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Skills Competency Education for

New PI Directors & Coordinators

Session Five March 14, 2007

Quality Management Team Meetings

Sponsored by: The MT Rural Healthcare PI NetworkCo-Sponsored by: Mountain Pacific Quality Health

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Today’s Session Recap Session 4: Performance reporting

Session 5: QMT Meetings Purpose Members and mechanics Managing team conflict Evaluating team effectiveness Evaluating PI program effectiveness

CAH Annual Evaluation and Work Plan

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QMT Meeting Purpose

Improve organization performance by…

Integrating PI program components Data collected

Building stakeholder collaboration

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Integrate PI Program Components

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Why Integrate Components

Share knowledge, information, data

Clarify complex, inter-related issues Example: safety, patient safety

Reduce duplication of effort Minimize waste, staff frustration

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Integrate Components

Improve Performance

Strategy

Clinical Quality

Customer

Satisfaction

Hospital

Operations

Community Relations, PR

Staff, Medical Staff

Regulators

Mission, vision, values

Strategic initiatives

All services

MS Committees

Patient Safety, Risk M

Finance

Human Resources

Building, Environment

Annual work plans

Purchasing, Materials Management

Information Management

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Integrate Component Data

Improve Performance

Strategy

Clinical Quality

Customer

Satisfaction

Hospital

Operations

Satisfaction surveys

Grievances, complaints

Regulatory surveys

Strategic plan measures

Dept PI reports

Inf Control, P&T, others

Incident/occurrence rpts

PIN Benchmark data

Staff Competencies

Med Records, HIT

Safety, Life Safety Data

QIO & PIN CIS data

Financials

Work plan measures

Incident/occurrence rpts

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Build Stakeholder Collaboration

Team Membership and RolesAn Improvement Cycle

Meeting MechanicsManaging Team Conflict

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Team Members: Stakeholders Stakeholders are:

Individuals who have a vested interest in the outcome of the meeting discussion

Can be internal, staff members

Can be external, community and/or Board members

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Team Membership

Improve Performance

Strategy

Clinical Quality

Customer

Satisfaction

Hospital

Operations

Community member

Staff member

PR Director

CEO

Clinical Service Leaders

Inf Control

Pt Safety Officer/RManager

Purchasing, MM

HR Director

Med Records, HIT, HIPAA

Safety Cmtee rep, Engineer

Quality/PI Coord, Dir

CFO

Board member

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Team Membership Balance membership, 7-9 ideal

System and front-line perspectives Decision-makers and process-

performers Personalities

Drivers Cheerleaders Interpersonal facilitators Data, process junkies

Rotating membership is acceptable

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Team Member Role Responsible for independent assessment of

objective evidence concerning the hospital’s overall quality management system

Proactive, prevention-oriented, proactive Objective evidence, fact and data-based decisions Engage in continuous assessment and

improvement cycles Holds other team members accountable Makes decisions about how to move forward

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Team Member Role Eliminates barriers to improvement

Educates the organization about PI

Coordinates resource utilization and allocation for PI activities

Objectively evaluates the soundness of the organization’s approach to performance measurement, assessment, and improvement

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Team Leader Role Calls meetings

Location, time, notification, agenda

Ensures the needed information available

Identifies current & future opportunities

Identifies current, needed and new resources

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Team Leader Role

Maintains and follows up on action plan

Documents meetings or delegates this

Helps move team through improvement cycle Plan, Do, Study, Act (PDSA)

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Plan, Do, Study, Act Plan

Opportunity for improvement identified All aspects of the opportunity clarified

and understood Plan for improvement is developed

Do Test the plan for improvement Collect data about the impact of change

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Plan, Do, Study, Act Study

Aggregate and assess data from “Do” Decide if improvement was made

Return to Plan if not; try again until succeed Proceed to Act if it did

Act Formalize the change (policies,

procedures) Monitor to ensure improvement

maintained Spread the change as appropriate

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Team Meeting Mechanics

Before the MeetingAgendasMinutes

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Before the Meeting Give a heads-up to reporting members

Distribute the agenda and attachments

Distribute minutes from last meeting

Room availability and set up

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Traditional Team Agenda Review, approve

minutes

Review, revise agenda

Old Business

New Business

“Other”

Next Meeting

Attachments

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Sample Traditional Agenda

1. Review minutes, agenda2. Follow ups3. Quarter reports

a. Acute careb. Swing bedsc. Ambulatory care

4. PI Team reportsa. CAP, pneumoniab. Heart Failure

5. Other6. Next meeting

Kathy 5 minnoneKip 10 minCarol 10 minKathy 10 min

Kirsten 5 minKim 5 min

5 minMarch 10 1 pm

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Traditional AgendaAdvantages

Template for clear meeting record

Clear order of discussion; flexible

Effective follow up of pending issues

Disadvantages

Easily run out of time

Lots of attachments

Easy not to be data, objective evidence focused

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Traditional Agenda Tricks List pending and critical discussion issues first

Assign discussion time for each item Assign time keeper for the meeting

Identify the “owner” of the item; accountability

Learn to facilitate data-based discussion discourage team rushing to decisions; wasting time

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Consensus Agenda

Like the traditional agenda, except…

Reports to be given are listed A motion is made to accept as presented Members must request discussion on

reports they want to discuss Discussion items are noted and addressed

in order requested

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Consensus Agenda

Advantages

Move through standing items quickly

Increased time for new discussion items

Disadvantages

Members have to request discussion

Assumes members have reviewed reports & data prior to meeting

Easy to bypass important pending items

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Work Plan Agenda Last meeting’s work

plan is this meeting’s agenda

Current, pending and in-progress activities listed

Task ‘owner’ clearly identified

Individual activity steps identified

Target completion dates clearly identified

Attachments

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Work Plan AgendaFocus Who Will Do

WhatWhen Follow

up

Quarter Reports

Kip Q4 06 AcuteQ4 06 Swing

Jan 07Feb 07

Next meeting

Staff PI Ed

Carol In-service managers

Feb 07 March

Heart Failure PI

Kim - Revise DC instruct form-MS approval

Jan

Feb

March

CAH Ann Eval

Kathy Prep and lead meeting

Dec 07 Fall 2007

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Work Plan AgendaAdvantages

Activity focus

Clear accountabilities

Effective follow up of pending issues

Future activities identified

Easy to track progress

Disadvantages

Less documentation of discussion

Easy to get stuck in operational details

Easy to overlook data

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Team Meeting Minutes

List items in same order as agenda Date, time of meeting; members present Agenda items Assessment of relevant data presented Brief summary of discussion Specific actions to be taken

who, what, when date of next report

Next meeting date, time, location

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Managing Team Conflict

Team WorkConflictManagement techniques

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Team Work¹

Team Task Function: what we are doing

Inte

rper

son

al F

un

ctio

n:

how

w

e ar

e w

orki

ng

with

eac

h ot

her

Team Effectiveness

Maximized when we perform both task and interpersonal functions well

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4 Stages of Team Development² Forming: orientation to group and

task Safe, “best” behavior put on Need approval; avoid controversy, conflict Opinions about each other forming

Storming: conflict over control Competition and conflict emerge as

attempt to organize task functions Leadership, structure, responsibilities,

power, authority are all at stake

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4 Stages of Team Development

Norming: group solidifies Interpersonal cohesiveness develops Acknowledge each other’s contributions Ideas, opinions can change based on facts Leadership shared; questions OK

Performing: maximum productivity Rare to reach this stage Interdependence in personal relations and

problem solving; roles and authority adjust as needed; group identity and loyalty high

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Team Conflict

Conflict is inherent in the team process

Different points of view borne out of different perspective, personality, experience

Different personal, organization “agendas”

Has been described as “functional” or “dysfunctional”

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Functional Conflict Enlarges mutual understanding through

the constructive expression of… Different points of view, passionate beliefs Competing goals Unique, creative solutions to problems

For the purpose of respectfully working together to achieve consensus Win-win outcomes; “I can live with that…”

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Dysfunctional Conflict Undermines collaboration, trust &

quality because members…

Compete for control of the process, outcomes

Express aggressive, manipulative behaviors Fail to share information and listen

Prevents team achieving effectiveness Win-lose outcomes; “Live with it…”

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Techniques forManaging Team Conflict Team roles clarified (see previous section)

Team rules established

Team facilitator

Team and program effectiveness evaluations group members mature to manage

themselves

One on one interventions

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Team Rules How the team will work together

Process or system, not people

“Each process/system is perfectly designed to produce its current outcome.”

Mutual respect; all contribute, all listen

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Team Rules Differences of opinion, perspective, passion

are desirable and must be expressed freely Members come to share information

What we say here stays here

Titles are left at the door

Data-based, objective decision-making

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Team Rules Primary decision-making method is consensus

Meeting value, importance: “100 mile Rule”

Will respect each other’s time

complete between-meeting work start the meeting on time end on time minutes and reports reviewed prior to meeting

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Team Facilitator Sole interest is getting to the best decisions

No vested interest in a particular decision

Keeps discussion focused on current topic

Tactfully stops side conversations

Tactfully prevents domination of discussion by one or a few members and that all participate

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Team Facilitator Stops task discussion when dysfunctional

interpersonal conflict is building

Aggressive verbal or non-verbal behaviors Discussion is shutdown, members

withdraw

Encourages members to deal honestly, respectfully with interpersonal conflict

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Team Effectiveness Evaluation

At the end of the team meeting, ask…

What did we do well; what didn’t we do well Did we pay attention to interpersonal

functions as well as the task function What barriers to effectiveness did we

encounter What do we need to do differently to

improve Did we orient new members to the team

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PI Program Effectiveness Eval

For the CMS/Regulatory perspective…

See SOM tags C-0336 through C-0343

Session 1: Leadership and Provider roles and responsibilities; PI Program policy and purpose statements

Session 2: data to be collected

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PI Program Effectiveness Eval

Ask: “In our organization culture…”

Do our leaders demonstrate commitment to improving performance and patient safety

Are our mission, vision, values, objectives aligned with improving customer satisfaction and patient safety

Do we value the uniqueness and contribution of all members of the organization

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PI Program Effectiveness Eval

Ask: “In our PI Program…”

Do we use an understandable approach to improving performance

Do we clearly define our goals in terms of achievable, measurable objectives that stretch us

Are there clear lines of communication through all organization levels and services

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PI Program Effectiveness Eval

Ask: “As a result of our PI Program…”

Can all staff articulate our mission, values

Can staff describe the PI process we use

Has my own professional practice improved

Have patient safety and customer satisfaction increased

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One on One Interventions Always attempt to let people “save face”

Minimal Risk Interventions as a Facilitator Outside the meeting, ask a disruptive member

what would increase his/her satisfaction with the meetings; give constructive feedback about specific behaviors

Within the meeting, ask in very general terms about any group process concerns identified in team evaluations; avoid identifying individuals unless they volunteer themselves

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One on One Interventions Moderate Risk Interventions as a

Facilitator After lower risk attempts have failed, outside

the meeting, tell the disruptive member what specific behavior improvement you are looking for

Add humor; offer to help correct a bad habit CEO may need to do this

High Risk Interventions as a Facilitator As a last resort and only in a mature team,

address the undesirable behavior in the group

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CAH Annual Program Eval

C-0331 “The CAH carries out or arranges for a periodic evaluation of its total program. The evaluation is done at least once a year and includes review of…”

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CAH Annual Program Eval The utilization of CAH services, including

at least the number of patients served and the volume of services (C-0332)

Acute care, including outpatient & emergency

Surgery, anesthesia, OB if provided

Swing beds

Ancillary clinical services

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CAH Annual Program Eval

A representative sample of both active and closed clinical records (C-0333)

“means not less than 10% of both active and closed patient records”

Can be conducted throughout the year Includes records reviewed for CART/CMS,

PIN studies, other PI projects, etc Includes records sent for external peer

review

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CAH Annual Program Eval

The CAH’s health care policies (C-0334)

“evidence demonstrates that the health care policies are evaluated, reviewed and/or revised”

Policies developed by a team of professionals that includes one or more physicians, mid-level providers, and individuals not members of the staff (C-0272, C-0258, C-0263)

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CAH Annual Program Eval “The purpose of the evaluation is to

determine…

whether the utilization of services was appropriate

the established policies were followed

any changes that are needed (C-0335)” Work plan generated, approved for the next 12

months

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CAH Program Annual Work Plan

Focus Who Will Do What

When Follow up

Quarter Reports

Kip Q4 06 AcuteQ4 06 Swing

Jan 07Feb 07

Next meeting

Staff PI Ed

Carol In-service managers

Feb 07 March

Heart Failure PI

Kim - Revise DC instruct form-MS approval

Jan

Feb

March

CAH Ann Eval

Kathy Prep and lead meeting

Dec 07 Fall 2007

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Questions?

Next Time

Drafting Policies and Procedures

Wed, March 28 1 pm

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Footnotes and References

¹ Structured Experience Kit, University Associates, Inc.; ©1980 International Authors B.V.; San Diego, CA.

² Team Building: Blueprints for Productivity and Satisfaction, W. Brendan Reddy. ©1988 NTL Institute for Applied Behavioral Science, Alexandrian, VA and University Associates, Inc., San Diego, CA.

The Team Handbook; Peter R. Scholtes et al; ©1988 Joiner Associates, Inc.; Madison, WI.

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Addendum: from the SOM, aQA Program is effective if it…

Evaluates the quality and appropriateness of diagnosis and treatment (C-0336) including:

Ongoing monitoring and data collection Problem prevention, identification and data

analysis Identification of corrective actions Implementation of corrective actions Evaluation of corrective actions Measures to improve quality of a continuous basis

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Addendum: from the SOM, aQA Program is effective if…

All patient care services and other services affecting patient health and safety are evaluated (C-0337)

RT, therapeutic gases and lab testing (C-0200) Drugs and biologicals use (C-0203, C-0276, C-0227) Blood utilization (C-0205) Emergency Preparedness and Life Safety (C-0227 through C-0231) Dietary, Nutrition (C-0279), Rehab (C-0281), Radiology (C-0283) Medical records quality (C-0300 through C-0310)

Nosocomial infections and medication therapy are evaluated (C-0338, C-0276 through C-0278)

Diagnosis and treatment provided by both mid-levels and physician providers are evaluated (C-0339, C-0340, C-0259, C-0264)

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Addendum: from the SOM, aQA Program is effective if…

CAH considers findings and recommendations from the QIO and takes corrective action is necessary (C-0339, 0341)

The CAH takes appropriate remedial actions to address deficiencies found through the QA program (C-0342). Note, this includes survey deficiencies.

Outcomes of all remedial action documented (C-0343)