Download Introduction - Behavioral Health System Baltimore

Continuous Quality Improvement1
Introduction
Continuous Quality Improvement (CQI) is an approach to quality management that uses data to analyze
and improve service processes and outcomes. CQI uses the root causes of a problem to identify areas of
improvement. In order to be successful, CQI should be integrated into the everyday flow of the program.
BMHS’ goal is to provide the framework for CQI. Once implemented, CQI will promote a culture where
programs continuously seek to improve the quality of services for members. We hope programs
incorporate a recovery-oriented, strengths-focused approach to this process, and engage staff,
members and families in identifying opportunities for change.
Continuous Quality Improvement versus Quality Assurance
Quality Assurance (QA) and CQI are two points along the quality management continuum. QA assures
that basic tenets of accountability and safety are followed and that negative outcomes are corrected,
whereas CQI is aimed at improving processes and achieving better outcomes.
CQI
QA
Focus is on systems first and individual performers
second. CQI aims to seek root causes in a process
that can be improved rather than attribute blame.
Focus is on human error and identifying and
eliminating outliers (poor performers).
Strives to ensure that policies, procedures, and
protocols make sense and meet the current and
evolving needs of members.
Strives to ensure that individuals are following
their policies, procedures, and protocols.
Relies on teamwork between different
stakeholders of the organization, as those closest
to the problem usually have the best ideas about
the solution. Incorporates evidenced-based care.
Relies on following the rules and policies of the
organization to meet the standards required by
regulatory and accrediting bodies.
Monitors improvement in quality of care through
continuous review.
Monitors compliance through periodic audits and
inspections.
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Some of the content of this document was extracted, with permission, from New York City Department of Health
and Mental Hygiene, Division of Mental Hygiene, Bureau of Planning, Evaluation & Quality Improvement. (2008).
Quality IMPACT Basic CQI Course. New York, NY.
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Implementing a Continuous Quality Improvement Project
Act
Plan
Check
Do
Step 1: Establish a Structure to Implement your Project
Your program should create an internal team to implement CQI projects. It is essential that program
staff and management are all on board with the idea of implementing a CQI project. Ideally, this team
will include representatives of all stakeholder groups close to the problem/opportunity. It is often
helpful to include members and family members as well.
Step 2: PLAN – Develop your CQI Project
A. Identify the Aim of the Project
An aim statement is a measurable and time-sensitive statement that captures the expected results
of an improvement process. A good statement describes the quality area you are hoping to improve
and defines the measure for recognizing improvement. Make sure the improvements you are
striving for will really make a significant difference to your program.
Identifying an Aim Statement
1. Identify an area for improvement
2. Consider the evidence
3. Consider your workflow and business processes
4. Incorporate member feedback
(example on next page)
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Example: Aim Statement
The CQI team plans to increase the number of consumers who are gainfully employed or work in
volunteer positions. Consumers consistently state that employment is an important goal for them,
and evidence shows that employment and volunteering increases consumers’ quality of life. We
will achieve this by providing vocational assessments as part of consumers’ treatment plans. The
project duration will be six months.
B. Identify Root Causes
A CQI project is aimed to improve a certain area or aspect of services. Before initiating efforts to
improve services, it is necessary to assess the current state of service delivery. The team should
meet with wider program staff to brainstorm possible reasons for the identified area needing
improvement. Then the team should categorize and prioritize the list, including distinguishing which
root causes are actionable and which are not.
Example: Root Causes
Program Causes
 Program doesn’t engage in treatment planning until 6 months after consumer enrolls
 Program doesn’t have the capacity to support employment activities
Consumer Causes
 Consumers don’t say they want employment during treatment planning
 Consumers aren’t motivated to work because they’re afraid they’ll lose benefits
Staff Causes
 Some staff don’t believe consumers are capable of working
 Staff doesn’t know how to do vocational assessments
Environmental Causes
 The economy is bad; everyone is having a hard time finding jobs
 There are no jobs available in the area
C. Develop Project Indicators
An indicator measures an improved outcome or a process associated with an improved outcome.
Indicators clarify the aim of your project, and they allow you to monitor your overall progress as you
initiate small interventions. Most indicators are rates; however, they can also be counts or means
(averages).
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Developing Project Indicators
1. Find out what is already known about the topic you selected
2. Select indictors
3. Define indicators
Example: Process Indicators
Numerator:
Number of vocational assessments integrated into treatment plans
Denominator:
Number of consumers with treatment plans
Numerator:
Number of treatment plans with documented discussions about employment
Denominator:
Number of consumers with treatment plans
A rate-based measure has a denominator (made up of the population that the measure will be
applied to) and a numerator (made up of that portion of the population who meet the specific
circumstance you are measuring). Although both the denominator and the numerator will vary over
the course of your project, implementation of quality improvement efforts should result in an
overall increase of your numerator relative to your denominator.
D. Develop a Data Plan
Once you have developed indicators to track your progress towards your aim, you will need to
develop a starting point (baseline) and a target for desired improvement. Baseline data can be found
through sources such as agency-wide billing systems, electronic medical records, consumer
satisfaction surveys and chart reviews. Your target should be challenging, but realistic. Targets can
be established by reviewing literature and past program performance. In cases where there is no
information available, the target can be a noted increase or decrease (percent change).
Developing a Data Plan
1. Determine the Indicator Baseline
2. Establish an Indicator Target
3. Develop a Plan for Measurement
Example: Data Plan
Baseline: 25% of consumers currently have vocational assessments in their treatment plans
Target: 75% of consumers will have vocational assessments in their treatment plans after 6 months
1. Do a random sampling of charts to estimate the number of treatment plans with vocational
assessments to establish the indicator baseline.
2. Do a literature review to determine the most reasonable target.
3. Check the number of vocational assessments in treatment plans each month.
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Step 3: DO – Carry Out the Intervention and Collect Data
Carry out the plan, collect data on progress, and document problems and unexpected observations.
Example: CQI Project Implementation




Staff was instructed to ask all consumers about employment during treatment planning and to
document consumer responses.
Training was provided to staff to increase their skills in facilitating discussions with consumers
about their vocational interests and conducting comprehensive vocational assessments.
When consumers were interested in employment, staff completed a vocational assessment.
Program staff met after the first two months of implementation to discuss progress.
Step 4: CHECK/ACT – Measuring and Evaluating Your Project
Track your overall project measures by measuring your indicators at predetermined time intervals
(weeks, months, quarters, etc.). You can plot the relevant numbers on a line graph (also called a “run
chart”). This can be helpful to show your progress visually. Project success is gauged by how well the
program was able to meet or approach the established aim. When considering your successes, look both
at quantitative and qualitative evidence of change. Keep in mind that results may not always be
immediate.
Example: Measuring and Evaluation
Percentage of Consumers with Vocational
Assessments in their Treatment Plans
60%
Percent
50%
40%
30%
20%
10%
0%
Baseline 31-Jul
31-Aug 30-Sep
31-Oct 30-Nov 31-Dec
Date
A review of the treatment plans revealed that 50% of consumers now have vocational assessments in
their treatment plans. Additionally, 60% of treatment plans noted a discussion about employment.
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Step 5: PLAN – Re-Evaluate Project
Continuous is the operative word here. The outcome of this year’s project can become the baseline for
next year’s. If enough improvement is achieved, then you can move on to a different project.
Example: Re-Evaluation
The CQI team determined that this project has significantly increased the number of vocational
assessments being done and would like to continue with this same project for another six months to
try to meet the target of 75% of consumers with vocational assessments.
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