establishing an effective cqi program by: shannon bentley, rn,c and lois sacher, rn

Establishing an Establishing an Effective CQI Program Effective CQI Program

By:By:Shannon Bentley, RN,cShannon Bentley, RN,c

AndAndLois Sacher, RNLois Sacher, RN

Welcome CQI Team!Welcome CQI Team!

Each team member will:Each team member will:

1.1. Help establish the project Help establish the project objectiveobjective

2.2. Listen to each other’s ideas Listen to each other’s ideas and acknowledge their point of and acknowledge their point of viewview

3.3. Define project roles and Define project roles and responsibilities together  responsibilities together 

4.4. Promote responsibilityPromote responsibility

CQI Meeting Agenda CQI Meeting Agenda Monday, June 22, 2009Monday, June 22, 2009

Introduction Introduction Julie (0:00-5:00) Julie (0:00-5:00)

Participant Introductions Participant Introductions All (5:00-10:00) All (5:00-10:00)

Brief Overview Brief Overview Lois (10:00-15:00) Lois (10:00-15:00)

Creating the CQI Program Creating the CQI Program All (15:00-35:00) All (15:00-35:00)

Center Success Stories Center Success Stories Loydene and Brenda (35:00-55:00) Loydene and Brenda (35:00-55:00)

Wrap-Up Wrap-Up Shannon (55:00-1 hour) Shannon (55:00-1 hour)

IntroductionsIntroductions

Hello my name is Hello my name is .. My position on center is My position on center is . . The thing I dislike the most The thing I dislike the most

about the service I receive at my about the service I receive at my personal doctor’s office is personal doctor’s office is

. .

CQI CQI

Improves Improves organizationorganization and and systemssystems

Most things can be improved!Most things can be improved! This philosophy does not This philosophy does not

subscribe to the theory that “If it subscribe to the theory that “If it ain’t broke, don’t fix it."ain’t broke, don’t fix it."

CQI or QA?CQI or QA?

1. Focus is on human error and eliminating poor performers

2. Ensure that policies, procedures and protocols make sense

3. Monitors compliance through periodic audits and inspections

4. Relies on teamwork and incorporates evidence-based care

Source: The NYC Division of Mental Hygiene. Quality IMPACT Basic CQI Course. http://www.nyc.gov/html/doh/downloads/pdf/qi/qi-training.pdf

What are you doing—CQI or What are you doing—CQI or QA? QA?

1.1. Corrective Action Plans Corrective Action Plans (CAPS)(CAPS)

2.2. Surveying students on the Surveying students on the service they receive in the service they receive in the HWCHWC

3.3. Tracking Chlamydia test Tracking Chlamydia test positives and experimenting positives and experimenting with different sex education with different sex education initiativesinitiatives

Steps in CQI Steps in CQI

Plan

DoStudy

Act

ToolsTools

BrainstormingBrainstorming PurposePurpose Time limitTime limit Note takerNote taker

MultivotingMultivoting Relies on popular opinion Relies on popular opinion Prioritizing projects or elements of projectsPrioritizing projects or elements of projects

Please be creative! There are no bad ideas! Please be creative! There are no bad ideas!

PlanPlan

Step 1Step 1

Data Collection Methods:Data Collection Methods:

Surveys of staff and students Observation Chart audits Review of current protocols Focus groups Student suggestion boxes Individual discussion Use of the SGA/or Wellness

Committees

Survey ResultsSurvey Results

Nursing staff’s skills and ability = Nursing staff’s skills and ability = 3.23.2

How well the nursing staff How well the nursing staff listened to you = 3.0listened to you = 3.0

Extent to which the nursing staff Extent to which the nursing staff involved you in decisions about involved you in decisions about your care = 2.5your care = 2.5

Target Identification:Target Identification:Wellness Center ComplaintsWellness Center Complaints

0

5

10

15

20

25

30

35

40

45

50

Rude staff

Limited hours

Tylenol for everything

Too far from class

Confusing forms

DoDo

Step 2Step 2

What cause are we going to What cause are we going to tackle?tackle?

Possible InterventionsPossible Interventions

Writing or revising formal Writing or revising formal policies and procedurespolicies and procedures

Obtaining new equipment Obtaining new equipment Create or revise educational Create or revise educational

materials for students or staffmaterials for students or staff Student/staff trainingStudent/staff training

StudyStudy

Step 3Step 3

What does this tell us?What does this tell us?

Student Perception

0

10

20

30

40

50

60

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

% of students

Intervention

Interpreting DataInterpreting Data

Pilot test the system and make necessary revisions

Establish a schedule for follow-up data collection

Analyze and present findings to health and wellness team or supervisor, as appropriate

Identify and implement corrective actions

ActAct

Step 4Step 4

Where should we go with this?Where should we go with this?

BrainstormBrainstorm

CQI is a never-ending CQI is a never-ending process!process!

Re-evaluate for:Re-evaluate for: ResultsResults Changes needed in processChanges needed in process New or different goalsNew or different goals

PolicyPolicy

PRH and Desk ReferencePRH and Desk Reference

PRH RequirementsPRH Requirements

R15. Continuous Quality Improvement

Center health staff shall seek feedback

Quality of care provided, and document quality improvement activities

Desk ReferenceDesk Reference

Seek feedback from students Seek feedback from students through surveys and utilize the through surveys and utilize the SGA and health and wellness SGA and health and wellness committees to develop a quality committees to develop a quality management system that works management system that works for your centerfor your center

Center Success StoriesCenter Success Stories

Loydene and BrendaLoydene and Brenda

Gary Job CorpsGary Job Corps

Wellness Committee Wellness Committee ““Top 3” studentsTop 3” students Panther Club Staff leaderPanther Club Staff leader

Student satisfaction surveys Student satisfaction surveys Confidential way in which the Confidential way in which the

students may lodge a complaint  students may lodge a complaint  Development of a quality Development of a quality

improvement plan annuallyimprovement plan annually

Weekly MeetingsWeekly Meetings

Starting a MAR Updating the Infection Control

Plan Starting weekly power meetings

for the nurses Noting medication orders Staffing issues

Guthrie Job Corps CenterGuthrie Job Corps Center

Continuous Quality ImprovementContinuous Quality Improvement

(Performance improvement)(Performance improvement)

CQI/PI Plan contains:CQI/PI Plan contains: PAT (Performance Action Teams)PAT (Performance Action Teams) Trial period or pilot testing periodTrial period or pilot testing period Performance measuresPerformance measures Follow upFollow up

PerformancePerformance

Examples of data the Wellness Center may Examples of data the Wellness Center may choose for monitoring its performance choose for monitoring its performance include the following:include the following:

Risk ManagementRisk Management Quality controlQuality control Patient safetyPatient safety Medical Records CQIMedical Records CQI Performance measurement data on the Performance measurement data on the

needs, expectations, and satisfaction of the needs, expectations, and satisfaction of the individuals it servesindividuals it serves

GuthrieGuthrie

Collection of performance measurement data by Collection of performance measurement data by asking Wellness customers (both internal and asking Wellness customers (both internal and external) it serves the following:external) it serves the following:

How the Wellness Center can improve its serviceHow the Wellness Center can improve its service How the Wellness Center can improve patient safetyHow the Wellness Center can improve patient safety Patient surveys, student satisfaction surveys, Health Patient surveys, student satisfaction surveys, Health

Services Committee, other Department concerns/complaintsServices Committee, other Department concerns/complaints Performance measures that are related to the Performance measures that are related to the

following processes:following processes: Significant medication errorsSignificant medication errors Emergency ProtocolsEmergency Protocols Lab Testing ProtocolsLab Testing Protocols State Mandated STD/Communicable disease reportingState Mandated STD/Communicable disease reporting

Undesirable patterns or trends in performance are Undesirable patterns or trends in performance are extensively analyzed and addressed. extensively analyzed and addressed.

ResourcesResources

Resources Resources

Institute for Healthcare Institute for Healthcare ImprovementImprovement—This —This program provides the user with the program provides the user with the ability to set up and document ability to set up and document individual or team improvement individual or team improvement projects, including collection of data, projects, including collection of data, and track/trend changes over time and track/trend changes over time http://www.ihi.org/IHI/Topics/Improvehttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethodsment/ImprovementMethods

ResourcesResources

Center for Evidence-Based Medicine—Center for Evidence-Based Medicine—This website provides the user with tools to This website provides the user with tools to implement a project that evaluates practice implement a project that evaluates practice against evidence-based medicine. against evidence-based medicine. http://www.cebm.net/http://www.cebm.net/

Agency for Healthcare ResearchAgency for Healthcare Research and and Quality provides several resources for tools Quality provides several resources for tools to help design and support quality to help design and support quality improvement programs and projects. improvement programs and projects. http://www.ahrq.gov/qual/pstools.htmhttp://www.ahrq.gov/qual/pstools.htm

Quality ToolsQuality Tools http://www.syque.com/quality_tools/tools/Thttp://www.syque.com/quality_tools/tools/Tools_usage.htm#colools_usage.htm#col