cqi in healthcare organizations

8/14/2019 CQI in Healthcare Organizations

1/35

Continuous QualityImprovement

in

Health Care Organizations

Prepared by: Dr. Alber Paules


2/35

Definition

Quality Improvement (QI): the sum of all activities

which create desired change in the quality.

An effective QI system results in a stepwise increase

in quality of care. QI approach emphasizes reducingthe variability in the entire process and shifting the

process in the desired direction; rather than just

taking actions whenever thresholds are exceeded.

Continuous Quality Improvement (CQI): implies the

continuity of the improvement efforts(i.e.)whenever

an improvement is achieved, we might seek another

opportunity to achieve further improvement.


3/35

Why Healthcare Organizations

Adopt CQI Strategies/Initiatives?1. To maximize their quality of care as defined in both

technical and customer preference terms.

2. To gain more competitive advantages and increasetheir share in the local health care market through

excelling in the service they provide.

3. To gain or maintain an accreditation status with

bodies such as the JCAHO (JCI), NCQA, and others.

4. To respond to the pressures imposed on them by the

patient advocacy groups, employers, payers, and

regulatory bodies.


4/35

Why Should Health Care

Organizations adopt CQI?1. To maximize their quality of care as defined in both

technical and customer preference terms.

2. To gain more competitive advantages and increase

their share in the local health care market throughexcelling in the service they provide.

3. To respond to customer requirements/expectations

which change over time because of changes in

education, economics, technology, and culture; in

addition to changes in thecompetitorsperformances.

Such changes require continuous improvements in the

administrative and the clinical methods that affect the

quality of care.


5/35

Elements of CQI

1. Philosophical elements

2. Structural elements


6/35

1. Strategic Focus--Emphasis on having a mission, vision,

values, and goals that performance improvement processes

are designed, prioritized, and implemented to support.

2. Customer Focus--Emphasis on both customer satisfaction

(whether external or internal ones) and health outcomes as

performance measures.

3. Processes ViewEmphasis on analysis of the system

processes.

4. Continuing Improvementemphasis on continuing the

process analysis even when a satisfactory solution to the

presenting problem is obtained.

Philosophical Elements

of CQI


7/35

4. Top Management Commitment.

5. Emphasis on avoiding personal blame. The initial assumption

is that the process needs to be changed and that the personsalready involved in that process are needed to help identify

how to approach a given problem.

6. Encouraging participative management (through encouraging

the involvement of all personnel associated with a particularwork process to provide a contribution and share in solving

the problem) and decentralization (through placing

responsibility for ownership of each process in the hands of its

implementers).


of CQI


8/35

7. Increasing the pride and the morale of the employees by

recognizing their important role when they become

members in a process improvement team and become

involved in the re-design of a relevant process.8. Data-driven AnalysisEmphasis on gathering and use of

objective data on process performance with subsequent

fact-based decision making.


of CQI


9/35

1. Process Improvement TeamsEmphasis on forming and

empowering team of employees to deal with existing

problems and opportunities.2. Seven Toolsuse of one or more of these seven quality

tools: flow charts, cause-and-effect diagrams, histograms,

Pareto chars, run charts, control charts, and correlational

analysis (e.g.) scatter diagram.3. Quality Councildevelopment of the quality council,

which is an organizational structure formed from the top

institutional leaders, to set priorities for and monitor CQI

strategy and implementation.

Structural Elements of CQI(elements which structure, organize, and support the CQI

process)


10/35

4. Development of a comprehensive set of indicators to

monitor our performance.5. Benchmarkinguse of benchmarking to identify best

practices in similar settings to use as performance targets.

Structural Elements of CQI


11/35

The Iceberg Model of QI

Tools (what we can see and do)

Systems, Frameworks, and Models

(shaped by theories and assumptions;

unseen)

Theories and Assumptions

(deep under the surface;

we are largely unaware of)

Tip

Base


12/35

These include the contributions of the quality leaders,

like:

1. Walter Shewhart

2. Edwards Deming

3. Joseph Juran

4. Philip Crosby, and others.

Foundation of the Iceberg Model:

Theories and Assumptions


13/35

They are derived from the ideas and theories developed by thethought leaders; they include:

1. FOCUS-PDCA:

o Designed by a healthcare QI consulting group in the 1980s .

o Uses theDemingsCycle (PDCA cycle).

o FOCUS-PDCA is an acronym for the following:

Find an opportunity for improvement

Organize a team that knows the process

Clarify current understanding of how the process works

Understand the process variation

Select a strategy for improvement

The PDCA cycle tests the strategy to determine its

effectiveness (i.e., if it results in improvement)

Middle of the Iceberg Model:



14/35

Find a process to improve This is relatively easy when the organization first begins

performance improvement activities.

A comparison has been made to a fruit tree. When you firstbegin to harvest the fruit, it is very easy since it probably is

lying about the ground; however, the more harvested the

more difficult it becomes to obtain.

Selected improvement opportunities should be approved by

the quality council.

FOCUS-PDCA


15/35

Find a process to improveBecause of this increasing difficulty in identifying

opportunities, there are many ways for finding opportunities

than simply picking one up from the ground.The following references may suggest opportunities for

improving performance:

Standards of Care

Customer Satisfaction Surveys

Incident Reports

Action/Recommendation Sections of Committee Minutes

Employee Suggestions

Accreditation Surveys

FOCUS-PDCA


16/35

Find a process to improveMistakes to avoid while searching for improvement

opportunities:

Selecting a System to study instead of a Process:(e.g., selecting a phase on the medication management

system rather than addressing the whole system)

Selecting a desired Solution instead of a Process:

Frequently managers will already have a desired solution

to the problem in mind and will convene this solution to

the team to study. Teams must be free to select whatever

interventions they think are best. Sure, the suggested

solution may be the best, but this is determined only after

thorough analysis of the process.

FOCUS-PDCA


17/35


18/35

Organize a team that knows the process The Facilitator:

o Assigned by the quality council to assist the team.

o

Attends the meetings.o Not a team member.

o He/she facilitates not dictates.

o He/she is more concerned with how decisions are made

rather than with what the decisions actually are.

o Responsibilities include: assist team in using PI tools, assist

team in preparation of presentations to management,

assist team in measurement and understanding of

statistics, assist team leader in dealing with divisive

members..etc.

FOCUS-PDCA


19/35

Organize a team that knows the process The Recorder:

o A team member.

o

Assigned by the team leader.o Responsible for keeping the minutes of the team and for

documentation of the progress of the team.

o A single team member may serve for the duration or this

responsibility may rotate among all team members.

o If one team member is asecretary,he/she should not be

automatically chosen to serve as the recorder.

FOCUS-PDCA


20/35

Organize a team that knows the process The Time Keeper:

o A team member.

o

Assigned by the team leader.o Responsible for periodically reminding the team of the

assigned time remaining for agenda items and the meeting

as a whole, aiming at keeping the team on track and

focused.

FOCUS-PDCA


21/35

Organize a team that knows the process Team Members:

o They are usually the process experts (i.e., those who best

understand the process to be improved). Sometimes, the

team member may be a supervisor of the expert (i.e., does

not have direct knowledge of or experience with the

process).

o Chosen by the leader and approved by the quality council.

o Responsibilities include: attending team meetings on aregular basis, full participation in team activities, and

conducting the in-between meeting assignments in a

timely manner.

FOCUS-PDCA


22/35

Clarify current understanding of how the processworks Ensure that all members understand the whole scope of the

process to be improved. Frequently, members are familiar

with only a few steps of the process and are not aware of

what might be occurring on either side of their activity

segment.

A frequent problem that occurs at this stage is the temptation

to prematurely think about suggestions for process

improvement. Interjecting fragmented solution suggestions atthis point only makes it more difficult for the team to arrive at

a complete process analysis.

FOCUS-PDCA


23/35

Clarify current understanding of how the processworks Another barrier to good process analysis is the failure to

drive out fear. For example, a team member may be

afraid to tell that a process does not follow an existing

policy. Clearly, if this information is not available to the

team, the process improvement efforts will fail. The team

leaders political-sensitive approach towards encouraging

the team member to share his/her opinion is crucial.

Several tools are available to assist the team in driving outfear and facilitating the free and open communications

necessary to the project. One of the most important tools

used during the clarification (C) phase isflowcharting.

FOCUS-PDCA


24/35

Understand causes of process variation In this stage, the team strives to understand why the

existing process is not working well, i.e., what are the

reasons for process variation.

Cause-and-effect diagram, also known as "fishbone"

diagram, is an excellent aid in the (U) understanding phase

of the FOCUS-PDCA cycle. A cause-and-effect diagram is

actually only a graphic presentation of a list.

FOCUS-PDCA


25/35

Understand causes of process variation Whilebrainstormingmay be used anywhere in the FOCUS-

PDCA cycle, the first need for it will likely be encountered

in the (U) understanding phase. Brainstorming is effective

because it is free form and does not restrict people in

offering ideas. It encourages responses from team

members who may for a variety of reasons be reluctant to

participate.

Brainstorming can be followed by amultivoting technique. At this point, it may become necessary to use thePareto

analysis to determine what is causing most of the

problems.

FOCUS-PDCA


26/35

Select the strategy for improvement At this point in the cycle the team should be ready to

select the improvement or improvements that will be

made in the process. It may be necessary to use a structured approach that

results in a precise statement of the planned

improvements that was reduced down from a

thorough study of the alternatives (e.g., prioritizationmatrix).

FOCUS-PDCA


27/35

Plan the improvement Here, the team should outline how the improvements

will be accomplished, i.e., the who, what, where, and

when. Consideration should be given to developing a pilot

projectfor the selected changes.

Considering what resources, training, etc., shall be

needed is crucial.

FOCUS-PDCA


28/35

Do the improvement Implement the planned improvement.

Usually, the implementation is the responsibility of

the team.

FOCUS-PDCA


29/35

Check the results After the implementation of the improvements, it will be

necessary to continue data collection to determine if the

improvements have proven successful in bringing the processto the desired direction.

If continued checks indicate that the desired outcome has

not occurred, it may be necessary to return to theselection

stageand take another look at the alternative improvements.

If all is going well, the team should perform a self analysis oftheir performance with emphasis on how the team process

could have been improved. This team self-analysis can be

reported to the quality council to benefit future teams.

FOCUS-PDCA


30/35

Act to maintain the gains There is often a tendency for things to reverse to their

previous state if well-planned controls are is not in place.

It is very important to ensure that initial gains are not lostdue to subsequent satisfaction, failure to stick to on

implemented changes, etc.

Now after the new improvements have proven success, the

team should consider revising and modifying the relevant

policies and procedures, etc. Additionally, performingregular internal audits is crucial to ensure the compliance

to such new or modified policies and procedures.

Control charts are usually used to monitor the maintenace

of such gains.

FOCUS-PDCA

Middl f h I b M d l


31/35

2. ISO 9000:o The ISO 9000 Quality Management System was created

in 1987

o In 1994, ISO 9001 standards were released.

o The most recent version of ISO 9000 is ISO 9001:2008

o Applicable to both manufacturing and service sectors.

o Emphasizes:

documentation and recording.

conduction of internal audits on a regular basis.

taking corrective and/or preventive actions,

whenever needed.

listening to customers.

continuous improvement.




32/35

Middl f th I b M d l


33/35

4. Six Sigma:o A system for improvement that was

developed over time by GE and Motorola in

the 1980s.

o The aim of Six Sigma is the to reducevariation/eliminate defects in key business

processes.

o Methodology follows the following five

steps: Define, Measure, Analyze, Improve,and Control (DMAIC).



Middl f th I b M d l


34/35

o All of the pre-mentioned are systems or frameworksfor performance improvement, and each has a

slightly different focus, tools, and techniques

associated with it.

o However, all these programs emphasize customer-focus, process analysis, and teamwork.

o The compatibility of any of them within any

organization depends on the organizational culture

and infrastructure, the top management support

(both ideologically and financially), and the

employees buy-in and support (which is again

dependant on the top management commitment).




35/35

Tools, methods, and procedures are analogous

to the tip of the iceberg.

We can observe people using tools and

methods for improvement. We can see them

making a flowchart, plotting a control chart, or

using a checklist.

Tip of the Iceberg Model:

Methods, Procedures, and PI Tools

cqi in healthcare organizations

Documents