design quality imqiprove

7/29/2019 Design Quality Imqiprove

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Designing a Successful Quality

Improvement Program:Teambuilding and Writing a QI Plan

Bureau of Primary Health Care

Health Resources and Services Administration

March 10, 2011


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Introduction

Learning series on quality improvementplanning

Current core and FTCA requirements asa starting point

Focus on implementation Roadmap for getting there

Create a QI infrastructure

Seek resources and technical assistance

Third-party quality recognition Build on partnerships with HRSA and the national

cooperative agreements


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Health Center Performance

Calendar Year 2009

Among Health Center Patients:

67.3% entered prenatal care in the first trimester Rate of low birth weight babies (7.3%) continues to be lower than

national estimates (8.2%) 68.8% of children received all recommended immunizations by

2nd birthday 63.1% Hypertensive Patients with Blood Pressure


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FY 2011 HRSA

Strategic Priorities

Improve Access to Quality Health Care andServices Community/new site development

Expansion planning

Patient-centered medical/health home development Meaningful use adoption

Strengthen the Health Workforce Workforce recruitment and retention

Build Healthy Communities and Improve HealthEquity


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BPHC QI Strategy

1. Develop and enhance access points

2. Transform HC care delivery system PCMHH

HIT Meaningful Use

3. Recruit, develop, retain skilled workforce

4. Integrate Health Centers into local healthsystems Specialists, ER, Hospitals

ACOs

Public Health

5. Align policies and programs where possible


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HRSA Program Requirements

Ongoing QI/QA Plan encompassingmanagement and clinical services,maintaining confidentiality of patient

records Focused responsibility for QI

Periodic assessments of appropriate

service use and quality


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Benefits of an Effective QI Plan

Roadmap for HC organization

Leadership, focus, & prioritization

Efficient coordination of staff &

resources Better outcomes

Satisfy external requirements

HRSA, State

Third-party quality accreditation andrecognition


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QI Resources

Local

Your own staff

Other HCs

Academia

Health Departments

State/Region

PCAs & HCCNs

Medicaid, AHEC, PCOs


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B thi Lif


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Breathing Lifeinto Your QI Plan


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Where Do We Start?

OK Great!!

So how do we actually do this when we are:

Short staffed

Busy with lots of complicated patients

Short on resources (shouldnt all our

money go for patient care?)

Lacking QI skills (not covered well inmedical school, nursing school, businessschool)


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Where Do We Start?

Depends on where you are, who you are,when you began, how big you are

One site 3 providers rural Alaska 2,000

users

12 sites NYC 52 providers 100,000users

35 year history of organization, fullyimplemented EHR for 6 years

New start 2010 paper medical records


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Where Do We Start?

The Steps:

1. Create the Basic Structures

2. Evaluate & Determine Priorities

3. Select Performance Measures

4. Collect Data/Determine a Baseline

5. Analyze Data/Evaluate Performance

6. Plan & Implement Changes forImprovement

7. Monitor Performance Over Time


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Quality as an integral part of theorganizations culture.

Buy-in at all levelsBoard, management,

staff and patients. Resourcesstaff time, meetings,

information systems.

Provide education


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Role of the board

Approve QI plan

Receives reports at

least quarterly BOD QI Committee


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Continuousresources (time,money, staff)

dedicated for TA You cannot afford

not to do this!


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QI Committee QI Plan & Health care plan QI calendar Clinical practice guidelines

Policies & procedures Peer review Chart audits Patient satisfaction surveys Tracking systems Credentialing and privileging Data sources

2 E l t & D t i


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2. Evaluate & DeterminePriorities

Set aside a specific time/place where allessential staff plan how to develop your QIPlan

Remember this work will never be DONE--Continuous QI

2 E l t & D t i


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2. Evaluate & DeterminePriorities

Focused areas

High risk

High volume

Low performingmeasures


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A Performance Measure is a quantitativetool that provides an indication of anorganizations performance in relation to a

specified process or outcome.


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Set goals for measures:

A SMART goal is a goal that is specific,measurable, attainable, relevant and time

based. In other words, a goal that is veryclear and easily understood.


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Outreach/Quality of CareIndicators

Trimester of entry into perinatal care

Childhood (2 year old) immunization

rate

Pap tests for adult (21 64 year old)women

Health Outcomes and

Disparities

Infant birth weight (normal vs. low)

Hypertension (controlled vs.uncontrolled)

Diabetes (adequate control vs.

inadequate control)


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Required two

additional measures One Oral Health

One Behavioral Health

Supplemental

measures


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Working capital to monthly expense ratio Liquidity in # of months - ability to pay bills on

time - current financial condition

Long-term debt to equity ratio Portion of net assets tied up in long-term debt - long-

term financial condition Change in net assets as a percent of expense

Financial results from operations in relationship to totalexpenses

Total cost per patient

Annual average cost per patient served - value ofservice provided based on costs

Medical cost per medical encounterAverage cost per billable medical encounter (less: lab &

pharmacy) - cost efficiency

4 Collect Data/Determine


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4. Collect Data/Determine

a Baseline



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a Baseline

Define measurement population anddelineate eligibility criteria.

Create a data collection plan to include:

Sampling strategy; Determine method of data collection,

i.e. chart abstraction, interviews



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a Baseline

Create data collection tools:

Create instructions for data collection tools

Train personnel who will collect data

Conduct pilot test of tool Establish process of communicating with

staff about measurement process

Collect data

5 Analyze Data/Evaluate


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5. Analyze Data/Evaluate

Performance

Analyze data and review the results.

Identify areas where additional data isrequired.

If historical data are available, compare fortrends.

Display and distribute data to communicatefindings and results.

Identify areas for improvement and select aquality improvement project.



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Performance

How do we know ifperformance is satisfactory?

Benchmarks useful insetting feasible andchallenging goals

The most importantcomparisons are internal

Most relevant when patientpopulations are similar

UDS data will reveal state

and national trends overtime, rural vs. urban, etc.



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Performance

Healthy People 2010:

www.healthypeople.gov

National Quality CenterImproving HIV Care:http://www.nationalqualitycenter.org/index.cfm/22

AHRQ Effective Health Care:http://effectivehealthcare.ahrq.gov/

National Quality Forum:

http://www.qualityforum.org/

State Primary Care Associations:http://www.bphc.hrsa.gov/technicalassistance/pcadirectory.htm

6 Plan & Implement Changes
http://www.healthypeople.gov/http://www.nationalqualitycenter.org/index.cfm/22http://effectivehealthcare.ahrq.gov/http://www.qualityforum.org/http://www.bphc.hrsa.gov/technicalassistance/pcadirectory.htmhttp://www.bphc.hrsa.gov/technicalassistance/pcadirectory.htmhttp://www.qualityforum.org/http://effectivehealthcare.ahrq.gov/http://www.nationalqualitycenter.org/index.cfm/22http://www.healthypeople.gov/


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6. Plan & Implement Changes

for Improvement



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6. Plan & Implement Changesfor Improvement

Discrepancy between goals or standardsand reality

Solve the problem!

Can it be solved?

Is it worth solving?

Who should do it?

What is the goal? (MEASUREABLE) How soon?



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Establish project-specific QI team thatrepresents all staff integral to the serviceor issue.

Identify a team leader or sponsor.

Delineate specific goals for the team.

Allocate time and resources for the team.

Delineate team responsibilities.

Develop timeline for reporting findings andimprovement strategies.



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for Improvement

Develop a time line or calendar of activitiesfor the year.

Select a QI approach, such as PDSA or

the Chronic Care Model. Clarify QI responsibilities of staff.



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Utilize QI tools and techniques tounderstand the process, such as flowcharts, facilitated brainstorming, cause and

effect diagrams, etc. Document and track progress by using

activity logs, issue identification logs,meeting minutes, etc.

Report progress on a regular, definedbasis.



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Identify potential solutions to makeimprovement to the systems of care.

Recognize quick fixes and longer termsolutions.

Try a small test of change and analyzeresults.

Refine improvement plan. Develop timeline for implementation of

plan. Delineate team responsibilities. Implement changes. Track changes and improvement actions.



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Plan-Do-Study-Act

(PDSA) :

PDSA is a widely

used framework fortesting change on asmall scale.

7. Monitor Performance


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7. Monitor PerformanceOver Time

Determine interval for remeasurement.

Remeasure indicator after change hasbeen implemented.

Look for incremental improvement. Communicate results to team, staff and

leadership.

Determine need for and/or level ofremeasurement on an ongoing basis.

Develop a plan for sustained improvement.

CHC Difficult Areas


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CHC Difficult AreasQI Improvement

Performance Measures

Data bases/Data Collection/DataReliability

Identify/Use Benchmarks

Identifying/Documenting necessity forchange in provision of services

Result in change being implementedremeasure to assure improvement

A Real Life E ample


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A Real Life Example

Steps 1 4


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Steps 1 - 4

XCHC Diabetes measure (HbA1C < 9%)was 83% (HDC participant for 6 yrs)

HTN rate


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5. Analyze Data/EvaluatePerformance

Discrepancybetweenbenchmarks (HP

1998 benchmark79%; 2009 BPHCUDS 58%) andreality (20%)

Solve the problem!



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Establish project-specific QI team thatrepresents all staff integral to the serviceor issue.

Scheduler, provider, nurse manager, medicalrecords, IT

Identify a team leader or sponsor. Chair of CQI program (COO)

Set specific goals for the team. Initially wanted to improve to 25%...

Verify baseline data

Identify restricting & contributing factors



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Allocate time andresources for the team. Initially meet weekly to

monitor PDSA cycles

Delineateresponsibilities.

Develop timeline forreporting findings and

improvement strategies. Report to next CQI

meeting in one week thenmonthly



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p gfor Improvement

Processes

EHR now being implemented

Staff training Patient education

Plan to institute new consent formspecific for womens health and policy to

ensure its use



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6 a & p e e t C a gesfor Improvement

Clinical practice guideline Review Pap guidelines and present to provider staff

Access to care issue Many pts seek Paps at State Health Department

Hispanic patients prefer female provider Many mobile migrant patients with multiple providers

Outcomes data Incomplete because only queried practice management

system which did not include transferred records

Tracking No consistent mechanism for obtaining records from

other providers Have meeting with health dept staff to assure

cooperation



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p gfor Improvement

Pt. satisfaction survey?are they happywith the system?

Will consider in the future to exploreattitudes regarding various interventions

Documentation of process

Plan to keep meeting minutes, goals,outcomes



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p gfor Improvement

Analyze data and review the results. Monthly review of women seen for Pap status

Identify areas where additional data is required.

Data collection method did not capture all Paps done

If historical data are available, compare for trends. Not previously measured

Display and distribute data to communicatefindings and results.

Plan to inform CQI committee and staff of results Graphic presentation of data readings over time

7. Monitor Performance


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Over Time

Communicate resultsReports to BOD, staff

Congratulate team

Newsletter articleSelect a new projectand begin with a newmeasure.

Oral health forpregnant women

Additional Webinars


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in This Series

Implementing your QI plan How to choose specific strategies

How to evaluate

Connection to risk management, peer review,

accreditation and PCMH

How to use data that you are already collectingto fuel your QI process

Setting goals and performance metrics

Increasing data reliability

Using HIT

Discussion and Questions


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Discussion and Questions

Please share your qualityimprovement successes, challenges,and training and technical assistance

needs Contact your HRSA Project Officer or

the Office of Quality and Data at

[email protected] or(301) 594-0818
mailto:[email protected]:[email protected]

design quality imqiprove

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