QUALITY IMPROVEMENTWorking with your QI TeamValerie J. Vesich, RHIT, CTR

Onco, Inc.

Overall How QI Program is managedDefinitions, elementsStructure - ProcessesInitiation, Planning, Execution,

ClosureTribute to Those Studies that

Failed

BACKGROUND & SIGNIFICANCE

Efforts to EnsureQATQMQICQIQMPI

WHAT IS QUALITY – HEALTHCARE?

Requires Inspection***Tracking changes in

measures over time with Benchmarks

DocumentationJudgmentImprovement of Clinical

Performance

AN EFFECTIVE QUALITY QI TEAM & MANAGEMENT PROGRAM

Effective

Accountable

Responsible

WHY??

DEVELOP A QI PLAN

How are your qi project selected, managed and monitored

How are your staff trained in qi What methodology- six sigma, psda Describe your communication plan, updates,

who/when etc Description of measurement/analysis- How will your studies be evaluated

ELEMENTS OF A QUALITY DEPT.Proactive

Patient/Family Centered CareClinical InformaticsEducation

ReactivePeer ReviewRisk ManagementTJC, CMS, DOH Reviews/Visits

STRUCTURE - VARIESQuality functions – multiple depts.

Within Clinical Service Lines Half report to QI department Matrixes QI department - across depts. Larger Multi-hospital systems and Veterans

Affairs – corporate level quality staff Facilities have their own quality staff – reporting

to leadership Advisory Board – There is no one model that

performs better. Most Effective Model – Unique Dynamics to advance the culture and goals

STRUCTURE• Strategic Planning Process Outgrowth

SWOT – Strengths, Weaknesses, Opportunities and Threats Validates Mission, Provides Direction

• Knowing who is Responsible for PI/QI at Your Hospital is Important

WHAT PROBLEMS ARE YOU SOLVINGDefects---something that happens

that isn’t supposed to happenReducing healthcare-acquired

infectionsPerforming well in core measuresReducing re-admissions for the

same problem

TOP FOUR DEFECTSErrors in Communication (handoff

with patients and families) Issues related to Lack of LeadershipMedication ErrorsData Accuracy/Completeness

Reporting

Do

StudyAct

Plan

FOUR STEP PROCESS

PDSA Worksheet for Testing Change Aim: (overall goal you wish to achieve) Every goal will require multiple smaller tests of change

Describe your first (or next) test of change: Person responsible

When to be done

Where to be done

Plan List the tasks needed to set up this test of change Person

responsible

When to be done

Where to be done

.

Predict what will happen when the test is carried out

Measures to determine if prediction succeeds

Do Describe what actually happened when you ran the test Study Describe the measured results and how they compared to the predictions

http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx

FIVE STEP PROCESS

Identify Target Areas What

Processes Can be

Modified to

IMPROVEDevelop Effective

Strategies to

Improve Quality

Track Performan

ce and Outcomes

Disseminate Results

to Spur Broad

Spectrum Improvem

ent

TWO STEP PROCESS- TEXAS STYLE

PI PROCESSDefined differentlyShare one characteristic- cyclical in

natureMonitoring performance is DATA DRIVEN Data internal/external builds the

foundation Identifying issues that can be improvedTaking powerful steps—envision results

WHY DO STUDIES FAIL?Using Half-Baked IdeasUnrealistic Project DeadlinesAssigning jobs to those Who Might

Be Unable to HandleNo Monitoring of DataNo Comprehensive Project Portfolio

PI PROCESSES AND PHASES InitiationPlanningExecution (Implementation)Closure

PI PROCESSES Identify an improvement

opportunityResearch and DefineDesign and Re-Design

Process/EducationMeasure PerformanceDocument and Communicate

FindingsAnalyze and compare internal and

external data

INITIATION Input from Organization PI team

member importantDeveloping a Team – helps define

who is doing what and whenNeed a Team Lead or Facilitator – QI

Coordinator

CANCER PROGRAM – BUILDING A PI TEAM (S)Hospital PI member AdvisoryCancer Committee or serve as an

Ex-Officio or QI CoordinatorCancer Committee or Cancer

Program responsible for report to ??

Help build your QM Plan

PLANNING Identify ActivitiesDevelop system requirementsCriteria for standards for successDevelop a schedule/cost analysisPerform tasks and track progressDevelop the “plan” – how to

implement

DESIGN OF YOUR PLANRegistry Data ReviewCancer Program/Cancer Committee

Surgery Pathology Outpatient Therapies Support Services

Cause and Effect- Gantt Charts - PERT

Benchmarks, Guidelines, PathwaysDevelop In-House (ok per CoC)

ORGANIZE THE PLAN-Program Evaluation, Review,

Technique (PERT)Aka Critical Path Method (CPM)

Follow a path of arrows from start to finish

Adding duration time- total time to complete the project

QUALITY METRICS National Quality Forum (NQF)NCCN GuidelinesASCO/QOPICenters for Medicare Services-PQRSHospital Quality Alliance (HQA) Institute of Medicine (IOM)National Committee for Quality

Assurance (NCQA)

EFFECTIVE STRATEGIES TO IMPROVEAmerican Society of Breast

SurgeonsMastery of Breast Surgery℠ Program

https://www.breastsurgeons.org/new_layout/programs/mastery/

HHS- AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care National Quality Measures

Clearinghouse

Health Resources & Services Administration www.hrsa.gov/

Source: National Assoc of Community Health Ctrs

AAPPPPEENNDDII XX AA:: SSTTOORRYYBBOOAARRDD TTEEMMPPLLAATTEE LOCAL HEALTH DEPARTMENT NAME:

ADDRESS:

PHONE NUMBER:

SIZE:

POPULATION SERVED:

PROJECT TITLE:

PLAN Identify an opportunity and

Plan for Improvement 1. Getting Started Start typing here 2. Assemble the Team Start typing here 3. Examine the Current Approach Start typing here 4. Identify Potential Solutions Start typing here

5. Develop an Improvement Theory Start typing here

DO Test the Theory for Improvement

6. Test the Theory Start typing here

CHECK Use Data to Study Results

of the Test 7. Check the Results Start typing here

ACT Standardize the Improvement and

Establish Future Plans 8. Standardize the Improvement or Develop New Theory Start typing here 9. Establish Future Plans Start typing here

Jan-12

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0%

10%

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30%

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50%

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70%

80%

90%

100%

84%87%

77%81% 79%

84%

60%65%

72% 72%77%

84%

92%90%94% 94% 96% 98%0.91 0.90.95

%

EXECUTIONPresent recommendations to leadershipExecute implementation plan - monthlyBegin TrainingTrack and Monitor ProgressRevise Project as Needed

CLOSURE

DISSEMINATE RESULTSPLAN SHIFTS TO BECOME AN INTEGRAL PART

CONTINUED FOLLOW-UP, MONITORING

EVALUATION/CONTROL TESTING LESSONS LEARNED

THANK YOU

VALERIE VESICH

Valerie.Vesich@oncolog.com

Senior Sales ExecutiveOnco, Inc.