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“ Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skilled execution. It represents the wise choice of many alternatives” – Willa Foster. Our Problem To Solve. - PowerPoint PPT Presentation


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Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skilled execution. It represents the wise choice of many alternatives Willa FosterWhere Results BeginWhere Results BeginWe dont have a health care delivery system in this country. We have an expensive plethora of uncoordinated, unlinked, economically segregated, operationally limited micro systems, each performing in ways that too often create suboptimal performance both for the overall health care infrastructure and for individual patients.

George Halvorson, Author of Health Care Reform Now!: A Prescription for Change.

Our Problem To SolveWhere Results BeginThe FormulaHealth Information TechnologyContinuous Quality ImprovementMeaningful UseStructure and ProcessIncorporating Evidence-Based Standards of CareProviders Outcome

Where Results Begin

The Window of Opportunity is Now

Where Results BeginYour window of opportunity is now. 4An ongoing effort to provide services that meet or exceed customer expectations through a structured, systematic process for creating organizational participation in planning and implementing quality improvements based on meaningful use of data that results in improved outcomes.What is this thing called Continuous Quality Improvement ?

Where Results Begin5How do Quality Assurance and Quality Improvement Compare ?

Where Results Begin6Why Invest in System-wide Continuous Quality Improvement?Providing ongoing feedback improves patient outcomes, health center operations and systems by encouraging continuous adjustments of programs, policies and activities.Collecting information about how things are done and the results helps to understand how health center initiatives develop and disseminate lessons others can profit from.Involving all members of the health system, people who havent had a voice gain the opportunity to better understand and contribute.Finally, effective quality programs helps hold everyone accountable to health center expected outcomes and to the grant makers who provide funding.Where Results BeginSTRUCTURE: Quality is not just about implementing a system or working towards a set of standards. It is an attitude, a way of working, that not only improves an organization butalso the way the organization works.

Where Results BeginWhere Results BeginAn organizational culture centered in Qualityis a MUST.

Involvement of People: Service Providers, Executive Management, Managers, Supervisors, Staff, Contractors, Board Members, Everyone!!!!!!Building A Successful Quality ProgramStructure First Things First

Where Results Begin9Who are the members?What are the roles and responsibilities?What is the meeting format? (who staffs, minute-taking, participation requirements, confidentiality, etc.)Where does the Committee report?When does the Committee meet?How long do committee members serve?

The Quality Committee StructureWhere Results BeginSafe: Avoid injuries to patients from the care that is intended to help them. Effective: Match care to science; avoid overuse of ineffective care and underuse of effective care. Patient-Centered: Honor the individual and respect choice. Timely: Reduce waiting for both patients and those who give care. Efficient: Reduce waste. Equitable: Close racial and ethnic gaps in health status.

Source: Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine. 2001You Must Take Aim: Targeting Your Quality Improvement Activities.

Where Results BeginBasic Tenets of Quality ImprovementWhat are we trying to accomplish?What change can we make that will result in improvement?How will we know a change is an improvement?

Where Results BeginQM Program DescriptionQM Work PlanProvider Credentialing and PrivilegingPeer Review ProcessAssessing Organizational Satisfaction (Employee, Provider and Patient)Complaint ManagementIncident ManagementInfection Prevention and Control ManagementMedical Record StandardsMedical Record Review ProcessConfidentiality and Privacy of Personal Health InformationUse of Clinical Protocols

Primary Quality Related Policies and Procedures Where Results BeginMeeting Community Health Center HRSA QA/QI Program Requirements.The QA/QI program must:Include clinical services and managementMaintain the confidentiality of patient recordsInclude a Clinical Director whose focus of responsibility is to support the QA/QI program and the provision of high quality patient care.Include periodic assessment of the utilization and quality of services provided or proposed to be provided.

Quality Program Description Where Results BeginKey Components: I. OverviewII. Quality Program StructureIII. Quality Improvement MethodologyIV. Communication and CoordinationV. Confidentiality and Privacy of Information VI. Program Review Process (Timeframes) VII. Health Care and Business PlanQA/QI Program Description Where Results BeginPerformance Measures and Key Activities Tracker

Where Results BeginExamples available for pick-up at the end of the presentation.16PersonnelData ManagementData Processing, Analysis and ReportingPrevent a Headache: Make Sure you Have the Right Tools and Resources

Where Results BeginPROCESS: Knowing is not enough; we must apply. Willing is not enough; we must do. - Goethe

Where Results BeginWhere Results BeginIncreasing the Value of Your ResultsAnalyze and Synthesize FindingsIdentify Program Performance StandardsInterpret the FindingsMake Judgments/RecommendationsShare the ResultsWhere Results BeginMonitoring and Tracking Establishing Performance Targets and BenchmarksIf you dont know your destination you wont know which way you are heading.

Where Results Begin20System Wide Quality Work Plan

Where Results BeginSystematically identifying patterns in the information gathered and deciding how to organize, classify, interrelate, compare, and display it. Data Analysis

Where Results Begin22Effectively Communicating PerformanceCaptivating Focuses on things that are timely and meaningful. Credible This is for real Data-driven performance based on sound methodology and performance standards.Continuous Displays results over time with summary of findings.

Where Results Begin23Example:Diabetes Management

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Where Results Begin

DEMINGS Model:Plan: Analyze the process, determine what changes would most improve the process, and establish a plan for making the improvement; Do: Put your change into motion; Study: Check to see whether the change is working; Act: If the change is working, implement it on a larger scale. If the change is not working, refine it or reject it and begin the cycle again.Where Results Begin27PLAN: Understanding Clinical Standard Variation

Where Results Begin28The solution(s) most likely to be successful should be implemented. It is often preferable to do this on a small scale to see if the change(s) will work.Make the data collection easy enough and the time frames short enough so that data collection can be repeated frequently to allow for trending of changes over time.Allow enough time to improve performance.Do: Things to Consider

Where Results Begin29Study the data in order to determine:What were the findings? Did the improvement action(s) effect a change?What were the positive and negative effects?What are the potential causes contributing to these effects?What could have been done better? What would we change and do differently?

Study: Things to Consider

Where Results Begin30Act on what you learned.Continue to make improvements in the process by going through the cycle again, starting at Plan.Dont forget a good outcome starts with a good process.Act: Things to Consider

Where Results Begin31OUTCOME: Quality is not an act. It is a habit. Aristotle, Greek philosopher and scientist.

Where Results BeginWhere Results BeginHierarchy of Effective Quality Program Effects




ActionsSystem and Environmental ChangeHealth OutcomesWhere Results BeginImproves outcomes for consumers Improves consumer satisfactionImproves workforce retention and satisfactionIncreases use of preventive interventionsIncreases best practices/innovationFoundation for performance based incentivesReduces wasteReduces reworkReduces errorsSaves resourcesReduces liabilityImproves processes for persons served/other stakeholdersVALUE OF HIGH QUALITY Where Results Begin34Thank you ... Questions?

Where Results Begin