implementing a robust quality program - ecri...12/14/2016 1 ©2016 ecri institute barbara g. rebold,...
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12/14/2016
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©2016 ECRI INSTITUTE
Barbara G. Rebold, BSN, RN, MS, CPHQ
Director, Engagement and Improvement
December 22, 2016
Implementing a Robust
Quality Program
©2016 ECRI INSTITUTE
• Power Point Slides viewed here• Today’s session is recorded• Today’s slides and recording will be
posted to the ECRI website.
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How to Ask Questions
Please submit your text
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How to Download Slides
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This activity has been approved for up to 1.0 California State Nursing contact hours by the
provider, Debora Simmons, who is approved by the California Board of Registered Nursing,
Provider Number CEP 13677. Credit will only be issued to individuals that are individually
registered and attend the entire program.
All faculty members involved in this December 22, 2016, live webinar, Implementing a Robust
Quality Program, have disclosed that there are no conflicts or financial affiliations.
To be eligible for credit:
Credit will only be issued to individuals that are individually registered and attend the entire
program. Each individual participant must log on prior to the start of the program and remain on
the line for the entirety of the program. This is how individual timed attendance is verified. In
addition you must complete an attestation survey included in the postwebinar evaluation at the
conclusion of the webinar. Once all that information is verified, qualified attendees will receive a
certificate via e-mail within 60 days of today’s program.
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About ECRI Institute
Independent, not-for-profit applied research institute focused on patient safety, healthcare quality, risk management
Nearly 50 years of experience, 400+ person staff
■ AHRQ Evidence-Based Practice Center (since 1997)
■ Federally designated Patient Safety Organization (since 2005)
ECRI Institute website resources about quality and safety
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Learning Objectives
Describe the integration of quality, risk management, and
patient safety
Identify key steps in developing a quality program
Recognize how to determine the structure and purpose of
a quality committee
Recall how to develop a quality plan
Identify methods for collecting and analyzing data
Identify methods for monitoring quality improvement (QI)
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What Is Quality?
Health and Medicine Division of
the National Academies of
Sciences, Engineering, and
Medicine*
*formerly the Institute of Medicine
High-quality care
Safe
Effective
Patient centered
Timely
Efficient
Equitable
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Overlap of Quality, Risk, and Patient Safety
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Why Focus on Quality?
Serious and widespread quality problems of underuse,
overuse, and misuse (Chassin)
Frequent harm and infrequent delivery of full benefits
■ Institute of Medicine
■ For 30 clinical conditions, evidence-based care provided 55% of
the time (McGlynn et al.)
■ For 11 clinical areas in pediatric settings, adherence to quality
indicators occurred 47% of the time (Mangione-Smith et al.)
Evidence that commitment to QI principles leads to
improved patient care and better outcomes (Asch et al.)
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Focus on Value
Increase quality
Decrease costs
Align with Patient Protection and Affordable Care Act
■ Delivery system reform
Paying for quality/accountable care
Improving healthcare
Participate in Quality Payment Program
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Key Steps in Developing a Quality
Improvement Program
Organize a QI committee
Develop a QI plan
Assess quality, patient safety, and risk issues
Set performance improvement goals
Identify performance measures
Collect and analyze data/evaluate progress toward goals
Develop and implement corrective actions
Report QI data to leadership
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Structure and Purpose of Quality Committee
The quality committee oversees the quality plan
Designate a chair and vice chair
Quality committee should be a multidisciplinary team
including administration, providers, and frontline staff
(e.g., executive director, nursing director, physicians,
nurses, administrative assistants, dentists, pharmacists)
Members of the committee may be permanent or rotating
(e.g., 1- or 2-year term) with some staff members invited
to participate temporarily (e.g., dentist invited to
participate during dental QI initiative)
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Quality Committee Meetings
The committee should meet on a
regular basis (e.g., monthly)
Agenda
■ Reviewing QI data/
progress toward goals
■ Analyzing trends/identifying problem areas
■ Brainstorming strategies for improvement
■ Developing improvement plans
Develop, revise, and implement QI plans
Document meeting minutes and keep on file
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Quality Committee
Meeting Agenda
Template
Use clear titles for
agenda items
Identify the individual
responsible for each
agenda item (if
applicable)
Set a budgeted time for
each item and stick to it
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Quality Committee Meeting Agenda Template
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Quality Meeting
Minutes Template
Include:
■ Attendees
■ Agenda items
■ Discussion topics
■ Recommendations
■ Action items
Clearly label with
consistent titles
Provide sufficient
detail
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Quality Meeting Minutes Template
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Quality Improvement Plan
Structure and purpose of quality committee
Clinical, financial, or administrative areas addressed in
QI activities (e.g., continuity of care, chronic disease
management, credentialing, patient/staff education,
patient satisfaction, access/availability)
Assessments/identification of risk areas
Improvement plans
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Quality Improvement Plan (cont.)
Data collection
Monitoring progress and improvements
Communicating results to senior
leadership
Communicating results to departmental
leadership
Communicating results to staff members
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Assess Quality, Safety, and Risk Issues
Patient satisfaction surveys
Administrative data
■ Demographic data, census logs,
patient flow data, wait times in
emergency department
Employee reports/surveys
■ Employees should be encouraged to
report quality concerns
Event reports
Medical record reviews
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Set Performance Improvement Goals
Focus on three main questions:
■ Set aims: What are we trying to accomplish? (e.g., reduce wait
times for patients in the emergency department)
■ Establish measures: How will we know we are improving?
■ Select changes: What changes will result in improvement?
Set SMART goals:
■ Specific
■ Measurable
■ Actionable
■ Realistic
■ Timely
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Organize a Team
Organize teams responsible for
improving processes/performance
Designate a team leader
Ensure representation from all who
are familiar with the particular
process
■ Administration
■ Medical staff
■ Nursing
■ Therapists
■ Frontline staff
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Identify Performance Measures
Select performance measures based on identified
high-risk areas, clinical importance, feasibility, and
needs
■ Percentage of emergency department patients who wait less
than 15 minutes to be seen by a provider
Measures should relate to processes, performance,
outcomes, decision appropriateness, patient/staff
satisfaction
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Quality Measures Sources
National Quality Forum Performance Measures
http://www.qualityforum.org/Measures_List.aspx
National Quality Measures Clearinghouse
https://www.qualitymeasures.ahrq.gov/
National Committee for Quality Assurance HEDIS
Measures: http://www.psninc.net/blog/accreditation-
preparation/ncqa-accreditation/hedis-measures-national-
committee-for-quality-assurance-ncqa/
Quality Payment Program website: https://qpp.cms.gov/
Joint Commission Core Measure Sets:
https://www.jointcommission.org/core_measure_sets.aspx
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Collect and Analyze Data
Make sure practitioners routinely document needed
information (e.g., information related to quality measures)
Consider using checklists or standardized forms during
patient care activities to document quality information
Use electronic information systems to track and trend
data; plot data over time to identify trends and progress
Designate a staff member to compile trended data for
analysis during quality committee meetings
Compare data to benchmarks to determine what areas
need improvement
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Implement Change or Corrective Action
Education and training
■ Clinical skills training
■ Communication
Revise policies/procedures
■ Scheduling procedures
■ Medication reconciliation
Develop and implement
QI initiatives
■ Immunization reminders
■ Hand hygiene campaign
■ Falls prevention
■ Reduction in central line infections
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Strength of Corrective Actions
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Plan, Do, Study, Act
Plan: Plan your test or observation
■ State your objective, make predictions
■ Initiate a plan that addresses the who? what? where? when? and
why?
Do: Carry out a test
■ Document problems encountered, unexpected results
Study: Analyze data and results
■ Compare data to predictions, determine what lessons were
learned
Act: Refine your change based on lessons learned
■ Determine if any changes need to be made
■ Plan additional tests
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Plan, Do, Study, Act—in Action
Scenario: Hospital X realizes many people are being
discharged without review of the results of laboratory work
done on day of discharge.
Plan: A team consisting of the medical director, providers,
laboratory staff, and information technology staff brainstorms
ideas. The team researches modifications to the electronic health
record (EHR) to improve test result communication.
Do: The team selects and implements EHR modifications.
Study: The new EHR system is piloted over a 6-month period.
Periodic medical record audits are completed.
Act: Both patients and staff are satisfied with the new system; test
result communication is improved. The system is rolled out in the
hospital; staff education is provided.
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Six Sigma
Define: Identify steps of a process, individuals involved
Measure: Determine the ability to make changes within
current processes
Analyze: Identify areas of high variability and causes of
variability
Improve: Make changes to minimize variability
Control: Take steps to sustain improvements
(Sources: Mistry et al.; Revere et al.)
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Reporting to Leadership
Governing or appropriate oversight authority responsible for quality of
care
■ Vote and take action on quality issues
■ Provide guidance, oversight, approval of activities
■ Review and approve policies (e.g., credentialing and privileging
policies, QI plans)
■ Review and approve credentialing/privileging information
Prepare regular (i.e., quarterly) quality reports for leadership
■ Prepare reports in a format that is easy to understand, such as
by using graphs or tables
Designate a member of the QI committee (e.g., chair, vice chair) to
present to leadership on results, QI activities, and recommendations
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Monitoring Quality Improvement
Review QI activities regularly and revise processes when
necessary
Use QI data to identify areas for improvement and
develop strategies or initiatives to address these areas
(e.g., education campaign, policy and procedure changes)
Involve staff members in improvement strategies; solicit
input and ideas
Communicate progress toward goals and improvements
made to providers and staff
Celebrate and recognize success
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Case Study: Care Rounds Improve Quality
Inpatient oncology unit analyzed adverse patient
outcome
Poor communication identified as contributing factor
A team was organized to develop
and implement initiatives to
improve communication:
■ Daily care planning
■ Care rounds
Studied results of initiatives
through the use of staff
questionnaires (Source: Blough and Walrath)
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Quality Management
Resource Page
Webinars
Guidance articles
Self-assessment
questionnaires
Online education
Industry news
Toolkits
Policies
Technology overviews
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Quality Improvement Toolkit
Sample quality plan
Quality committee meeting agenda templates
Quality committee meeting minutes templates
Quality committee formation worksheet
Quality measure sources
Improvement project planning form
Worksheet for testing changes
Patient/employee satisfaction questionnaires
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References
Asch SM, McGlynn EA, Hogan MM, Hayward RA, Shekelle P, Rubenstein L,
Keesey J, Adams J, Kerr EA. Comparison of quality of care for patients in the
Veterans Health Administration and patients in a national sample. Ann Intern
Med 2004 Dec 21;141(12):938-45.
Blough CA, Walrath JM. Improving patient safety and communication through
care rounds in a pediatric oncology outpatient clinic. J Nurs Care Qual 2007
Apr-Jun;22(2):159-63.
Chassin MR, Galvin RW. The urgent need to improve health care quality:
Institute of Medicine National Roundtable on Health Care Quality. JAMA
1998 Sep 16;280(11):1000-5.
Institute of Medicine (IOM). Crossing the quality chasm: A new health system
for the 21st century. Washington (D.C.): National Academies Press; 2001.
Institute for Healthcare Improvement. How to improve. 2016 [cited 2016
Nov 1]. http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx
Mangione-Smith R, DeCristofaro AH, Setodji CM, Keesey J, Klein DJ, Adams
JL, Schuster MA, McGlynn EA. The quality of ambulatory care delivered to
children in the United States. N Engl J Med 2007 Oct 11;357(15):1515-23.
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References (cont.)
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA.
The quality of health care delivered to adults in the United States. N Engl J
Med 2003 Jun 26;348(26):2635-45.
Mistry KP, Jaggers J, Lodge AJ, Alton M, Mericle JM, Frush KS, Meliones JM.
Using Six Sigma® methodology to improve handoff communication in high-
risk patients. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances
in patient safety: new directions and alternative approaches. Vol. 3:
Performance and tools. Rockville (MD): Agency for Healthcare Research and
Quality; 2008 Aug. https://www.ncbi.nlm.nih.gov/books/NBK43658/
Revere L, Black K. Integrating Six Sigma with total quality management: a
case example for measuring medication errors. J Healthc Manag 2003 Nov-
Dec;48(6):377-91.
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Upcoming Webinar Dates and Topics
Date* Topic
January 26, 2017 Data-Driven Quality
Improvement
February 23, 2017 Global Trigger Tool
March 23, 2017 Healthcare Resolution and
Disclosure
* All webinars are held the fourth Thursday of the month from 1–2 p.m.
eastern.
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Questions?
Please contact ECRI Institute at [email protected] or
(610) 825-6000, ext. 5800
Thank You