Post on 28-Sep-2020
transcript
Provider Training
April 24, 2015
Presenter Introductions Selenna Moss, MHA, BS, RHIT, CHP
Partners BHM Chief Compliance and Quality Officer
Joel D. Leonard, MPACenterPoint Quality Management Director
Carolyn Shoaf LRT/CTRS CenterPoint QM Compliance Manager
Marsha Johnson, BS, QPPartners BHM QM Analyst
Elizabeth Pritchard, MSWCenterPoint QM Specialist, MH/SA
Logistics
Sign In
Restrooms
Breaks
Vending Machines
Completion Certificates
Post-training Evaluations
Key Points
Quality Improvement (QI) is vital
QI programs can be implemented by anyone
There are a lot of resources and tools available to assist your quality improvement efforts
The ABC’s of Quality Improvement
What is a Quality Improvement (QI) Program?
Systematic activities that are organized and implemented to monitor, assess, and improve an organization’s quality of health care (HRSA)
The Value & Importance of Effective QI Programs Enhances marketability
Provides better information for decision making
Supports implementation of the organization’s mission and vision
Identifies opportunities for improvement
Documents and evaluates the performance of key areas
Promotes coordination and collaboration
Assists in meeting regulatory, accreditation, and oversight organization requirements
Work Smarter – Not Harder
Scalability
LIP
Small Provider Agency
Medium Provider Organization
Large Provider Organization
Institute for Healthcare Improvement (IHI): Triple Aim
Institute of Medicine (IOM): Chasing the Quality Chasm
• Safety
• Effectiveness of Care
• Patient Centeredness
• Timeliness
• Efficiency
• Equitability
Six Aims to Improvement
in Healthcare
QI Plans: DefinedA QI Plan:
• Is an organizational work-plan
• Includes essential information on quality assurance/quality improvement (QA/QI)activities
• Updated regularly
• Outlines clinical focus areas
• Is an outgrowth of evaluation of QI activities, organizational priorities and program requirements
Why Do QI Plans?
• State/Federal Requirements
• LME-MCO Contractual Requirements
• Accreditation Requirements
• Current Industry Best Practices
• Research
How Do I Begin?
• Organizational Assessment- Identify Strengths/Weaknesses
• Identify Barriers (i.e. structure, resources, communication, performance measurement, staff, priorities)
• Identify External Requirements
QI Plan- 5 Key Elements
• Introduction
• Structure & Leadership
• Quality Improvement Objectives
• Performance Measurement
• Implementation & Evaluation
Source: Health Resources and Services Administration (HERSA)
Key Element 1: Introduction
The Introduction includes:
• Mission, Vision, Scope of Services
• Definitions of Key Concepts/Quality Terms
• Quality Statement
• Quality Model and Method
Mission, Vision, Scope of Service
Begin the QI Plan with a brief description of your agency, including:
• Agency Mission and Vision
• Services Provided
• Size of Agency
• Geographic Area
Definitions of Key Concepts/Terms
• Define the key concepts and quality terms for consistency
• Frequently Used Terms:
Quality Assurance
Quality Improvement
Continuous Quality Improvement
Quality of Care/Service
Quality Statement• Quality Statement- a description of your QI Program’s
goals and objectives
What do you want for your consumers, employees and community?
The answer to this question is your quality statement!!
• Connect Quality Statement to Mission, Vision and Strategic goals
• Include Accrediting Body Requirements (URAC, NCQA, Joint Commission)
Model & Methodology• Your quality model is your foundation
• Choose a model and use it as a guide for your QI planning
• Frequently Used Models:
PDSA- Plan, Do, Study, Act Six Sigma- Define, Measure, Analyze,
Improve, Control (DMAIC)
Key Element 2: Structure & Leadership
This element of the QI Plan includes a description of :
• Organizational Structure and Support
• Resources to Support QI Activities
• Training
Organizational Structure & Support
• Leadership Structure and Support of QI ActivitiesExecutive Management Board of Directors
• Committee Structure and Support of QI ActivitiesQuality Improvement CommitteeAgency Sub-Committees
• Stakeholder Involvement
QI Staff Structure & Support
• Role and Responsibilities of QI Staff:
Implementation of QI Activities
QI Plan writing and updates
Monitoring of QI Plan Performance
Gathering and validation of data
Training/Education
Resources to Support QI Activities
• Determine what is needed to achieve objectives:
Staff
Funding
Equipment
Training/Development
Training
• Describe training on the QI Process/Plan Include reason for training Include participants Identify training by topic, required intervals and
designated staff
• Include Training on Important Topics: NC TOPPS Evidence Based Practice (EBP) False Claims Act (FCA)
Key Element 3: QI Objectives• QI Plan versus Quality Improvement Project (QIP)
QI Plan Strategic Plan for Quality Improvement (Long-
Term Outcome) Ongoing monitoring and evaluation tool
QIP A QIP is born out of the QI Plan A QIP is the short-term goal utilized to meet the
long-term outcome identified in the QI Plan
QI Objectives Should Include
• Clinical Objectives Based on clinical performance measures Derived from evidence-based clinical guidelines
• Operational Objectives Set in consideration of the organization’s strategic
mission Support the organization’s growth and development
QI Objectives- Think S.M.A.R.T
• Specific- What are you going to do?
• Measureable- Is it measureable?
• Attainable- Can you get it done within time frame?
• Relevant- Will obtain the desired results?
• Time- How long will it take you?
Key Element 4: Performance Measurement • Performance Measurement is the process of
regularly assessing the results produced by the program.
• It involves identifying processes, systems and outcomes that are integral to the performance of the service delivery system, selecting indicators of these processes, systems and outcomes, and analyzing information related to these indicators on a regular basis.
Purpose of Measurement & Assessment
• Assess the stability of processes or outcomes
• Identify problems and opportunities to improve
• Assess the outcome of the care provided
• Assess whether a new or improved process meets performance expectations
Measurement & Assessment Involves
• Selection of a process or outcome to be measured
• Identification and/or development of performance indicators
• Aggregating data
• Assessment of performance
• Taking action
• Reporting
Performance Measures to Include
Performance Measures to include in QI Plan (if applicable)
• Risk Management
• NC TOPPS
• Evidence Based Practice (EBP)
• Incident Reporting
• First Responder
• Failure to Provider Backup Staffing Reports
Selection of Performance Indicator
• Performance Indicator: a quantitative tool that provides information about the performance process, services, functions or outcomes.
• Selection of a Performance Indicator is based on the following considerations:
Relevance
Clinical importance
Performance Indicator Characteristics
Factors to consider in determining which indictor to use:
• Scientific Foundation
• Validity
• Resource Availability
• Meaningfulness
Assessment of Performance Indicator
Assessment is accomplished by comparing actual performance on an indicator with:
• Self over time
• Pre-established standards
• Evidence Based Practice Information
• Similar behavioral health providers
Key Element 5: Implementation & EvaluationSuccessful implementation requires a strong infrastructure
• Review and Update QI Plan
• Prioritize Objectives/Goals/Projects
• Leadership Commitment
• Staff and Consumer Input
• Communicate with Relevant Individuals/Groups
• Staff Education and Training
Annual Evaluation
Review and update the QI Plan annually
Review should include:
• Progress on QI Objectives
• Training Completed & Effectiveness
• Progress On/Completion of QIPs
• Information from oversight agencies
• Changes to QI Plan For Coming Year
• Communication of Annual Review Results
QIP BenefitsQIPs are an efficient and effective method of solving a problem and/or improving a process.
Uses data to drive decision making
Focuses on results
A methodical process
Avoids wasting time/effort/resources
Helps identify the “root cause” so that the results are sustainable over time
Where to Begin?
Identify a problem that needs solving What are you getting complaints about?
What is a hindrance for your staff?
Are you out of compliance for a rule/regulation?
Identified risk management areas
Identify a process that needs improving Is something taking too long?
Would you like improve satisfaction scores?
Are staff/clients asking for a better way to do something?
Is there an agency goal?
A Topic is Chosen, What Next?
Give the project a name
Identify who will be affected by the project Clients or staff?
Who will be the key staff responsible for the project?
Identify the start and end dates for the project
Identify exactly what you want to improve
Why did you select the project?
What measures/data can be used to measure the problem and interventions?
Gain approval for the project within your agency
Identify Data and Analyze
What is your BASELINE data? What numbers measure the current state of things?
Admissions, turn over rate, length of time waiting, number of incidents or complaints, etc…
Look at the relationship between the measures
Spikes or dips in the data?
Trends? (should be 3 measures to identify a trend)
What happened to explain the results of the measures?
What is Causing the Problem?
Is this a knowledge/education issue?
Provide training
Is the problem an insufficient work process?
Identify key people to identify the work flow
Change the policy/procedure
Train staff, supervise and monitor by measuring
Identify what is needed for success?
IT/forms/prompts?
Identify Interventions
Identify actions to reduce/eliminate the problem OR improve the outcome.
Brainstorm all options (involve key “front-line” staff)
Select ONE action to take
What data is needed to evaluate if the action works?
Implement Your Intervention
Create a standard template to document your QIP
Use an interdisciplinary team to bring different perspectives and skills. Include “front line staff” and key stakeholders
Gain approval from leadership to begin the QIP
Gain “buy in” from staff as you implement
Share the who/what/where/when/why
Share the results of the re-measure data
Recognize the effort/result for changing processes
After the Intervention: Collect Data for Re-measures
Measure “apples to apples”
Same measure as your BASELINE data
# of calls / complaints / falls / denials
Same timeframe
Quarterly /monthly / weekly
Document re-measures on the QIP form
Tips for Data Collection
Clearly define the exact data being collected
What is the source of the data?
Reliable?
Collected electronically or manually?
Decide who will collect it and how often
Do resources need to be dedicated to data collection?
Make assignments and give deadlines for reporting
Make the data collection part of the current flow of work.
Additional Considerations
Are you using a billing warehouse? They can provide you with data
Excel
What do you have already available?
What are you currently required to do as part of your day to day work?
Do you receive any measures from outside sources?
Measuring Progress
Gather your numbers and compare re-measures
Sometimes a visual comparison gives more insightGraphs, charts, etc…
Is this measure showing you what you need?
Be specific and objectiveSometimes data results will surprise you!
Avoid rejecting results that do not validate your initial assumptions about the outcome
Be open to exploring alternate “root causes” or interventions
QIP Analysis
Did you reach the goal? Continue to measure for 1 year to assure gains continue
If improvement occurred, was it the result of the planned intervention or something else? This is “face validity”
If you did not reach goal, what barriers were encountered? What did you learn? What benefits came from the effort?
What are the next steps?Gain approval to end the project
Keep the goal, extend the project with new interventions
Start a new project with different goal or different measures
Provider QIP Highlight
QIP Activity
Quality Improvement Toolbox
Next Steps
If you don’t have a QI Program, implement one
If you do, look to improve it
Participate in your Provider Forums and Provider Quality Improvement committees
Stay abreast of resources
Attend trainings
Always focus on a cycle of continuous improvement efforts