-PDCA)

• (F) ind a process to improve - Identification
  method
• Feedback (Community, Patient, Physician, Staff)
  PI Data Regulations JCAHO Standard Practice
  Guideline Other _________
• (O) rganize the Team that knows the process
• Persons who contribute to the improvement process
  (define roles)
• (C ) larify the current knowledge of the process
• Policy/Procedure Review
• Flow chart current process
• PI data - PI Tools
• (U) nderstand causes of process variation
• PI data Logs Fishbone diagram
  Surveys Flow chart
• Check sheets Graphs Pareto Charts Control
  charts
• (S) elect the process improvement
• Identify the process to be planned
• Prepare proposal

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PDCA

• (P) lan - Revise or develop policy/ procedure
  Identify resources required (Staff, Equipment,
  Space, Supplies)
• Gantt Chart, Affinity Diagram, Story Board,
  Critical paths/guidelines - Identify PI
  indicators
• (D) o - Implement on a trial or pilot basis
• (C ) heck Collect, aggregate, and analyze data
• (A) ct - Reevaluate, Replan, Implement

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Statistical Data

• Variance a measure of the differences in a set
  of observations
• Variation The differences in results obtained
  in measuring the same phenomenon more than once
  (common and special causes)
• Source JCAHO

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Display of Data

• Run Charts
• Control Charts
• Bar Graphs
• Pie Charts
• Histograms

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Bar Graph
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Standard Deviation

• A measure of variability that indicates the
  spread of a set of observations around a mean
• Source JCAHO

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Data Management

• What data measurements are required?
• What data measures are important to the
  organization decision- making process?
• What data measures are important to day to day
  management?

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Critical Components to Effective Data Management

• Define what data to measure?
• Define the process for data collection and
  reporting (allocate appropriate resources)
• Provide appropriate data analysis
• Define the responsibility for Action Plan
• Research products and process for managing data

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Excel Training

• Resource to enhance data management
• Data collection
• Measurement/Aggregation
• Assessment/Analysis
• Improvement

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CAH QA/PI

• Resource for data collection, reporting, and
  benchmarking with other CAHs (Financial data,
  Transfers)
• Resource to enhance organization data management
  (Risk Management, Utilization Management,
  Infection Control, Medication Use, Restraint Use,
  Complaints, etc.)
• Provide Training
• Provide resources for use or purchase

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FY 03 Indicators
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Volume Indicators

• Patient Days
• Inpatient
• Observation
• Skilled
• Emergency Room Visits

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Financial Indicators

• Debt to Asset Ratio ()
• Donor Government Support ()
• Profit Margin ()
• Medicare Inpatient Costs per adjusted discharge
  ()
• ARDs (Days)

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Human Resource Indicators

• Total FTEs
• RN FTEs
• LPN FTEs
• CNA FTEs
• Unit Clerk FTEs
• Pharmacy FTEs
• RT FTEs
• Lab FTEs
• Social Service FTEs
• Dietitian FTEs
• Nursing Hours/ED Visit

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Clinical Indicators

• Transfers
• Reason for Transfers
• Equipment
• Staff
• Space/Bed availability
• Services (Imaging, Surgery, etc.)
• Patient/Family preference

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Summation

• Description of QA/PI process
• Components to ensure effective teams
• Methods for displaying statistical data
• Components for effective data management

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QA/PI RepresentativesAfternoon Agenda

• Group discussion of QA/PI processes in place
  Whats Working Whats Not? (Participants)
• Identify needs to enhance the current QA/PI
  processes

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Evaluation