establishing a quality management framework: a journey in...

Dawn Hartfield BScMed, MPH, MD, FRCPC

Medical Director Quality, Integrated Quality Management

Edmonton Zone, Alberta Health Services

Associate Professor, Department of Pediatrics

Faculty of Medicine and Dentistry, University of Alberta

Establishing a Quality Management Framework:

A Journey in Health Care

2

Project Team

• Donna Daniec – Executive Director

• Malanie Greenaway – Manger

• Christine Taam – Project Director

• Janine Cousineau – Executive Assistant

Integrated Quality Management, Edmonton Zone, AHS

3

Goal of Quality Management Framework

• Provide vision, leadership and direction for quality

planning, quality monitoring and quality improvement

within the Edmonton Zone.

• Enhance an integrated approach to quality within the

Edmonton zone

– Develop a structure that links frontline to senior

administration

Deliver better quality, better outcomes, and better

value to our population

4

QMF Phases

• Phase 1: Requirements and Analysis

– Completed December 2013

• Phase 2: Design

– Development of framework and supporting tools required for

implementation

– Completed April 2014

• Phase 3: Pilot

– Pilot implementation at Stollery Children’s Hospital June 2014

• Phase 4: Implementation

– Completed : December 2014

5

QMF Phase 1: Literature Review & Stakeholder

Interviews

Literature Review

• Patient Engagement

• Leadership

• Measurement & Reporting

• Partner Engagement

• Capacity Development & Data

• Capability Development

• Governance

• Process Support

Stakeholder Interviews

• Patient & Family Centered

• Leadership: “walk the talk”

• Just Culture

• Accountability

• Physician & Staff Engagement

• Capacity Building

• Capability Development

• Infrastructure

• Process Support

• Recognizing Achievement

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• Five organizations were interviewed:

– Kaiser Permanente (United States)

– Mayo Clinic (United States)

– Interior Health (British Columbia)

– Providence Health (British Columbia)

– North York (Ontario)

• Standardized questions:

– Structure

– Resources

– Quality culture

– Educational requirements

QMF Phase 1: Environmental Scan

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• All have an over-arching Committee

• Most have Program Based Committees

• All large QI Projects have a formal approval process

• All have a Project prioritization process

• Culture is very important

– Supported by leadership & communication

– Data and patients stories

• Education of frontline is critical

– Supported by trained experts

QMF Phase 1: Environmental Scan

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Edmonton Zone

Quality Improvement

Structure

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Rationale for this Structure

• Develop clear line of site Unit to Program/Site to Zone

• Establish relationships and effectively utilize resources

• Develop capacity and capability

– Means to empower frontline care providers

• Build relationships by working in multidisciplinary team

• Improve just culture

• Improve job satisfaction

Ultimately: Improve patient outcomes

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Role of Quality Councils

• Quality Planning

– Coordinate QI activities on the unit

– Engage staff and patient/families in QI

• Quality Monitoring

– Utilize data to prioritize QI activities

– Work closely with QA/Patient Safety

– Set performance targets and initiate QI activities to achieve and

sustain goals

• Quality Improvement

– Conduct QI work using standard methodology

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QMF Phase 4: Implementation

January 2015

•18/23 have existing Program/Site Quality Councils

•12 of these may have Unit Quality Councils

•8/12 have existing Unit Quality Councils

•12/23 minor improvements required

•6/23 moderate improvements required

•5/23 just “starting up”

•Strongest groups are part of provincial programs

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Early learnings from the successes

• Engaged frontline teams can do QI work

• Satisfaction and pride was readily apparent

• Time and patience is required to see results

“If we are together, nothing is impossible. If we are

divided all will fail” Winston Churchill

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Supporting Rapid System GrowthChallenge Action

QI Education for all •QI Education strategy for EZ

Data & Infrastructure to support QI •Improve data access for frontline teams

System Assessment:

Quarterly reporting process

•Improve quarterly reporting process

•Electronic platform

•Biannual

Further clarity for frontline quality

teams of how they “fit in” to the QMF

•Inventory of quality councils in the EZ

•Connection Forums to build teams

Ongoing facilitation of frontline

councils by IQM team, medical and

operational leadership

•Clinical Quality Consultants assigned

to programs/sites to facilitate processes

•Senior leadership support

•remove barriers

•QI part of job descriptions

•Ongoing follow-up by IQM leadership

with Site/Program QC

Biannual Report June 2015

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Key Priorities for EZ Quality Councils

June 2015 until present#1 Improving Transitions in Care

Client / Family Role in Safety

Dangerous Abbreviations

Information Transfer

Medication Reconciliation

Safe Surgical check list

Two client identifiers

#2 Improving Patient Flow

Client flow

Client safety: Education & Training

Client Safety Plan

Preventive Maintenance

#3 Decreasing Hospital Acquired Infections

Hand Hygiene compliance and education

Infection rates

Pneumococcal vaccine

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Biannual Report October 2016

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• 109 Quality Councils reported

– 20/38 (53%) Program/Site QC reported

– 89 Unit Quality councils reported

• Highlights:

– 66% of QC have 5 to 15 members

– 80% have 3 or more disciplines involved

– 69% have a quality board where activities displayed

– 68% have quality boards in a public facing location

– 94% have identified priority areas of work

• Excellent QI work completed throughout the EZ

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Area of future opportunity:

– 9% have a patient or family representative

Top three barriers identified by teams:

– 73% sufficient time

– 56% frontline staff availability

– 32% change management

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Strategic Planning 2017

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Information Gathering and Key Steps

• SWOT analysis of current state

• Literature review 2013-2016

• IHI Capacity and Capability Assessment tool

• Collaboration with QHI

• Full day session March 15, 2017

– Socialize the concepts

– Brainstorm barriers and solutions

• Establish three year plan for roll out

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RESULTS: SWOT ANALYSIS

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SWOT Analysis

Strengths• Framework

• Available education

• Leadership support

• Increasing awareness

• Desire to participate

• Data available

• Grant funding available

• QHI supports

• Biannual report data

Weaknesses• Inconsistent function of QC

• Quality literacy low

• Not part of performance

• Variable MD participation

• Barriers to data access

• Data not suitable for QI work

• Insufficient number CQC &

data analysts

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SWOT Analysis

Opportunities• Alignment with IHOT

• Leverage QHI resources

• QI generate cost-saving

• Improve safety culture

• QI/PS as academic

career path

• Build capacity in EZ

Threats• Lose momentum if

disengagement

• Lose trained personnel to

Universities/province

• Budget constraints

• Without progress, system

collapse

• Turnover of QC members

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RESULTS: IHI ASSESSMENT TOOL

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Capacity

Having the right number and level of people who

are actively engaged and able to take action.

Helen Beven, “How can we build skills to transform the healthcare system?” Journal of

Research in Nursing 152(2) 139-148, 2010

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Capacity Assessment

Capacity Building Issue 2015 2017

Mission/Vision in context of QI 2.2 2.6

Education in QI 2 2.1

QI is part of Performance Evaluation 1.6 1.7

Suppliers are partners in QI 1.8 2

Employee Support & Resources in QI 1.8 1.7

Set Up QI teams 2 2.1

Process in place to prioritize QI Initiatives 2 2

Developing Performance Indicators of QI Initiatives 2 2.1

Preparing communication tools that share information

on quality goals and initiatives

2 1.8

Overall Mean Score 1.9 2

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IHI Capacity Assessment

0

0.5

1

1.5

2

2.5

3

2015 2017

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Capability

The people have the confidence and the

knowledge and skills to lead the change and

take action

Helen Beven, “How can we build skills to transform the healthcare system?”

Journal of Research in Nursing 152(2) 139-148, 2010

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Capability 2015 2017

Leadership for Improvement – clear improvement goals, expectations,

priorities, accountability and integrate support for same through organization

2.9 3.3

Results – ability to demonstrate measureable results 2.8 3.1

Resources- capability to provide sufficient resources to QI teams 1.9 1.9

Workforce & HR – capability to encourage & reward participation in QI work

& defined leadership roles which include QI as component

2.1 1.9

Data Infrastructure & Management – capability to establish, manage &

analyze data for QI

1.9 1.8

Improvement Knowledge & Competence – capability to execute on skills and

competencies to undertake QI throughout organization

2.3 2.7

Overall Mean Score 2.3 2.4Score 1 = Just Beginning

Score 2 = Developing

Score 3 = Making Progress

Score 4 = Significant Impact

Score 5 = Exemplary

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IHI Capability Assessment

0 1 2 3 4 5

Leadership for Improvement

Results

Resources

Workforce & HR

Data Infrastructure &…

Improvement Knowledge…

Average Score

2015

2017

Score 1 = Just Beginning

Score 2 = Developing

Score 3 = Making Progress

Score 4 = Significant Impact

Score 5 = Exemplary

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RESULTS: LITERATURE REVIEW

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Ten Common Challenges

1. Disconnected communication

2. Lack of frontline involvement

3. Lack of physician engagement

4. Budget and resource constraints

5. Lack of leadership involvement and support

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Ten Common Challenges

6. Importance of safety culture

7. Lack of appropriate QI training and knowledge

8. Lack of optimization in process for continuous

improvement

9. Lack of collaboration from operational teams

and support teams

10.Lack of standardized data collection,

management and measures

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Literature Review

Four Key Themes:

Four recurring themes that demonstrated support in

sustaining quality improvements in health care include:

1. Positive patient safety culture

2. Competence and empowerment of frontline

3. Leadership commitment to quality

4. Organization-focused quality indicators

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EZ QMF Strategic Plan 20171. Safety Culture

• Foundational to success in systems improvement

• Aligns with provincial priorities

2. Building quality and safety literacy

• Structured plan for all AHS employees

• Institute for Healthcare Improvement and AHS internal resources

3. Leadership development: Leadership Management System

• Incorporate quality/safety into leadership practice

4. Use of Organization-focused quality indicators

• Quality data literacy (Run Charts)

• Improving access to data at the frontline

• Common strategic direction from province to frontline

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1. Improving Safety Culture

2016 Our People Survey

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Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and Effective Care. White

Paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017.

(Available on ihi.org)

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Improving Safety Culture: TeamCare

• Educational model co-developed by with Dr. A. Frankel

• Training in teamwork and communication

• Establishes behavioral norms and common language

• Reinforces principles of QI

• Site based approach with 3 courses:

– Coach (1 day),

– Leader (senior leader, PCM and UM (1 day)

– Frontline team training (3 day)

• Sustained by local champions & embedded experts

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• Site preparation with leaders

– The site champions for each site plus dyad leaders

– Establish a physician engagement plan

– Governance model

• Site quality councils

– Plan for training sessions

– Financial implications

• Cost of back-filling

• Split training days for cost-effectiveness

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• Site training of frontline teams

– PCM/UM take one day leader course

• responsible for preparing their areas

– Three days of “training for teams”

• Team is often comprised of quality council

members from a unit

– Practice coaching between sessions

– 6 weeks between each training day

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2. Building Quality and Safety Literacy

• A three year curriculum has been developed

• Education is role-dependent

• Includes:

– IHI – global quality and safety perspective

– AHS- local context

• Combination of web-based and in-person sessions

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3. Leadership Management System

• Assists leaders in focusing on strategic objectives by:

• Deep understanding of strategic alignment

• Establishing key priorities with measures

• Utilizing clear communication plan

• Use of visual tools

• Coaching problem solving skills

• Establishing high functioning quality councils

• Led by experts in PI and leadership management system

• Train experts from sites to build capacity in the EZ

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Leadership Management

System Implementation

1. Pre-site meeting preparation with site leaders

– Assess current state:

• evidence of strategic alignment/communication plan.

For example, how do you ensure that key priorities

make to frontline?

– Decide on timelines for site implementation

– Establish embedded site experts who will be trained as

facilitators

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2. Complete a site assessment and establish strategic priorities

and measures

– Review the Internal Assessment Tool

– Site leadership develops key priorities

– Develop measures

– Establish psychological safety

– Plan for educational sessions – schedule/plan timeframes

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3. Foundational Education: Understanding and utilizing

elements of management system

– Strategic Alignment – what does that mean

– How to coach and mentor problem solving

– Visual communication

4. Ensure high functioning quality council in place

– Empower people to meet strategic priorities

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4. Using Quality Indicators

to Drive Improvement

• Establish a working group of the ZQC to collaborate with

provincial partners to:

– Ensure timely access to data

– Ensure quality indicator data reported at unit level

– Standardize reports to improve visual communication

– Improve educational support for QI quality data

management (analysis tools, use of QI Macros, run

charts, control charts, and presentation of data)

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QMF in the EZ Strategic Plan 2017

• Safety Culture

– TeamCare

• Quality and safety education

– Three year curriculum

• Leadership development

– Leadership Management System

• Use of organization focused quality indicators

– Enhance access to data and education

Compassion

Accountability

Respect

Excellence

Safety

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