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QUALITY & PERFORMANCE IMPROVEMENT For Basic Manager Education Quality & Performance Improvement Defined Continuous cycles of improvement Driven by our mission and vision That stimulate individuals and teams to look at the way they deliver care and services To identify the root causes of problems in our systems And innovate to make improvements THE GOAL: A “Highly Reliable” Organization The right care for every patient, at right time, every time (Sec. Michael Leavitt, HHS, 2007) Humans are not highly reliable Systems and processes can be It is the job of leadership to develop and maintain systems that make it hard for staff to make an error It is also leadership’s job to hold staff accountable for using highly reliable systems Terminology: What’s the Big Difference?! QC: quality control QA: quality assurance or assessment QI: quality improvement PI: performance improvement “If I had six hours to chop down a tree, I’d spend the first four sharpening the axe.” Abraham Lincoln Quality Control (QC) is about putting routine checks in place to ensure that your service or output will be safe and effective It is routinely documented and is a task that is generally easily shared among staff; all have a role to play in making day-to-day work safe Examples: temp checks, routine preventive maintenance, running test controls (sharpening your axe!) “The beginning is the most important part of work.” Plato Quality Assurance (QA) is meant to determine where we are in relation to where we want to be; we have to start somewhere It compares measured performance to a predetermined benchmark or threshold Examples: medical record documentation review; CAH PIN clinical studies (stroke, surgical care, patient safety) “The significant problems we face cannot be solved at the same level of thinking we were at when we created them.” Albert Einstein Quality & Performance Improvement (QI/PI) are about making changes for the better This requires setting specific goals and making changes to achieve those goals They rely on measuring progress routinely They need participation by everyone in the organization Quality Improvement focus is on improving clinical quality Performance Improvement focus is organization-wide Approaching improvement by Hardwiring Excellence Into the way we provide service Into the way we deliver clinical quality Into the way we develop our staff Into the way we manage our finances Into the way we grow our business Quint Studer, Hardwiring Excellence, © 2003 Studer defines our systems as “pillars” Service: consistently exceeding customer expectations results in increased satisfaction Clinical Quality: patientcentered care that is safe, effectively, timely, efficient, equitable (IOM, 2001) People: well-trained, recognized, and rewarded staff bring commitment and dedication to the workplace Finance: solid planning and management results in a positive margin to sustain current ops and provide future needs Growth: a well-researched, methodical approach involving key stakeholders results in steady growth The pillars work together, synergistically, to achieve mission CMS: I’m from the Government & I’m here to help. Conditions of Participation for Medicare and Medicaid require hospitals to have a hospital-wide QA/PI program that focuses on the outcomes of their organization’s services Prospective Payment System (PPS) hospital payments are dependent on this – CAH payments may soon be, too Quality Conditions of Participation Conduct annual evaluation of the CAH program Must have an effective quality program Includes all patient care and other services affecting patient health and safety Includes nosocomial infections and medication therapy Quality Conditions of Participation Program must include the quality and appropriateness of diagnosis and treatment Considers the findings and recommendations from the Quality Improvement Organization (QIO) and takes corrective action Takes appropriate remedial action to address deficiencies found through the program, including regulatory survey deficiencies But we already give good care … PROVE IT! All right, we will! Performance reporting – “What gets measured gets managed.” BUT … not everything that can be measured is worth managing… …and everything that should be managed can’t always be easily measured. Monitoring Hospital-wide Performance Service: customer satisfaction, complaints Quality: patient safety, best practices, risk People: performance evals, staff development Finance: revenue, expenses, productivity Growth: market share, volume, new services National Patient Safety Goals Medication safety (reconciliation, look alike-sound alike drugs, concentrations, labeling) Healthcare acquired infections (pneumonia, MRSA, hand hygiene) Falls (reduction program) Patient identification (2) Communication among caregivers (verbal order read back, abbreviations, critical values, hand offs) Preventable deaths are sentinel events IHI 5 Million Lives Campaign Protect patients from 5 million incidents of medical harm; Dec 2006 through Dec 2008 – – – – – – – Includes the 6 aims of the 100,000 Lives Campaign Prevent harm from high-alert medications Reduce surgical complications Prevent pressure ulcers Reduce MRSA infection Deliver evidence-based care of CHF Get boards on board CMS Core Measures Surgical Infection Prevention: appropriate antibiotic given within 1 hour of cut time & discontinued within 24 hr of close Acute Myocardial Infarction: aspirin on arrival & discharge, beta blocker on arrival & discharge, 30 min door to drug time for thrombolytic, lipid assessment Heart Failure: left ventricular failure (LVF) assessment, ACE inhibitor for LVSD, complete discharge instructions (meds, follow up, weight, diet, activity, symptoms) Pneumonia: appropriate antibiotics within 4 hr of arrival but after blood cultures, blood cultures within 24 hr if obtained, O2 saturation assessment All: smoking cessation education; pneumococcal & influenza immunization Department Performance “With great power comes great responsibility” Everyone gets to report in some way how they are – – – – – Ben Parker Exceeding customer expectations Improving the quality of care and/or services Developing your staff Managing your finances Growing your service You decide how you and your staff will measure performance You decide what processes need improvement and how to improve them “Stop a moment, cease your work, look around you.” Leo Tolstoy Quality is not about data, graphs, and reports These are tools to show whether or not you’ve hit your target or reached your destination If you don’t know where you’re headed then you’re never lost The PDCA Improvement Cycle Data Collection – Essential Elements Operational definition – describe in quantifiable terms what you will measure & how to measure it consistently (inclusion & exclusion criteria) Know why you are collecting the data – what will you do with it once you have it? What stratification will be important to have – what level of detail will you need to get to the meat of the issue Will you collect all data points or just a sample - how will you sample to ensure your data is valid? That is presents a complete picture? Data Pitfalls – Watch out! Misunderstandings about how to collect data Inaccurate measuring instruments Cheating/ fear Poor choice of collection period Poor sampling techniques Lost data Bias Data Analysis – Run Charts Depicts data over time 100 90 80 70 60 50 40 30 20 10 0 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Data Analysis – Control Charts 100 Shows trends over time 90 80 Uses statistically determined upper and lower limits to define a range of acceptability 70 60 50 40 30 20 Goal is to gain consistency in operation 10 0 1st Qtr 2nd Qtr East lower limit 3rd Qtr upper limit 4th Qtr mean Data Analysis - Histograms 90 Frequency distribution 80 70 60 50 Presents data organized in categories 40 30 20 10 0 Fri Sat Sun Mon Data Analysis – Pareto Charts 30 Tool to rank-order or prioritize problems, causes of a problem, or categories of some event or issue 25 20 15 10 5 0 adm trans presc disp Data Analysis – Cause & Effect Diagram (Fishbone) Identify multiple causes of any result, outcome, or problem Data Analysis - Flowchart Create a step by step picture of a work process Identify and add missing steps Streamline areas of overlapping efforts & eliminate unnecessary steps Standardize a process or system “Opportunity is missed by most people because it is dressed in overalls and looks like work.” Thomas Edison Failure Mode and Effects Analysis (FMEA) is proactive risk assessment The object is to identify hazards and put control measures into place to prevent bad things from happening Root Cause Analysis (RCA) is after the fact – something undesirable has already happened, but we can learn from it and prevent it from happening again “If you put off everything till you’re sure of it, you’ll get nothing done.” Norman Vincent Peale Tips for a Success Keep after it – it benefits the patients, the hospital, & you personally Involve your staff; they have some great ideas and will be more likely to buy in to goals and action plans (don’t forget to assign them data collection, too) “To improve is to change, to succeed is to change often.” Winston Churchill Talk to your comrades in other facilities; they can give you a different perspective Use the program to help you make things better and recognize staff for a job well done Generate a sense of teamwork in your department and with other departments Celebrate your success (no matter how small); reward yourself and your staff “Our life is frittered away by detail. Simplify, simplify.” Henry David Thoreau Don’t bite off more than you can chew; make your projects worthwhile but not overwhelming Use the Quality Coord/Director as a resource for ideas, data collection and display, etc. Don’t reinvent the wheel; research best practices; you don’t have to make stuff up Align projects with department priorities; we’ve got plenty to keep us busy, we don’t need more busywork “Excellence is a habit, not an event.” Align your QI/PI improvements with the hospital strategic plan and vision Keep it in front of you; put it on your calendar, your task list, your office door, your monthly staff meeting agenda, your refrigerator, your mirror Aristotle Be prepared when you are due to report Attitude is everything; this doesn’t have to be a meaningless paperpushing process; YOU have the power to make it meaningful to you and your staff “Celebrate, celebrate!! Dance to the music!” Three Dog Night Find joy in your work; if you don’t, what’s the point?