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Designing a Successful Quality
Improvement Program:Teambuilding and Writing a QI Plan
Bureau of Primary Health Care
Health Resources and Services Administration
March 10, 2011
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Introduction
Learning series on quality improvementplanning
Current core and FTCA requirements asa starting point
Focus on implementation Roadmap for getting there
Create a QI infrastructure
Seek resources and technical assistance
Third-party quality recognition Build on partnerships with HRSA and the national
cooperative agreements
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Health Center Performance
Calendar Year 2009
Among Health Center Patients:
67.3% entered prenatal care in the first trimester Rate of low birth weight babies (7.3%) continues to be lower than
national estimates (8.2%) 68.8% of children received all recommended immunizations by
2nd birthday 63.1% Hypertensive Patients with Blood Pressure
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FY 2011 HRSA
Strategic Priorities
Improve Access to Quality Health Care andServices Community/new site development
Expansion planning
Patient-centered medical/health home development Meaningful use adoption
Strengthen the Health Workforce Workforce recruitment and retention
Build Healthy Communities and Improve HealthEquity
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BPHC QI Strategy
1. Develop and enhance access points
2. Transform HC care delivery system PCMHH
HIT Meaningful Use
3. Recruit, develop, retain skilled workforce
4. Integrate Health Centers into local healthsystems Specialists, ER, Hospitals
ACOs
Public Health
5. Align policies and programs where possible
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HRSA Program Requirements
Ongoing QI/QA Plan encompassingmanagement and clinical services,maintaining confidentiality of patient
records Focused responsibility for QI
Periodic assessments of appropriate
service use and quality
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Benefits of an Effective QI Plan
Roadmap for HC organization
Leadership, focus, & prioritization
Efficient coordination of staff &
resources Better outcomes
Satisfy external requirements
HRSA, State
Third-party quality accreditation andrecognition
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QI Resources
Local
Your own staff
Other HCs
Academia
Health Departments
State/Region
PCAs & HCCNs
Medicaid, AHEC, PCOs
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B thi Lif
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Breathing Lifeinto Your QI Plan
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Where Do We Start?
OK Great!!
So how do we actually do this when we are:
Short staffed
Busy with lots of complicated patients
Short on resources (shouldnt all our
money go for patient care?)
Lacking QI skills (not covered well inmedical school, nursing school, businessschool)
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Where Do We Start?
Depends on where you are, who you are,when you began, how big you are
One site 3 providers rural Alaska 2,000
users
12 sites NYC 52 providers 100,000users
35 year history of organization, fullyimplemented EHR for 6 years
New start 2010 paper medical records
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Where Do We Start?
The Steps:
1. Create the Basic Structures
2. Evaluate & Determine Priorities
3. Select Performance Measures
4. Collect Data/Determine a Baseline
5. Analyze Data/Evaluate Performance
6. Plan & Implement Changes forImprovement
7. Monitor Performance Over Time
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1. Create the Basic Structures
Quality as an integral part of theorganizations culture.
Buy-in at all levelsBoard, management,
staff and patients. Resourcesstaff time, meetings,
information systems.
Provide education
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1. Create the Basic Structures
Role of the board
Approve QI plan
Receives reports at
least quarterly BOD QI Committee
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1. Create the Basic Structures
Continuousresources (time,money, staff)
dedicated for TA You cannot afford
not to do this!
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1. Create the Basic Structures
QI Committee QI Plan & Health care plan QI calendar Clinical practice guidelines
Policies & procedures Peer review Chart audits Patient satisfaction surveys Tracking systems Credentialing and privileging Data sources
2 E l t & D t i
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2. Evaluate & DeterminePriorities
Set aside a specific time/place where allessential staff plan how to develop your QIPlan
Remember this work will never be DONE--Continuous QI
2 E l t & D t i
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2. Evaluate & DeterminePriorities
Focused areas
High risk
High volume
Low performingmeasures
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3. Select Performance Measures
A Performance Measure is a quantitativetool that provides an indication of anorganizations performance in relation to a
specified process or outcome.
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3. Select Performance Measures
Set goals for measures:
A SMART goal is a goal that is specific,measurable, attainable, relevant and time
based. In other words, a goal that is veryclear and easily understood.
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3. Select Performance Measures
Outreach/Quality of CareIndicators
Trimester of entry into perinatal care
Childhood (2 year old) immunization
rate
Pap tests for adult (21 64 year old)women
Health Outcomes and
Disparities
Infant birth weight (normal vs. low)
Hypertension (controlled vs.uncontrolled)
Diabetes (adequate control vs.
inadequate control)
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3. Select Performance Measures
Required two
additional measures One Oral Health
One Behavioral Health
Supplemental
measures
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3. Select Performance Measures
Working capital to monthly expense ratio Liquidity in # of months - ability to pay bills on
time - current financial condition
Long-term debt to equity ratio Portion of net assets tied up in long-term debt - long-
term financial condition Change in net assets as a percent of expense
Financial results from operations in relationship to totalexpenses
Total cost per patient
Annual average cost per patient served - value ofservice provided based on costs
Medical cost per medical encounterAverage cost per billable medical encounter (less: lab &
pharmacy) - cost efficiency
4 Collect Data/Determine
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4. Collect Data/Determine
a Baseline
4 Collect Data/Determine
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4. Collect Data/Determine
a Baseline
Define measurement population anddelineate eligibility criteria.
Create a data collection plan to include:
Sampling strategy; Determine method of data collection,
i.e. chart abstraction, interviews
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4. Collect Data/Determine
a Baseline
Create data collection tools:
Create instructions for data collection tools
Train personnel who will collect data
Conduct pilot test of tool Establish process of communicating with
staff about measurement process
Collect data
5 Analyze Data/Evaluate
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5. Analyze Data/Evaluate
Performance
Analyze data and review the results.
Identify areas where additional data isrequired.
If historical data are available, compare fortrends.
Display and distribute data to communicatefindings and results.
Identify areas for improvement and select aquality improvement project.
5 Analyze Data/Evaluate
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5. Analyze Data/Evaluate
Performance
How do we know ifperformance is satisfactory?
Benchmarks useful insetting feasible andchallenging goals
The most importantcomparisons are internal
Most relevant when patientpopulations are similar
UDS data will reveal state
and national trends overtime, rural vs. urban, etc.
5 Analyze Data/Evaluate
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5. Analyze Data/Evaluate
Performance
Healthy People 2010:
www.healthypeople.gov
National Quality CenterImproving HIV Care:http://www.nationalqualitycenter.org/index.cfm/22
AHRQ Effective Health Care:http://effectivehealthcare.ahrq.gov/
National Quality Forum:
http://www.qualityforum.org/
State Primary Care Associations:http://www.bphc.hrsa.gov/technicalassistance/pcadirectory.htm
6 Plan & Implement Changes
http://www.healthypeople.gov/http://www.nationalqualitycenter.org/index.cfm/22http://effectivehealthcare.ahrq.gov/http://www.qualityforum.org/http://www.bphc.hrsa.gov/technicalassistance/pcadirectory.htmhttp://www.bphc.hrsa.gov/technicalassistance/pcadirectory.htmhttp://www.qualityforum.org/http://effectivehealthcare.ahrq.gov/http://www.nationalqualitycenter.org/index.cfm/22http://www.healthypeople.gov/7/29/2019 Design Quality Imqiprove
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6. Plan & Implement Changes
for Improvement
6 Plan & Implement Changes
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6. Plan & Implement Changesfor Improvement
Discrepancy between goals or standardsand reality
Solve the problem!
Can it be solved?
Is it worth solving?
Who should do it?
What is the goal? (MEASUREABLE) How soon?
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6. Plan & Implement Changesfor Improvement
Establish project-specific QI team thatrepresents all staff integral to the serviceor issue.
Identify a team leader or sponsor.
Delineate specific goals for the team.
Allocate time and resources for the team.
Delineate team responsibilities.
Develop timeline for reporting findings andimprovement strategies.
6 Plan & Implement Changes
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6. Plan & Implement Changes
for Improvement
Develop a time line or calendar of activitiesfor the year.
Select a QI approach, such as PDSA or
the Chronic Care Model. Clarify QI responsibilities of staff.
6 Plan & Implement Changes
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6. Plan & Implement Changesfor Improvement
Utilize QI tools and techniques tounderstand the process, such as flowcharts, facilitated brainstorming, cause and
effect diagrams, etc. Document and track progress by using
activity logs, issue identification logs,meeting minutes, etc.
Report progress on a regular, definedbasis.
6 Plan & Implement Changes
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6. Plan & Implement Changesfor Improvement
Identify potential solutions to makeimprovement to the systems of care.
Recognize quick fixes and longer termsolutions.
Try a small test of change and analyzeresults.
Refine improvement plan. Develop timeline for implementation of
plan. Delineate team responsibilities. Implement changes. Track changes and improvement actions.
6 Plan & Implement Changes
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6. Plan & Implement Changesfor Improvement
Plan-Do-Study-Act
(PDSA) :
PDSA is a widely
used framework fortesting change on asmall scale.
7. Monitor Performance
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7. Monitor PerformanceOver Time
Determine interval for remeasurement.
Remeasure indicator after change hasbeen implemented.
Look for incremental improvement. Communicate results to team, staff and
leadership.
Determine need for and/or level ofremeasurement on an ongoing basis.
Develop a plan for sustained improvement.
CHC Difficult Areas
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CHC Difficult AreasQI Improvement
Performance Measures
Data bases/Data Collection/DataReliability
Identify/Use Benchmarks
Identifying/Documenting necessity forchange in provision of services
Result in change being implementedremeasure to assure improvement
A Real Life E ample
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A Real Life Example
Steps 1 4
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Steps 1 - 4
XCHC Diabetes measure (HbA1C < 9%)was 83% (HDC participant for 6 yrs)
HTN rate
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5. Analyze Data/EvaluatePerformance
Discrepancybetweenbenchmarks (HP
1998 benchmark79%; 2009 BPHCUDS 58%) andreality (20%)
Solve the problem!
6. Plan & Implement Changes
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6. Plan & Implement Changesfor Improvement
Establish project-specific QI team thatrepresents all staff integral to the serviceor issue.
Scheduler, provider, nurse manager, medicalrecords, IT
Identify a team leader or sponsor. Chair of CQI program (COO)
Set specific goals for the team. Initially wanted to improve to 25%...
Verify baseline data
Identify restricting & contributing factors
6. Plan & Implement Changes
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6. Plan & Implement Changesfor Improvement
Allocate time andresources for the team. Initially meet weekly to
monitor PDSA cycles
Delineateresponsibilities.
Develop timeline forreporting findings and
improvement strategies. Report to next CQI
meeting in one week thenmonthly
6. Plan & Implement Changes
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p gfor Improvement
Processes
EHR now being implemented
Staff training Patient education
Plan to institute new consent formspecific for womens health and policy to
ensure its use
6. Plan & Implement Changes
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6 a & p e e t C a gesfor Improvement
Clinical practice guideline Review Pap guidelines and present to provider staff
Access to care issue Many pts seek Paps at State Health Department
Hispanic patients prefer female provider Many mobile migrant patients with multiple providers
Outcomes data Incomplete because only queried practice management
system which did not include transferred records
Tracking No consistent mechanism for obtaining records from
other providers Have meeting with health dept staff to assure
cooperation
6. Plan & Implement Changes
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p gfor Improvement
Pt. satisfaction survey?are they happywith the system?
Will consider in the future to exploreattitudes regarding various interventions
Documentation of process
Plan to keep meeting minutes, goals,outcomes
6. Plan & Implement Changes
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p gfor Improvement
Analyze data and review the results. Monthly review of women seen for Pap status
Identify areas where additional data is required.
Data collection method did not capture all Paps done
If historical data are available, compare for trends. Not previously measured
Display and distribute data to communicatefindings and results.
Plan to inform CQI committee and staff of results Graphic presentation of data readings over time
7. Monitor Performance
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Over Time
Communicate resultsReports to BOD, staff
Congratulate team
Newsletter articleSelect a new projectand begin with a newmeasure.
Oral health forpregnant women
Additional Webinars
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in This Series
Implementing your QI plan How to choose specific strategies
How to evaluate
Connection to risk management, peer review,
accreditation and PCMH
How to use data that you are already collectingto fuel your QI process
Setting goals and performance metrics
Increasing data reliability
Using HIT
Discussion and Questions
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Discussion and Questions
Please share your qualityimprovement successes, challenges,and training and technical assistance
needs Contact your HRSA Project Officer or
the Office of Quality and Data at
[email protected] or(301) 594-0818
mailto:[email protected]:[email protected]