Continuous Quality Improvement 101

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Continuous Quality Improvement 101

• Amelia Broussard, PhD, RN, MPH
• broussardco1_at_msn.com

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WHY DO WE NEED TO KNOW ABOUT CQI?

• Provision of Quality Care
• CQI tools and techniques work in healthcare. 
• Bureau of Primary Health Care requires quality
  improvement
• New process relates health care plan, QI, UDS
  info, needs assessment
• Focus on Core Clinical Measures

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A Few Questions to Ask

• Services provided in timely manner?
• Was necessary care provided?
• Efficient provision of care?
• Was the expected outcome achieved?
• Are patients, clients and customers satisfied
  with provided services?

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Success is achieved through meeting the needs of
those we serve.
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Quality Assurance vs. Quality Control

• Quality assurance and quality control are often
  used interchangeably to refer to ways of ensuring
  the quality of a service or product.
• The terms, however, have different meanings.

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Quality Assurance

• The planned and systematic activities
  implemented in a quality system so that quality
  requirements for a product or service will be
  fulfilled.
• American Society for Quality

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Examples of Quality Assurance Activities

• Activities that are based on public health
  standards, licensing standards, institutional
  policies, etc.
• Annual infection control and safety training
• Review medication closet for outdated meds
• Review emergency chart once a week for supplies
  and outdated meds
• Can help identify a problem, but are more often
  used to comply with the standards.

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Quality Control

• The observation techniques and activities used
  to fulfill requirements for quality.
• American Society for Quality

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Examples of Quality Control

• Infection control training sign-in sheets
  cross-referenced with staff roster
• Review sheet of emergency cart
• Direct observation of counseling session

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Quality Improvement

• Continuous improvement is an ongoing effort to
  improve products, services or processes. These
  efforts can seek incremental improvement over
  time or breakthrough improvement all at once.
• American Society for Quality

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Philosophy of CQI

• Based on concept of balance between quality
  improvement performance measurement
• QI programs are built upon foundation of program
  support infrastructure
• Emphasizes development of systems processes to
  support QI

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Guiding Principles

• Ongoing QI activities improve patient care
• Performance measurement lays foundation for QI
• Infrastructure supports systematic implementation
  of QI
• Indicators are based on clinical guidelines
  formal group-decision making

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Core Clinical Measures for Health Care Plan

• Diabetes
• Cardiovascular Disease
• Prenatal Care
• Perinatal Care

• Child health
• Behavioral Health
• Oral Health
• Other x2

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Goals of Quality Improvement

• The goals of QI
• to understand process, reduce unintended
  variation in care, eliminate errors, remove
  unnecessary steps, and improve communication and
  accountability.
• process is designed toward outcomes.
• Quality improvement depends on measurement.

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Core Concepts of CQI

• Quality defined as meeting and/or exceeding
  expectations of customers.
• Success is achieved through meeting the needs of
  those we serve.
• Most problems are found in processes, not in
  people. 
• CQI does not seek to blame, but rather to improve
  processes. 

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CORE CONCEPTS OF CQI

• Unintended variation in processes can lead to
  unwanted variation in outcomes
• Possible to achieve continual improvement through
  small, incremental changes using the scientific
  method. 
• CQI most effective when it becomes natural part
  of way everyday work is done.

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Comparison of QA QI
QA QI
Motivation Measuring compliance with standards Continuously improving processes to meet standards
Means Inspection Prevention, monitor over time
Attitude Required, defensive Chosen, proactive
Focus Outliers or bad apples, individuals Processes, systems, majority
Players Selected departments Organization wide, benchmarking
Disciplines Within profession Multidisciplinary approach
Scope Medical profession focused Patient care focused
Responsibility Few All
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QA versus QI
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Exercise on Quality

• What is the benefit for
• Patients
• Staff
• Organization

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Putting It All Together

• QA CQI Peer Review Consumer
  Satisfaction QM

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• Process Indicator
• Are we doing what we said wed do?

Outcome Is it working for the clients?
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GUIDING VALUES of CQI

• Most problems are found in processes, not in
  people. 
• If you focus on everything, you cant focus on
  anything.
• The best solutions are staff designed.

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Roles and Responsibilities

• Leadership/Board/Consumers Oversight and
  resources. Help set priorities.
• QI Committee Review data, pick projects and
  goals, review results of tests.
• Project Team Brainstorm ideas and design tests.
• All Staff Help perform tests and collect data.

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PITFALLS OF CQI

• The paperwork can bury you

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SET PRIORITIES
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PITFALLS OF CQI

• Staff view it as a ball and chain, hindering
  their daily work

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PITFALLS OF CQI

• The Process can tie you up in knots

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Lessons Learned

• The shorter the timeframes between test cycles,
  the more tests can be conducted and therefore,
  more opportunities for learning will emerge. -
  HIVQUAL Workbook
• Lets be as opportunistic as a virus! -
  Anonymous

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Common Themes among QI Models

• Improvement is about learning
• trial and error (scientific method)
• improvements requires change, however not all
  changes are an improvement
• Measure your progress
• only data can tell you whether improvements are
  made
• integrate measurement into the daily routine
• Improvements thru continuous cycles of changes
• Plan-Do-Study-Act approach
• changes are initiated on a small scale to test
  them before implementation
• Leadership is needed
• establish organizational commitment and support
  staff and activities

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One MODEL FOR IMPROVEMENT

• Model consists of
• three questions (aim, measure, change) to form
  context for improvement
• Plan-Do-Study-Act (PDSA) Cycle to structure tests

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Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in
improvement?
Model for Improvement
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Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in
improvement?
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Model for Improvement
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Model for Improvement
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PDSA CYCLE

• Plan - Plan a change
• Do - Try it out on a small-scale
• Study - Observe the results
• Adopt, adapt, or abandon -Refine the change as
  necessary

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PRINCIPLES OF PDSA CYCLES

• Short cycles of changes to accelerate rate of
  improvement
• small scale tests (What can you test till next
  Tuesday)
• collect just enough information
• Create flow of ideas, then emphasize
  implementation
• increase frequency of tests
• build knowledge sequentially - use multiple
  cycles to adapt a change to your system
• Adopt existing knowledge (not more research but
  more application of existing knowledge)
• Steal shamelessly, Share senselessly
• Promote peer learning

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Tips for PDSA Cycles

• - formulate question and predict results
• - test first in safe zones (with team members,
  volunteers)
• - Just-do-it mentality
• collect useful just enough data, not perfect data
• think a couple of cycles ahead
• scale down size of test ( of patients, clinics)
• be innovative to make test feasible

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PDSA Cycles Testing a pap Cuing Plan
Improved Decision Support
DATA
Cycle 1D Implement thruout clinic and
monitor the impact.
Cycle 1C Test with all patients for a full
week, document feedback and time required.
Cycle 1B Debrief staff did it help, how long
did it take? Test with Dr. Stranges patients
for a full week.
Use of flowsheet will improve care to known
standards
Cycle 1A On Mon., prescreen Freds Tues. pts,
mark appointment sheet for those who are due for
paps.
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Smaller Scale Tests Scale Down Timeframe

• Years
• Quarters
• Months
• Weeks
• Days
• Hours
• Minutes

Reduce your timeframe to plan Test Cycle!
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Analysis Tools Flowcharts

• Flowchart is picture of any process,
• Flowcharts help visualize process
• Easier to understand and easier to improve.
• Identifies potential sources of problems and
  solutions

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FLOWCHART

• Flowchart symbols
• Oval shows beginning or ending step in a
  process
• Rectangle depicts particular step or task
• Arrow shows direction of process flow
• Diamond indicates a decision point

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FLOWCHART EXAMPLE
Patient arrives at front desk
Receptionist asks for patients name searches
database for his/her file
Receptionist asks patient to complete paperwork
for new clients and return it to front desk
Patient in system?
NO
YES
Ask patient to be seated in the Waiting room
ETC.
Medical assistant takes patient into exam room
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CAUSE-AND-EFFECT DIAGRAM

• Used to map variables that may influence a
  problem, outcome, or effect
• Also called
• Ishikawa diagram
• Fishbone diagram

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CAUSE-AND-EFFECT DIAGRAMCAUSES

• The four Ms
• Methods, Materials, Machines, Manpower
• The four Ps
• Place, Procedures, Policies, People
• The four Ss
• Surroundings, Suppliers, Systems, Skills

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CAUSE-AND-EFFECT DIAGRAMSAMPLE
Skeleton
Equipment
Environment
Computer
System down for routine maintenance
Low show rate for appointments
Patients
Patient unaware of appointment
Procedures
People
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Exercise

• Construct Cause and Effect Diagram with staff

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Performance Measurement and Data
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Why Measure?

• Separates what you think is happening from what
  is really happening
• Establishes a baseline
• Helps to avoid putting ineffective solutions in
  place
• To monitor improvements and prevent slippage

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What is a good indicator?

• Relevance. Does the indicator relate to a
  condition that occurs frequently or have a great
  impact on the patients at your facility?
• Measurability. Can the indicator realistically
  and efficiently be measured given the facilitys
  finite resources?
• Accuracy. Is the indicator based on accepted
  guidelines or developed through formal
  group-decision making methods?
• Improvability. Can the performance rate
  associated with the indicator realistically be
  improved given the limitations of your clinical
  services and patient population?