Connie T. Chuang, MD, MPA, MPH

connie.chuang@nyu.edu

Spring 2014 (631) 756-2204 ext. 103

Wednesdays: 6:45 to 8:25pm

Location: Global Center for Academic &

Spiritual Life, 238 Thompson St, Room 269

Continuous Quality Improvement (CQI) HPAM-GP.2825

Introduction This course encourage students to think creatively about what it means for a healthcare organization to make quality the highest priority. We will

explore the current forces driving the push toward quality outcomes and accountability at all levels and settings of healthcare, while focusing on

the philosophy of continuous improvement through teamwork and statistical thinking. Students will use structural tools for analysis, decision

making and performance measurement.

Prerequisites:

CORE-GP.1011 Statistical Methods for Public, Nonprofit, and Health Management,

HPAM-GP.4833 Health Care Management I: Control and Organizational Design, and

Computer Proficiency.

Students lacking the prerequisites must obtain permission to enroll in the course.

Learning Outcomes At the successful completion of this course, students will be able to:

Appreciate the historical evolution of healthcare quality improvement,

Understand the current forces driving changes in healthcare quality,

Describe the major models for improvement that provide a framework for change,

Apply a systematic method of improving a process using a team approach,

Understand the use of structural, process, and outcome indicators for measuring quality,

Recognize the implications of organization-wide transformation to continuous systems improvement,

Appreciate the challenges facing leaders in sustainability and spread of improvement efforts, and

Determine skills in working collaboratively.

Learning Strategies This course is based on:

1. Discussion of current events and the common themes emerging that are affecting the delivery of healthcare services and

2. Learning by doing, i.e. applying methods learning in class to process improvement assignments.

3. Process analysis provides the student the opportunity to think, read, write and present ideas logically in an organized manner. Emphasis

will be placed on oral and written communication and working in teams.

In this course, students will take the role of a team in a specific department or service in a healthcare organization. Students will use

management tools and techniques, diagnose problems and develop innovative, practical and cost-effective solutions to address a process

needing improvement. Assignments are geared toward analyzing a specific process that is producing a less than optimum outcome, identifying

the data required to analyze the problem and using specific QI tools and techniques for innovative solutions.

This course will integrate with the IHI Open School for Health Professions, an online school for helping students learn about quality improvement

and patient safety competencies.

Course Expectations Attend every class on time,

Read all assigned materials prior to class,

Actively participate in-class discussions and exercises,

Work with team members to complete assignments, and

Complete online and written assignments on time.

Please discuss with me as soon as possible should you foresee difficulty in adhering to any course expectation. All class absences must be

excused in advance. Extensions for assignment completion are granted only in cases of emergency.

Expectations of The Instructor In-person meetings: please make prior arrangements with me.

Email: this is the best way to communicate with me. I will do my best to provide a timely response; however, please allow yourself 24 hours to

ensure responses to any pertinent questions related to an assignment.

Grading 1. Written assignments. Total 50 points.

This course relies heavily on teamwork and communication. Because written assignments represent a team effort, all team members

will receive the same written assignment grade, unless the team evaluation forms reflect a lack of involvement deemed unacceptable by

fellow team members.

All written assignments are submitted in-person on the due date in class.

2. IHI Open School course completion. Total 16 points.

Each IHI course (16 total) completed by the due date earns 1 point

IHI Open School Courses completed past the due date without approved extensions will not be credited.

3. Team charter and evaluations. Total 14 points.

Team charter completion earns 4 points.

Mid-semester and final team evaluation completions are each worth 5 points. Depending on your team members’ evaluation of you,

such an evaluation may affect your final course grade, e.g. your active participation in team meetings and completing assignments.

Team charter to be submitted with Assignment 1.

All team evaluations are to be handed to me in-person on the due date in class.

4. Final presentation. Total 10 points.

5. Class Participation/Attendance. Total 10 points.

A point will be deducted for any unexcused absence.

6. Each written assignment, including team charter and evaluations handed in late without approved extensions will be penalized 2 points per

day after the due date.

Wagner’s Academic Honesty and Grading Policy All students are expected to pursue and meet the highest standards of academic excellence and integrity. This course will abide by Wagner’s

general policy guidelines on grading and academic honesty, including plagiarism. It is the student’s responsibility to become familiar with these

policies.

Grading Guidelines: http://wagner.nyu.edu/students/policies/grading.php

Incomplete Grades: http://wagner.nyu.edu/students/policies/incompletes.php

Academic Honesty: http://wagner.nyu.edu/students/policies/

Proper citation of ideas, data and published work is expected in this course.

Writing references: http://wagner.nyu.edu/students/services/tutoring.php

Recommended References Scholtes , Peter R., Brian L. Joiner and Barbara J. Streibel. The Team Handbook. 3rd ed. Madison: Oriel Inc., 2003. Print.

Zelazny, Gene. The Say It with Charts Complete Toolkit. New York: McGraw-Hill, 2006. Print.

Executive Learning Inc. Handbook For Improvement: A Reference Guide for Tools and Concepts. 3rd ed. Nashville: Healthcare

Management Directions Inc., 2002. Print.

Required Articles Posted on NYU Classes under “Resources.”

Required Online Courses IHI Open School online courses are free to students and provide important lessons in patient safety, quality improvement and leadership.

Completion by the required date as noted in the syllabus is required. To receive credit for each completed course:

1. Generate the course completion certificate (you must complete the evaluation at the end of each course to generate the certificate)

2. Submitted the certificate through the NYU Classes site under “Assignments” as an attachment.

The IHI Open School offers a basic certificate of completion for the 16 “core courses.” An IHI Open School iPhone/iPad app is also available to

view and complete the courses.

Written Assignments

Team Charter (4 points)

Complete the provided charter template. Use this charter to set team expectations and roles, including acceptable forms of communication,

process used to complete assignments and process used if an expectation of a team member “does not meet team standards.” Be as clear and

detailed as possible. Feel free to revise the charter throughout the semester.

Grading 1. Description of team expectation and roles [1 point] 2. Description of process should an expectation is not met by a team member [2 points] 3. Grammar, formatting, spelling [1 point]

Mid-Semester and Final Team Evaluations (total 10 points)

Complete the provided evaluation forms. Use the mid-semester evaluations as a gauge of successfully meeting team expectations and if needed,

to alter team dynamics. Use the final team evaluations to learn and develop your “personal style” as a healthcare manager. I will be sharing

comments among appropriate team members for professional growth. To obtain your final course grade, you must submit your final team

evaluation form to me by the due date.

Grading (for each team evaluation) 1. Completion of team evaluation form [2 points] 2. Constructive criticism for improvement [3 points]

Process for Improvement Submission

In teams of 3-5, students will select an organization, to which at least one team member has access and investigate a process that needs

improvement. The process you choose should be meaningful to the organization so that recommended changes can be adapted. You must be

able to collect data (concurrently or retrospectively) about the process over time, so be sure to choose a process that is well-defined and lends

itself to measurement.

Note: Teams will be formed during the first and/or second class. Each team will submit its process for improvement to the instructor for approval

no later than the third class session.

Assignment #1: Flowchart (10 points)

The first step on the improvement journey is to select the process for improvement. Answer the 3 Model for Improvement (MFI) questions and diagram the process flow. When selecting the process to analyze, consider “measurability” since you will be collecting data on this process for your next assignments. Identify the process concretely and think about the type of information needed. Be sure your flowcharts are well-defined with beginning and end points. Label your flowchart to clearly state the process being mapped. Format

1. Cover page with team member names, organization and process being examined. 2. One-page description of process being analyzed, ending with MFI questions/answers. You can use the IHI Open School’s Charter Form as

a guide. a. What are we trying to accomplish?

b. How will we know that a change is an improvement?

c. What changes can we make that will result in improvement?

3. Flowcharts: each team creates a chart based on interviews of at least 2 key and relevant stakeholders (e.g. physician, health care provider, manager, and/or patient).

Grading

3. Flowchart: appearance and flow, including correct use of basic flow chart symbols [5 points] 4. Written description of process – start with why you picked this process [3 points] 5. MFI questions with answers – one sentence answers [1 point] 6. Grammar, formatting, spelling [1 point]

Assignment #2: Run/Control Chart (10 points)

Run charts are graphs of data taken over time. Control charts build on the run chart and are one of the key tools used to display variation in the process, and identify the presence or absence of special or common cause variation. The purpose is to determine the type and cause of variation so that appropriate actions can be taken. Gather data and prepare a run chart (≥ 25 data points). Add upper and lower control limits (ideally 3 standard deviations), to turn your run chart into a control chart, which will help you identify causes of variation. Label your chart to clearly state the content. Prepare a written summary of your analysis of the variation. Format

1. Cover page as in Assignment #1. 2. Run chart/control chart

3. Brief (1 page) written analysis of variation

Grading 1. Technical quality of run/control chart [5 points] 2. Analysis of variation: special and/or common cause [4 points] 3. Grammar, formatting, spelling [1 point]

Assignment #3: Cause and Effect Diagram (10 points)

A cause and effect diagram (also known as an Ishikawa or fishbone diagram) is a tool used to explore the relationship between causes and an effect. Brainstorm possible causes of process variation as identified in Assignment #2.

1. Use the problem as your effect (the head of the fish); 2. Brainstorm the causes using the categories discussed in class

a. Use a combination of 5M’s: man, machine, methods, materials, measurement, 4P’s: people, plant, policies and procedures and/or Vincent et al’s “Contributory Factors.”

b. Group individual causes them under the appropriate “main cause” category (the scales of the fish). c. Each cause should be clearly stated as to how/why it’s contributing to the effect. Identify the most significant root causes

contributing to the problem. You can use the IHI Open School’s Cause and Effect Diagram Form as a guide. Format

1. Cover page as in Assignment #1 2. Cause and Effect diagram 3. Brief description of root causes

Grading

1. Technical quality of cause and effect diagram [5 points] 2. Analysis of root causes [4 points] 3. Grammar, formatting, spelling [1 point]

Assignment #4: PDSA Cycle, Recommendations for Improvement, Measurement Plan (20 points)

Now that you have gathered the data and determined the main causes for the problem, recommend a change. Conduct a PDSA cycle and describe the results. If not possible to conduct a PDSA cycle at the organization, describe the anticipated results. Write an implementation plan for your recommended change. Be specific and include the who, what, where, when and how of implementation. To help the organization determine if the plan is successfully implemented and effective after you leave, develop a measurement tool and plan that you will leave with the organization for ongoing measurement. At a minimum, the plan should include the data that will be collected, who is accountable for collection and specific timeframes. You can use the IHI Open School’s PDSA Form as a guide.

Format 1. Cover page as in Assignment #1, report should not exceed 5 pages. 2. PDSA results or anticipated results 3. Implementation plan 4. Measurement plan

Grading

1. PDSA cycle [9 points] 2. Written implementation plan [5 points] 3. Written measurement plan and tool [5 points] 4. Grammar, formatting, spelling [1 point]

Final Presentation for Class (10 points) Provide a handout of the presentation by the due date. Do not submit the presentation through NYU Classes. Bring an electronic copy on the day you are presenting. Summarize your journey through the improvement process, including at a minimum:

1. Overview of the specific healthcare organization with which you were involved 2. What problem did you set out to solve 3. Obstacles encountered along the way 4. Significant findings (or anticipated findings) 5. Recommendations that you made 6. Response from organization at end of project 7. Lessons learned

Grading

1. Incorporated Assignments 1 through 4 [3 points] 2. Discussed the above points [3 points] 3. Used evidence-based information [3 points] 4. Made the “business case” [1 points]

Use visuals and make the business case! All team members should actively participate in a professional, engaging and compelling performance!

“Design is not just what it looks like and feels like. Design is how it works.” - Steve Jobs

Class Schedule (Subject to change during semester; Guest lecturers to be announced; last updated 1/3/14

Week/ Date

Topics/ Class Agenda

Required Readings/IHI Open School Courses Suggested Readings/Resources Assignments Due

Week 1 Jan 29

Quality Yesterday

and Today: An

Introduction to

CQI

Organize into

teams. Discuss

team charter and

evaluations.

NYSDOH Hospital Profile:

http://hospitals.nyhealth.gov/

Commonwealth Fund:

http://whynotthebest.org

HHS: http://hospitalcompare.hhs.gov

National Scorecard:

http://www.commonwealthfund.org/Pub

lications/Fund-Reports/2011/Oct/Why-

Not-the-Best-2011.aspx

1) Complete “Tell me

about yourself” document

posted on NYU Classes

and bring to first class.

2) Review instructions for

IHI Open School course

completion on NYU

Classes.

Week 2 Feb 5

Frameworks for

Improvement

Organize into

teams. Discuss

team charter and

evaluations.

IHI QI 101: Fundamentals of Improvement

IHI QI 102: The Model for Improvement

IOM (2001). Executive Summary. In

Crossing the Quality Chasm: A New

Health System for the 21st Century.

Retrieved from

http://www.iom.edu/Reports/2001/Cross

ing-the-Quality-Chasm-A-New-Health-

System-for-the-21st-Century.aspx

Week 3 Feb 12

Safety as Driving

Force

Discuss

Assignment 1.

IHI PS 100: Introduction to Patient Safety

IHI PS 101: Fundamentals of Patient Safety

IHI PS 102: Human Factors and Safety

National Health Policy Forum (1999,

May 14). Reducing Medical Error: Can

You Be As Safe In A Hospital As You

Are In A Jet? Issue Brief, No. 740.

Retrieved from http://www.nhpf.org/library/issue-

briefs/IB740_MedicalError_5-14-99.pdf

Submit Process for

Improvement and Team

Charter for instructor

approval.

Week 4 Feb 19

Leadership and

Teamwork

IHI L101: So You Want to Be a Leader in Health

Care

IHI PS 103: Teamwork and Communication

IHI PFC101: Dignity and Respect

NCHL Catalyst Framework: http://www.nchl.org/static.asp?path=28

52

Week 5 Feb 26

Measurement Part

I: Variation,

Statistical Process

Control (SPC)

and Monitoring

Discuss

Assignment 2.

IHI QI 103: Measuring for Improvement

IHI QI 104: Putting It All Together

IHI QI 106: Level 100 Tools

Nelson, E.C., Splaine, M.E., Batalden,

P.B. and Plume, S.K. (1998). Building

Measurement and Data Collection Into

Medical Practice. Ann Intern Med,

128(6), 460-466.

NHS Improvement-Statistical Process

Control:

http://www.improvement.nhs.uk/lung/S

erviceImprovementTools/StatisticalProc

essControl/tabid/96/Default.aspx

Assignment 1 due.

Week 6 Mar 5

NO CLASS

Week 7 Mar 12

Measurement Part

II: Root Cause

Analysis

Wu, A.W., Lipshutz, A.K. and Pronovost, P.J.

(2008). Effectiveness and Efficiency of Root

Cause Analysis in Medicine. JAMA, 299(6), 685-

687.

IHI PS 104: Root Cause, Systems Analysis

Joint Commission Framework for

Conducting A Root Cause Analysis and

Action Plan in Response to a Sentinel

Event:

http://www.jointcommission.org/Frame

work_for_Conducting_a_Root_Cause_

Analysis_and_Action_Plan/

Week 7 Mar 12

Measurement Part

III: Outcome

Evaluation

Models

Randolph, G. et al (2009). Model for

Improvement-Part Two: Measurement and

Feedback for Quality Improvement Efforts.

Pediatr Clin N Am, 56, 779-798.

W.K. Kellogg Foundation (2004). Logic Model

Development Guide. Retrieved from http://www.wkkf.org/knowledge-

center/resources/2006/02/WK-Kellogg-

Foundation-Logic-Model-Development-

Guide.aspx

Mid-Semester Team

Evaluation and Mid-

Semester Course

Evaluation Forms due.

Week 8 Mar 19

Spring Recess No Class

Week 9 Mar 26

Apply the Culture

of Safety to the

Workplace

IHI QI 105: The Human Side of Quality

Improvement

IHI PS 105: Communicating With Patients After

Adverse Events

IHI PS 106: Intro to Culture of Safety

Marx, D. (2001). Patient Safety and the

“Just Culture” [PowerPoint slides].

Retrieved from http://www.health.ny.gov/professionals/

patients/patient_safety/conference/2007/

docs/patient_safety_and_the_just_cultur

e.pdf

Wachter, R.M. and Pronovost, P.J.

(2009). Balancing “No Blame” With

Accountability in Patient Safety. N

Engl J Med, 361(14), 1401-1406.

Assignment 2 due.

Week 10 April 2

Regulation and

Accreditation

Review websites noted on the right-hand side.

OSHA Safety and Health Topics:

Healthcare:

http://www.osha.gov/SLTC/healthcarefa

cilities/index.html

Joint Commission National Patient

Safety Goals: http://www.jointcommission.org/standar

ds_information/npsgs.aspx

NCQA HEDIS Measures:

http://www.ncqa.org/HEDISQualityMea

surement/HEDISMeasures/HEDIS2014.

aspx

Week 11 April 9

Transforming

Healthcare

Quality

Discuss

Assignment 4 and

Final

Presentations.

IHI (2003). The Breakthrough Series: IHI’s

Collaborative Model for Achieving Breakthrough

Improvement. IHI Innovation Series White Paper.

Retrieved from http://www.ihi.org/knowledge/Pages/IHIWhitePap

ers/TheBreakthroughSeriesIHIsCollaborativeMode

lforAchievingBreakthroughImprovement.aspx

PCDC (2007). Factors Contributing to Sustaining

and Spreading Learning Collaborative

Improvements. Retrieved from

http://www.pcdc.org/assets/pdf/7515_commonwea

lth_study_-_sustainability_12-07.pdf

Chronic Care Model:

www.improvingchroniccare.org

NCQA’s Patient-Centered Medical

Home:

http://www.ncqa.org/Programs/Recognit

ion/PatientCenteredMedicalHomePCM

H.aspx

IHI QI 202: Quality Improvement in

Action: Stories from the Field

TA 101: Introduction to Population

Health

Week 12 April 16

Business Case for

QI

Forum on the Science of Health Care Quality

Improvement and Implementation, IOM (2008).

Communicating a Value Proposition. In Creating

a Business Case for Quality Improvement

Research: Expert Views, Workshop Summary.

Retrieved from

http://www.nap.edu/catalog.php?record_id=12137

Leatherman, S. et al (2003). The Business Case

for Quality: Case Studies And An Analysis.

Health Aff, 22(2), 17-30.

IHI QCV 101: Achieving Breakthrough Quality,

Access, and Affordability

Assignment 3 due.

Week 13 April 23

Role of Evidence-

Based, Health

Information

Technology in QI

AHRQ (2007). Health Information Technology

for Improving Quality Care in Primary Care

Settings. Retrieved from www.ahrq.gov

AHRQ (2009). Clinical Decision Support

Systems: State of the Art. Retrieved from http://healthit.ahrq.gov/images/jun09cdsreview/09

_0069_ef.html

Meaningful Use: http://www.healthit.gov/providers-

professionals/ehr-incentives-certification

AHRQ’s Transforming Healthcare

Quality Through IT (THQIT) program: http://healthit.ahrq.gov/portal/server.pt/c

ommunity/ahrq-

funded_projects/654/health_it_portfolio

_transforming_healthcare_quality_throu

gh_health_it_projects/21178

National Quality Forum Endorsed

Measures:

http://www.qualityforum.org/QPS/

Week 14 April 30

Final

Presentations

Assignment 4 and a

handout of final

presentations due.

Final team evaluation

forms due.

Week 15 May 7

Final

Presentations

Week 16 May 14

Final Exam

Period

Make up class, if needed.