PERFORMANCE IMPROVEMENT

PERFORMANCE IMPROVEMENT

BRIDGING THE GAP BETWEEN “WHAT IS” AND “WHAT SHOULD BE”

A Step-by-Step Workbook and Reference Guide

ByLisa DeBilio, Ph.D.

QI Coordinator, UCHC, UBHCand

Shula Minsky, Ed.D. QI Director, UBHC

©All rights reserved

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CONTENTS

Introduction……………………………………………………………………………………..….

CHAPTER 1. A Few Basic Questions

What is Performance Improvement? …………………………......................................................... How is QI/PI Set Up at UBHC and UCHC?.....……………….......................................................... The QI Mission and Principles.......................................................................................................... The QI Model…................................................................................................................................

CHAPTER 2. The Performance Improvement Process

How Does this Workbook Work? …………………………………………………………………

STEP 1: PLAN/DESIGNActivity #1: Develop Your PI Team & Define Your Roles…..………………………………….. Activity #2: Generate Ideas for a QI Project through Brainstorming & Decide on project using

Multi-Voting or Selection Matrix. Submit PI Activity Notification Form………. Activity #3: Develop & Categorize Probable Causes using Brainstorming & Multi-Vote …….. Activity #4: Display Probable Causes on a Fishbone Diagram…………………………………. Activity #5: Display the Causes in a Pareto Diagram… …………………………………..….. Activity #6: Use the Flow Chart if There is a Need to Create or Change an Existing Process ……. Activity #7: Brainstorm Potential Interventions & Multi-Vote ………………………................

STEP 2: MEASUREActivity #8:Review Existing Data or Collect New Data, Develop a Plan, Implement Interventions,

and Collect Post Data……………………………………………….……………….

STEP 3: ASSESSActivity #9:Analyze Data and Compare Results……………………………….…………………

STEP 4: IMPROVEActivity #10: Implement, Educate and Monitor Improvements………………………………….

CHAPTER 3. The Performance Improvement Fair

What is a PI Fair? ……………………………………………………………………………..…… The Judges Criteria ........................................................................................................................... The Judges’ Scale……………………………………………………………………………….... Activity #11: PI Poster Boards………………………………………………………………….

PI Board Examples……………………………………………………………………………..... Registration Form..………………………………………………………………………………

Activity #12: Meeting Minutes…………………………………………………..……………...QI Help Line……………………………………………………………………………………....

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INTRODUCTION

If you are saying “I wasn’t hired into the Quality Improvement Department, so why do I need to know about the PI process?” then this booklet is for you.

In the ever-changing health care environment, continuous quality improvement(CQI) programs have become essential; not only because of the need to monitor and improve services, but also to ensure that programs adhere to the standards set by accrediting organizations like the Joint Commission on Health Care Organizations (for UBHC), and the National Commission on Correctional Health Care (for UCHC). CQI helps fulfill the mission of providing the best possible treatment and services to those under our care. Better services can make a difference and can help clients achieve their goals, overcome difficulties, and live better lives. We can achieve excellence through the collaboration of multidisciplinary Performance Improvement (PI) teams who identify areas of care in need of improvement, discover the root causes of problems, and take action by generating and implementing interventions, and monitoring improvement over time.

This workbook is designed to help staff follow step-by-step guidelines for carrying out PI projects from selecting and prioritizing issues for improvement all the way to presenting the final product at a Performance Improvement Fair. The workbook can also be used as a tool to document and track the progress of individual projects.

We hope that this workbook will make your job easier; however, please view it as a work-in-progress. If you have any feedback, suggestions or questions please send them to Lisa DeBilio at [email protected] or Shula Minsky at [email protected].

CHANGE

CHANGECHANGE CHANGE

mailto:[email protected]

mailto:[email protected]

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CHAPTER 1

A FEW BASIC QUESTIONS

What is Performance Improvement?You have heard the terms QA, CQI, QI, PI, etc.; rest assured that these terms are more or less interchangeable and they all refer to a systematic approach to analyzing current performance and designing, testing, implementing and monitoring interventions that bridge the gap between “what is” and “what should be”. The concept was derived from a set of management theories (Total Quality Management) first developed and applied in the manufacturing industry. Since then, the concept and strategies have been applied to the service industry with impressive results.

Performance Improvement (PI) focuses on processes, not individuals. Teamwork and measurement are a few of the core principles that drive performance improvement in health and behavioral healthcare environments like ours. In UBHC and UCHC we have adopted a four-step model to guide performance improvement activities throughout the organization.

How is QI/PI set up at UBHC and UCHC?The QI program at UBHC is overseen by the Quality Improvement and Patient Safety Committee (QIPSC). The committee is co-chaired by the director of the Quality Improvement Department and the Medical Director/VP for medical Affairs. The QIPSC has six subcommittees: Clinical Case Review, Clinical Documentation, Performance Measures/Outcome Assessment, Physical Health, Behavior Management, and Patient Safety Workgroup (see figure I).

UCHC, a subsidiary of UBHC, is one of two service providers working under the New Jersey Department of Corrections (DOC). The other service provider, Correctional Medical Services (CMS) provides medical services to the inmate population. The QI organizational structure at UCHC consists of a combined statewide and two provider-specific QI committees. In addition there is a QI committee on each of the DOC sites and numerous PI teams that report to the above committees (see figure 2).

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UNIVERSITY BEHAVIORAL HEALTHCARE

QI Organizational Structure

President & CEO

Executive Committee

QIPSC

Behavior Management

Performance Measures/ Outcome

Assessment

Physical Health

PatientSafety Work-group

Clinical Documentation

Clinical Case

Review

Figure I

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UNIVERSITY CORRECTIONAL HEALTHCARE

QI Organizational Structure

Statewide QI Committee

CMS Regional QI Committee

UCHC QI Committee

Site QI Committees

UCHCPI Teams

CombinedPI Teams

CMSPI Teams

Legend:Direction/Guidance

Summary reporting

Detail reporting/ minutes

DOCPI Teams

Figure II

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THE QI MISSION & PRINCIPLES

1. Performance improvement (PI) must be a high priority for all levels of staff in the organization.

2. PI is data-driven and requires the use of some data collection methods and appropriate statistical tools.

3. The focus of PI is on processes not individuals.

4. To be effective, PI must follow a coherent model.

5. PI is best when involving a collaboration between all relevant functions within the organizational structure.

6. The PI process information must be “communicable” (i.e., documentation is crucial).

What are the Principles of PI/CQI?

1. Continually seek opportunities to improve performance of all aspects of services and care.

2. Promote data-driven improvement efforts.

3. Achieve the above through collection, interpretation and the effective dissemination of relevant, accurate & timely information to management and staff.

The QI Mission statements at UBHC and UCHC are similar with one exception, while UBHC is a stand-alone organization, the UCHC team works in collaborationwith NJDOC and CMS.

QI strives to…

What is the QI Mission at UBHC/UCHC?

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THE QI MODEL

What QI Model is used at UBHC/UCHC?

The quality improvement model used at our organization is circular, and has four steps/phases (see figure 3. on page 9). Sometimes you may need to take a step back and work through previous steps before moving forward through the steps.

Step 1: Plan/Design

This is where you outline your plan or “road map.” All activities are thought about and planned during this step. Some questions to think about, clarify and document include:

1. What is the purpose of this project, how is it related to the mission and values of the organization?

2. Who should be involved? (A team is more then 1 or 2 people…)3. What resources will be needed (staff, time, and materials)?4. What possibly could cause the problem you are seeking to improve?5. How can the problem(s) be remedied? Which interventions are possible/feasible/likely to

succeed?6. What are the success indicators going to be (how will you know the interventions

worked?)7. How and when to measure effectiveness (baseline and outcome)?8. What data collection methods will be used?9. What will the project timelines be?

Step 2: Measure

This step involves implementing interventions and collecting data to measure the effectiveness of such interventions.

1. Review existing data or collect (baseline) pre-data; use organizationally available data whenever possible.

2. Implement interventions.3. Collect post-data.4. Analyze the data.

Step 3: Assess

This step involves review of data analyses, assessing the effects of the interventions, and comparing to baseline and other data. Compare the outcome to information from other sources (i.e., the literature, Mental Health Corporation of America, National Commission on Correctional Health Care (NCCHC), etc.), other sites in your organization, and your own past performance). The final product of this step is a decision to declare the project fully successful, continue to test it, or abandon the intervention.

Step 4: Improve

If the previous step indicates that the initiative was successful, implement the new or revised processes, educate staff or clients, share the improvements and continue to monitor the improvement to ensure gains are maintained.

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GENERAL MODEL FOR QUALITY IMPROVEMENTGENERAL MODEL FOR QUALITY IMPROVEMENT

PLAN

DESIGN

MEASURE

ASSESS

IMPROVE

Why do this? What are the objectives? Does it fit overall mission, values, plans? What are the expected results? Who must be involved? What exactly will we do? For how long will we engage in this activity? How will we measure baseline performance? How will we measure outcome?

Collect relevant baseline and outcome data, analyze, compare with past performance and with external resources.

Evaluate the results, interpret, discuss, is the new process/ strategy/improvement useful? Practical? Cost-effective?

If it works, implement, disseminate, publicize, do training and in-service, and maintain gains.

Figure 3.

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Chapter 2

THE PERFORMANCE IMPROVEMENT PROCESS

How Does This Workbook Work?This workbook will take you through the four steps of the PI model and beyond; from the time you begin thinking about a project to the time you present your final results at the PI fair.

Although there are a host of PI tools available, we selected only a few to be used in the 12 optional activities presented here. For each activity, we provide an overview, directions, examples, and blank worksheets. It is important to keep track of your work and document meeting minutes. Having all documentation in one workbook can help keep all the information organized and will make preparing for a PI Fair a snap. (You might want to punch holes and keep the workbook and any additional, relevant papers in a 3-ring binder.)

After completion of the project, you may put a title on the front cover and file it for future reference. Information documented in the workbook can be easily transferred to charts and tables for a poster boards you could prepare for a PI Fair, along with your team’s other creative touches. Pictures of two poster boards and project summaries are provided at the end of this workbook. The tools offered here are optional and could aid the teams to clarify their thinking about areas of care in need of improvement and interventions that could achieve such improvement.

Performance Improvement in a Nutshell: Four Milestones

1. Identify a problem that needs improvement2. Consider the most probable cause for the identified problem 3. Consider appropriate interventions and implement them4. Use data to demonstrate your effectiveness, i.e., the baseline and the post-intervention status

5, 8, 9Collect/present/review pre-data; develop pareto diagram, run/bar charts; timetable for specific tasks; minutes

You know all the above, so what now?

2, 3, 8, 9

Brainstorming; multi-voting; Pareto diagram

You know/are sure about what causes the identified problem, but you have no idea how to correct it (and/or different people have different ideas)

2, 3, 4, 5

Brainstorming; multi-voting; fishbone analysis; Pareto diagram

You have a topic already, but you are not sure about the causes of the identified problem (and different people think different things…)

2Brainstorming; multi-votingYou have to have a PI project, but you do not know what to select…

ActivityTools you may useSituation

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ACTIVITY #1Step 1: Plan/Design

DEVELOP THE PI TEAM & DEFINE MEMBERS’ ROLES

How Do PI Projects Get Assigned?Often you will be asked by your supervisor, by the quality improvement committee at your site, or by the statewide/organizational QI committee to lead or participate in a PI effort to address a specific problem. Other times, you may be asked to put a team together and come up with ideas for a PI project on your own. Sometimes a group of staff members realize they could/should correct a problem that is impacting their effectiveness or efficiency.

How Many Staff Should Be On A PI Team?A PI team should consist of 4 to 8 staff. You must include staff who are directly involved in the day-to-day operations. You also need at least one person who has decision-making responsibility, to help facilitate the implementation of the proposed interventions. Sometimes the team grows over time, depending on the need for additional resources to meet the goals of the PI initiative.

What Should be Accomplished During the First Meeting?

1. Decide how often to meet and where.

2. Decide on a few necessary roles:(a) A team leader/facilitator, (b) a record-keeper, (c) someone to document and distribute minutes and other documents

3. Begin the work of defining the problem.

THE FIRST MEETING

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SELECTING A PI PROJECT:GENERATE IDEAS THROUGH BRAINSTORMING

If you were not assigned a PI project, selecting the project or process in need of improvement should be data-driven and prioritized based on one or more of the following criteria:

The process to be improved should be…1. Related to your organization’s mission and values

2. A high-risk process (e.g., rates of restraint, suicide watch)

3. A high-volume process (e.g., medication variances, medication errors, group attendance)

4. Based on client needs (e.g., results from the client satisfaction surveys, clinical outcomes-basis-24)

5. Based on staff views (e.g., results from a staff satisfaction survey)

6. Provide opportunity for savings

How are ideas for a PI project generated?Ideas for PI projects can be generated with a Brainstorming activity, a method to generate ideas

efficiently and creatively. It is also a way to get all team members involved in the process and avoid the process being taken over by one vocal member.

How to Conduct a Brainstorming session?

1. Gather supplies: blank worksheet, flipchart, pens, markers, tape, etc.

2. Select one person to be the recorder, i.e., write ideas on a flipchart or on paper (on the wall).

3. Go around the table and ask each person to offer one idea at a time.

4. All ideas are accepted and written on the flipchart, no discussion, no debate, no critique is allowed at this time. State ideas in action terms reflecting your goal. (See example on page 13.)

5. When one round is done, start over. Individuals are allowed to “pass.” When no more new ideas come up or everyone “passes,” begin the next step (categorizing and multi-voting).

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IDEAS FOR A PI PROJECT

EXAMPLE

BRAINSTORM IDEAS

Increase compliance with outcome measures

Reduce readmissions

Reduce medication variances and errors

Increase inmate/client satisfaction with services

Improve the timeliness of completing treatment plan updates

Increase inmate/client satisfaction with staff-client interaction

Reduce no-shows for treatment

Improve tracking system of paper charts

Increase the number of groups offered to inmates/clients

Reduce time between appointments

Reduce the number of write-offs

Improve inmate attendance at community meetings

Increase correction officers’ attendance at treatment team meetings

Reduce number of times clinician supervisors are paged

Improve chart tracking system for inmate transfers

Reduce inmate PPD refusals

Improve documentation in progress notes for abnormal labs

Improve diagnosis/medication consistency in treatment plans

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WORKSHEET

BRAINSTORM IDEAS

What’s Next? Multi-Vote or use a Selection Matrix to decide on a PI project. See directions on page 16 &17

Vote

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SELECT A PI PROJECT WITH MULTI-VOTING OR A SELECTION MATRIX

MUTLI-VOTING

What Is Multi-voting?

Multi-voting is a tool used to build team consensus by incorporating individual preferences/ratings into the overall team decision. You can use this PI tool when you need to arrive at consensus but team members are torn between competing options or when there are many ideas/options and your team needs to focus on a few feasible ones.

How Do You Multi-vote?

1. Obtain supplies: paper, marker, and tape.

2. Use the list of ideas from the brainstorming (on flipchart or worksheet); put it on the wall where all can see it.

3. sometimes you need to categorize the list first, if there is a lot of overlap and duplication

4. Give each of the brainstormed ideas a number or letter.

5. Distribute 3x5 index cards or 3x3 pieces of paper to members (see page 65 for paper).

6. Members should be instructed to write the number or letter representing their choices on thecard/paper. Usually each member is allowed three choices.

7. Collect the cards and tally them on the brainstorming worksheet or on the flipchart.

8. If this was your project selection activity, complete and submit a copy of the PI registration/ Notification Form to QI Department or committee. See pages 21 & 11

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PI

WORKSHEET

SELECT A PI PROJECT WITH MULTI-VOTING

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Ideas/optionsDecisionTally

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SELECT A PI PROJECT USING ASELECTION MATRIX

What is a Selection Decision Matrix?

An alternative to the multi-voting tool, used to evaluate and prioritize a list of options against specific criteria.

When should this PI tool be used?

1. When you need to narrow your choices down to 1 or 2 from a list of possibilities.

2. When you want the decision to be based on specific criteria.

How to use a selection decision matrix?

1. Give each member a blank process improvement selection decision matrix grid.

2. Have group members individually and independently review each possibility/topic and rate them based on the decision matrix scoring guide.

3. Total the individual “sum of ratings”; the highest scoring option is selected.

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Selection Criteria

1. Alignment with organizational mission,priorities and goals

2. Customer needs andexpectations

3. High-volume services,functions or activities

4. High-risk services,functions or activities

5. Problem-prone services,functions, or activities

6. Staff’s view of importanceof the process

7. Organizational support for improvement

8. Opportunity for savings

9. Size and scope ofthe process

SUM O F RATIN GS

Potential Areas For Process Improvement

Process Improvement Selection Matrix-EXAMPLE

Use the following rating scale:1= low3= mediu m9= high

10. Stability of the process

Increa

se gro

ups

Increa

se sat

isfac

tion w

ith

group

s

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1

3

1

1

9

9

9

3

37

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9

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1

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3

9

1

3

3

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Note: This PI member selected a project to increase client satisfaction with groups

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Selection Criteria

1. Alignment with organizational mission,priorities and goals

2. Customer needs andexpectations

3. High-volume services,functions or activities

4. High-risk services,functions or activities

5. Problem-prone services,functions, or activities

6. Staff’s view of importanceof the process

7. Organizational support for improvement

8. Opportunity for savings

9. Size and scope ofthe process

SUM OF RATINGS

Potential Areas For Process Improvement

Process Improvement Selection Matrix

Use the following rating scale:1= low3= medium9= high

10. Stability of the process

WORKSHEET

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UNIVERSITY BEHAVIORAL HEALTHCARE

Notification of Local PI Activity (PI registration)

Unit/Department: ________________________________

Unit Code: ______________________________________

Date:_____/_____/_____

Contact Person: ___________________________ Phone: _____________________

Topic/Goal:

___________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

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New Jersey Department of CorrectionsCorrectional Medical Services

University Correctional HealthCare

PI RegistryNotification of Local PI Activity

Topic/Goal:

Team Leader:

Site:

Project Title:

Team Facilitator:

Team Members:

Membership Title

Phone #:

Contact Person:

Date: ___/____/____

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How Is Brainstorming And Categorization Done?

1. Obtain supplies, make extra copies of worksheet.

2. Brainstorm probable causes to problem by asking the question “why is this problem happening? Use same directions for brainstorming as in activity # 2 on page 12.

3. Decide on what categories apply to your list of probable causes.

4. You may use the table below to record the category for each cause.

5. Select the most probable cause using multi-voting. Use same directions for Multi-Voting used in Activity #2 on page 5.

IDENTIFY PROBABLE CAUSES OF A PROBLEM USINGBRAINSTORMING & CATEGORIZATION

Why is this happening

to me?

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PROBABLE CAUSES (BRAINSTORMING, CATEGORIZATION & MULTI-VOTING)

Identified Problem: Psychologist preliminary treatment plans are not being completed within specified time frames

1111X8. Officer did not let clinician talk to inmate due to a custody issue

1X7. Staff out sick

1X6. Inmate was not assigned to MH staff

1X5. Staff was covering another unit and not aware of inmate arrival

11X4. Computer not available

11X3.Computers were down

☺11111

X2. Inmate arrives Friday evening

☺11111

XX1.Inmate transferred toanother unit

DecisionTally Votes

Category 5:

Administrative/work process

Category 4:

Training

Category 3:

Staff

Category 2:

Resources

Category 1:

Client

Probable Causes

EXAMPLE

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BRAINSTORM & CATEGORIZEIdentified Problem:__________________

WORKSHEET

PROBABLE CAUSES:

Categories

Votes

Category 1

Client

Category 2

Resources

Category 3

Staff

Category 4

Training

Category 5

Work ProcessProbable causes

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What Is A Fishbone Diagram?

A Fishbone Diagram is a formalized way to display potential causes to an identified problem:

A fishbone diagram

1. Focuses on a specific problem to be fixed

2. Creates a snapshot of collective knowledge around the problem

3. Allows differentiating between proximate and root causes

4. Focuses on potential causes, not symptoms

When To Use It?

When you need a simple graphical way to explore and communicate possible causes for an identified problem and to facilitate focusing on the main issues that need corrective actions.

How To Do A Fishbone Diagram?

1. Place the problem statement on the Fishbone Diagram in the box labeled “problem statement.”

2. Using the brainstorming & categorizing activity, write the grouping categories in the boxes above the “bones.”

3. Write the causes on the lines under/over each of the categories then multi-vote.

DISPLAY PROBABLE CAUSES OF THE IDENTIFIED PROBLEM: USING A FISHBONE DIAGRAM

Note: you can also choose to display your data in a Pareto Diagram

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FISHBONE

EXAMPLE 1

Heart attack of Patient while on

Adult IP unit.

Patient

Staff Environment

Equipment

Green emergency bag/ Crash CartResident’s code

beeper

Refusal of medical workup

Work processes

Training

Pre-existing medical conditions

Health Habits

Noncompliance with health care(Refused Thyroid medication)Hereditary factors

Protective barriers

AED (defibrillator)

Code beeper and Code responsePublic safety response

On-site medical services/APNIdentification of medical issues (Tx plan)

Response to abnormal labs

Pt ed.

Key access to IP

Construction /Move-temporary changesACLS

Code response (& beeper)Medical clearance

Treatment planning for medical issuesSymptom recognition

Door width had nothing to do with the outcome, but is a root issue in future emergencies and in the use of restraint stretchers

Staffing pattern was excellent as was staff response, staffing issues did not contribute to the outcome

The important issues are around how we respond to these patient factors.

The Problem

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FISHBONE EXAMPLE 2The problem

CLIENT RESOURCES STAFF

CUSTODY ADMIN/WORK PROCESS

Inmate transferred to another unit Computers were down

Computer not available

Inmate referred to another

Inmate Arrives Friday Evening

Staff was covering another unit and not aware

Staff out sick

Inmate not available, went to clinic

Officers will not let you talk to inmate due to a custody issue

Lock Down

Inmate was not assigned to MH staff

Psychologists initial treatment plan not completed in expected time frame on IP unit

FISHBONE

EXAMPLE II

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A F

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Tally Decision Probable Causes

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WORKSHEET

SELECTING THE PROBABLE CAUSES FOR TEAM’S FOCUS

USING MULTI VOTING

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What Is A Pareto Diagram?

A Pareto Diagram is a sorted bar chart used to display the magnitude/importance of some problems/issues or to prioritize potential causes of identified problems

When To Use It:

When you want to:

1. Focus efforts on tasks that may have the greatest potential impact on the identified problem.

2. Provide a simple picture, easy to understand and communicate regarding the relative importance of specific issues/solutions.

How To Use It?

The Pareto diagram can be used with counts or percentages and is used to display magnitude or order and to prioritize issues (it can be used with the results of multi-voting following brainstorming or fishbone analysis).

1. Determine the categories related to your issue (e.g., wrong dose, wrong route, etc).

2. Determine your unit of measurement (number of events of different types of variances).

3. Collect/assemble the data.

4. Plot the highest one first, then second highest, etc.

PROBABLE CAUSES OF THE IDENTIFIED PROBLEM:

USING A PARETO DIAGRAM

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Root Causes of Sentinel Events A Pareto Chart:

Figure 4

Source: JCAHO publication

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WORKSHEET

PARETO DIAGRAM

0

________ ________ ________ ________ ________

Fill in variable names

Fill in the rangeof occurences:0, 20, 40, 60, 80, 100 or0, 2, 4, 6, 8, 10, etc

Title: _____________________

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DESCRIBE A PROCESS & HOW IT NEEDS TO BE CHANGEDUSING A FLOW CHART

What Is A Flow Chart?

The Flow Chart is a formalized way to describe a process or an event. When using this PI tool, involve staff who are familiar with the process/event, and focus on creating an “as is” flowchart before you work on the “as it should be”.

When To Use A Flow Chart:

You should use the Flow Chart when you need to:1. Understand what happened in a process;

2. Streamline a process;

3. Design a new process, and

4. Visualize a process change.

How To Do Flow Chart?

1. Obtain supplies: markers, flipchart/paper.

2. Get staff working closely with the problem to participate.

3. Write each activity that is part of the process/event, be careful to recognize concurrent activities and decision points, where actions diverge.

4. Do several drafts as needed until there is consensus among participants.

5. Identify the areas that need to be changed in order to improve the process

Another Option

When flipcharts are not available, try using sticky notes. Find workspace near a blank wall, write each activity on a sticky note and attempt to place them in order. (Someone would be responsible to copy all the work once you are done.)


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FLOW CHART – EXAMPLE

Scheduling MeetingsThe Process ‘As Is’

Identified need for meeting

E-mail to all participants with

dates

Got responses?Date/time acceptable?

Schedule meeting,

End

Yes Yes

No

No

Problem: if recipients do not respond, the process has no end point and can go on forever....

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Scheduling MeetingsThe Process ‘As it should be’

Identified need for meeting

E-mail to all participants with

dates

Got responses?Date/time acceptable?

Schedule meeting,

End

Yes Yes

No

No

Set time limit for

responding

Time limit expired?

Notify supervisor

Schedule meeting,

End

No

Yes

FLOW CHART – EXAMPLE

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WORKSHEET

FLOW CHART “AS IS”

Action Decision point

Start/end ConnectionSHAPES

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Action Decision point

Start/end ConnectionSHAPES

WORKSHEET

FLOW CHART “AS IT SHOULD BE”

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ACTIVITY #7Step 1: Plan/DesignSELECTING INTERVENTIONS USING:

BRAINSTORMING & MULTI-VOTING

EXAMPLE

Problem: Initial treatment plans are not being completed in specified time frame

Probable Cause: (#1) Inmate transferred to another unit

Votes Decision IDEAS FOR INTERVENTIONS

1. Communicate with the receiving unit responsible for initial treatment plan

2. Receiving unit to check record for current treatment plan

3. Assigned clinician to check time to ensure time frame was not exceeded

Problem: Initial treatment plans are not being completed in specified time frame

Probable Cause: (#2) Inmate Arrives on Friday Evening

Votes Decision IDEAS FOR INTERVENTIONS

4. Supervisor to inform staff that 48 hour standard must be adhered to even on weekends

5. Revise the standard since clinicians do not work on weekends

6. Revise clinician schedule

7. Have supervisor cover weekend

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WORKSHEET

SELECTING INTERVENTIONS USING MULTI-VOTING

Tally Decision BRAINSTORM INTERVENTIONS& MULTI-VOTING

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Problem Statement: ______________________________________

Probable Cause:_________________________________________

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ACTIVITY #8Step 2: Measure

IMPLEMENT AND TEST INTERVENTINS

What Is Involved In This Step?

This step involves implementing interventions and testing to see whether or not they were effective.

How?

1. Review existing data or collect (baseline) pre-data; use existing data when you can

2. Implement interventions: Use Activity Tracking Log

a. Involve the administration, clinical staff, support staff and get “buy in”.b. Adjust work flowsc. Monitor adherence to new processd. Identify problems and correct them

3. Collect post data.

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INTERVENTION ACTIVITY LOG (WORK PLAN)

EXAMPLE

Intervention Log (WORK PLAN)

Activity/task Responsibility Start Date

Anticipated Completion

Date Status

Develop data collection worksheet

Shula 12/01/2006 12/25/06

Meet with unit staff

Lisa 01/30/2007 2/30/06

Develop a consensus work flow

Jeff 02/07/07 02/07/07

Define client selection criteria

Lisa & Jeff 02/07/07 02/07/07

Select sample Lisa & staff 02/14/07 02/14/07

Implement intervention

Staff 03/01/07

Develop database

Lisa 03/01/07 03/03/07

Data entry Unit secretary 03/07/07 12/31/07

Data analysis Lisa & Shula 01/01/08 02/01/08

Final report Lisa 02/01/08 02/28/08

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WORKSHEET

Intervention Log

Activity/task Responsibility Start Date

Anticipated Completion

Date Status

INTERVENTION LOG (WORK PLAN)

43

ACTIVITY #9Step 3: Assess

ANALYZE DATA AND COMPARE RESULTS

What Is This Phase About?

The final product of this step is a decision to:

1. Declare the intervention fully successful

2. Continue to test the intervention, or

3. Declare the intervention a failure and start working on a different one.

How To Assess/Evaluate The Results Of A PI Project?

1. Review data analyses, assess the effects of the interventions and compareto baseline and other data.

2. Compare your outcome to information from other sources.

3. Use a Bar Chart or an Excel table to present/display comparisons between your pre- and post data or between different groups.

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BAR CHART

What Is A Bar Chart?

Bar Charts are used to show the differences between related measurements.

When To Use It?

When you want to show change (pre- and post data) or display data in several categories

How To Do A Bar Chart?

1. Decide on the data that must be displayed in the chart.

2. Decide how the individual bars will be set up (e.g., by month? by quarter? by type of respondents? by gender?).

3. Plot the data. (You may use PowerPoint, Excel or any othergraphing software).

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BAR CHART

EXAMPLE FROM UBHC

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INTERVENTION NON-INTERVENTIONpre-weight post-weight

Pre- and Post- Intervention Weight in Two Client Groups*

* From the healthy living study, Vreeland et al. 2003

Note: See page 45 for Bar Chart Directions

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Q4/05 Q1/06 Q2/06 Q3/06

Variances Errors

Inpatient Medication Variances and Errors

Quarter 4, 2005 to Quarter 3, 2006

BAR CHART

EXAMPLE FROM UCHC

47

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Fill in the names of the month


WORKSHEET

BAR CHART

Title: ___________________________

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EXAMPLEDISPLAYING COMPARISON DATA USING EXCEL

Mental Health Services

Scale:1=Poor 2=Fair 3=Good 4= Very Good 5=Excellent N Mean N Mean N Mean N Mean N Mean N Mean

1. Overall, how would you evaluate the quality of mental health services you received 654 3.6 767 3.6 983 3.6 47 3.2 947 4.0 58,101 3.9

2. The helpfulness of the mental health staff 694 3.7 864 3.7 1108 3.7 47 3.5 994 4.0 58,593 3.9

3. Courtesy shown you by the mental health staff 688 3.9 853 3.9 1103 3.8 --- --- 993 4.0 58,338 4.0

4. Attention to privacy during treatment sessions 694 3.8 860 3.8 1098 3.8 --- --- 981 4.0 57,747 4.0

5. Professionalism of the mental health staff 695 3.9 860 3.9 1102 3.8 --- --- 992 4.1 57,517 4.0

6. The extent to which your individual mental health needs were addressed 692 3.6 864 3.6 1104 3.7 47 3.8 974 3.9 57,016 3.8

7. Availability of mental health staff to talk with you 701 3.6 862 3.7 1098 3.6 47 3.3 975 4.0 56,934 3.9

8. The frequency of appointments with mental health staff 692 3.5 851 3.6 1095 3.6 --- --- 930 3.6 51,365 3.7

9. The length of t ime you had to wait for your first mental health appointment 688 3.5 859 3.6 1085 3.6 --- --- 923 3.7 49,185 3.7

10. The helpfulness of medication and/or other treatment that you received 692 3.5 849 3.6 1091 3.7 47 3.2 903 3.8 54,521 3.8

11. The degree to which mental health staff respect your confidentiality 694 4.0 856 4.0 1091 3.8 --- --- 986 4.1 57,640 4.1

12. The opportunity to participate in decisions about your mental health treatment 693 3.6 861 3.7 1079 3.6 47 2.9 966 3.9 56,516 3.8

Mean: 3.68 3.69 3.69 3.32 3.93 3.88

13. The availability of mental health groups (Mean 3.4)14. The helpfulness of mental health groups you participated in (Mean 3.4)

University Correctional HealthCareResults from the Statewide Inmate Satisfaction Survey

August, 2006

Georgia DOC

Q 4 (N=870)

MHCA

N=59,725Q 2 (N=1112)

UCHC

Q1 (N=709) N=1,000N=47

UBHC

49

ACTIVITY #10Step 4: Improve

How To Improve?

If the previous step indicates your initiative was successful:

1. Implement the new or revised processes in your unit and/or in your organization;

2. Educate staff or clients, as necessary;

3. Share the project and results with others (by preparing and presenting it at the PI Fair), and

4. Continue to monitor the improvement to ensure gains are maintained by using a Run Chart.

IMPLEMENT IMPROVEMENTS, EDUCATE STAFF,

AND

MONITOR RESULTS

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RUN CHART

What Is A Run Chart?

A run chart is used to present data over time, so that you can observe trends, changes and patterns.

When To Use A Run Chart:

1. When monitoring performance to detect trends over time.

2. When comparing a measure before and after an intervention .

How?

1. Select a performance measure.

2. Gather at least 20—30 data points.

3. Create a graph with time line on the horizontal axis and the measure on the vertical axis.

4. Plot the data points and connect them with a line (use PowerPoint, Excel or any other software for best looking results).

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0

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RESTRAINTS Poly. (RESTRAINTS)

CHILD AND ADOLESCENT INPATIENT SERVICES1991 - 2006 (BY QUARTER)

RESTRAINT USE AT UBHC’S

RUN CHART EXAMPLE

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RUN CHART EXAMPLE II

July 98-December 02

Seclusion Rates in Adolescent Inpatient settingsSeclusion Rates in Adolescent Inpatient settings

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Fill in the names of the months, times, etc.


WORKSHEET

RUN CHART

TITLE:____________________

____ ____ ____ ____ ____ ____ ____ ____FebJan Mar Apr May

T1 T2 T3 T4 T5

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THE PERFORMANCE IMPROVEMENT FAIR

What Is A PI Fair?A PI Fair is a forum for staff to share information about their PI initiatives and achievements. It is an opportunity to network and exchange ideas with staff from other sites. All staff including the teams who present projects must register prior to the PI Fair in order for the PI Fair Committee to make appropriate preparations for the event. So, keep your eyes open for notices, they will be distributed about two months prior to the event. Projects submitted by the deadline will be judged by three judges selected by the PI Fair Committee. The winners will be announced at the Fair.

How To Prepare For The PI FairEach team will assemble a poster board and write a one-page summary. The posters and summary page are submitted to the QI Department responsible for organizing the Fair by a specified deadline. This is necessary to allow the judges sufficient time to review the posters and render their decisions.

What Criteria Do The Judges Use In Evaluating PI Projects?1. A clear planning process

2. Sound/explicit data-gathering design

3. Evidence of the use of the QI model

4. Appropriate use/analysis of data

5. Evidence of plan for follow up

6. Visual appeal of poster

7. Reflects value of the organization

8. A clearly written summary

CHAPTER 3

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PI FAIR PROJECT JUDGING TOOL

1. A clear planning process, including choice of appropriate team members, including staff close to the processes) under study.

1 2 3 4 5 6 7

2. Sound/explicit data gathering design.

1 2 3 4 5 6 7

3. Evidence of the use of QI model.

1 2 3 4 5 6 7

4. Appropriate use/analysis of data.

1 2 3 4 5 6 7

5. Evidence of plan, for follow-up (if team was successful) or for further process improvements.

1 2 3 4 5 6 7

6. Visual appeal of poster as a whole.*

1 2 3 4 5 6 7

7. Reflects the agencies Mission

1 2 3 4 5 6 7

8. Clearly written description (summary page) of what was done by PI team, results, conclusions, and future plan.

1 2 3 4 5 6 7

*Starting 2007, UBHC will no longer judge posters on visual appeal.

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PI POSTER BOARDS

What Needs To Be Included On Your Poster Board?

1. The purpose of the project.

2. Team members (a picture of the team may be added).

3. Steps of the QI Model and where the project is/was on that model.

4. Methods used to arrive at identifying the problem, and its probable causes (fishbone chart, Pareto diagram, etc.).

5. A description of your interventions and how you selected and prioritized them.

6. Baseline data (or plans for it).

7. Outcome data (or plans for it).8. Conclusion, status of the project, plans for the future, etc.

How To Use Powerpoint To Create A Presentable Poster?

1. Use separate pages to stick on the board to show the content that needs to be included: bar charts, PowerPoints, Excel tables, the QI model.

2. Create one large poster using Microsoft PowerPoint, and have it printed at a print shop (Kinkos, Staples, etc, or for UBHC at RWJMS internal computing services) and attach to poster board.

What are PI Poster Boards?PI poster boards provide an organized and creative way to present the work and the results of a PI project. Presentations should be colorful, vivid, interesting, use few words in large fonts and present data in graphs and pictures. The boards are available from the QI Department or can be purchased by the team.

QI modelstaff

step

post data

results pre data

See examples on the next 2 pages

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BUILDING COMMUNICATIONS

Team Members: Judi D’Agostino; Sandra Iwasawa; Irene Szaloczi

Purpose: Effective communication is a foundation that compassionate care is built on. Our PI team’s goal was to create a new Handbook of Helpful Information for our clients, families and friends that use the AIPU/AADH/IOP units. The focus of the handbook was to provide clear and concise information about the units and a “picture” for what clients can expect when participating in our programs. It is our belief that clients who know what is expected of both staff and themselves can have anxiety about receiving treatment decreased. Our team also designed the Handbooks so that providers outside of acute services can better describe our programs to clients they hope to refer to our facility, thus reducing anxiety about attending a new program with new providers. We also plan to have these handbooks used as a manual for effective communication from shift to shift, unit to unit and also as a reference for staff training about our units.

Methodology Used: Our team met weekly to openly discuss what each person felt was important information to provide our clients. Our team membership consisted of professionals from disciplines that are most involved in daily patient care and have different experiences in our roles on the treatment team to best provide our clients with well-rounded information. Once we determined what we felt as staff for the pts to know we then presented our clients on both the units with a sample of the proposed handbooks and sought direct feedback from pts, this was done in a group format. The pt suggestions were compiled and the handbook re-edited for distribution. We then designed pre-tests for both staff and patients, using different questions with each population. Once we created a “sample” population, we then distributed the handbooks for use on the units. After a period of three months where the handbooks had become part of the unit milieu we implemented post tests to test the overall effectiveness of the handbooks.

Baseline and Outcome Data: Based on the data collected from each population of Staff: AIPU/AADH and Clients AIPU/AADH, there was an overall gain in knowledge of unit rules and expectations by all of the tested populations as seen in the increase of correct answers.

Interventions: Created two booklets, Adult Inpatient and Adult Partial, based on staff and patient input. Utilized pre- and post questionnaires with 30 random volunteers in each group, to test the knowledge of unit rules and expectations, before and after booklet distribution.

Current Status: The new handbooks are distributed to pts in the AIPU/AADH/IOPprograms as they are admitted. The handbooks are utilized in community meetings of each program during discussions of unit rules and expectations. Clients are also encouraged to share the information with their family. Staff from the PI team did visit one extended outpatient site to distribute and present the handbooks so that referral sources have a better understanding of the overall program and services provided.

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POSTER SUMMARY EXAMPLE-UCHC

DISCHARGE PLANNING AND AFTERCAREUCHC - RIVERFRONT STATE PRISON

Team Members: Wayne Blodgett, Ph.D.; John Blasé, Ed.Spec, LPC; Tamara Thompson, MSW, LCSW; Patricia Cummings, MSW; Cassaundra Gordon, A.A.

Project Purpose: The Discharge Planning and Aftercare PI Project will improve the Mental Health Special Needs Inmate’s opportunities for successful community re-entry through coordinated services for the individuals being released from a Department of Corrections facility.

Project Scope: Riverfront State Prison will be the pilot site for the project. RFSP has approximately 160 Special Needs Inmates living with a Severe and Persistent Mental Illness. Approximately 5-10 Special Needs Inmates are discharged from Riverfront State Prison on a monthly basis to the community.

Problem: The problem was examined via the NJ Department of Corrections Electronic Medical Records system, interdepartmental/interagency meetings with UCHS and NJ DOC Social Services Staff, and bi-weekly Mental Health Special Needs Meetings at Riverfront State Prison. Team members met to discuss factors that contribute to the high recidivism rate among the Severe and Persistently Mentally Ill Inmate related from prison within the state of NJ. Factors included: no discharge planning groups to assist in the transition from incarceration to community release, limited resources available to the inmates upon release, no follow up for scheduled appointments. Statistical review of the Electronic Medical Records revealed there was a 21% recidivism rate for MH Special Needs inmates from April 1, 2003 through April 11, 2005.

Plan: A Program design was developed that would place a MH Special Needs Inmate in a Discharge Planning Group, called Transitions. The group will run in 8-week intervals.

Format: Group Treatment including process time and psycho-education.

Size: 8-15 inmates

Length of Session: 1.5 hours every weekTHE UCHS Discharge Planning Social Worker will develop an aftercare plan for the inmate that includes a 2-week supply of medication from the treating psychiatrist. If the inmate is maxing out on his sentence, appropriate releases of information will be signed, and a mental health appointment will be scheduled at a Community Mental Health Center in his discharge county.

Outcome Measures: The total number of inmates released will be calculated by completing a query on the Electronic Medical Record using the following criteria: Search Documents from Riverfront State Prison AND beginning date on and after March 1, 2005 through March 1, 2006 AND Document Summary containing “MH Discharge Summary”.

Goal: Statistical review of the Electronic Medical Records will produce at least a 5% reduction in the recidivism rate for MH Special Needs inmates from March 1, 2005 through March 1, 2006. This will occur through increased discharge preparation and coordination of care between the Department of Corrections, University Correctional Health Services and the NJ State Parole Board and community social services and mental health services

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Facility: ______________________________ Unit: _________________________________ Date: ____/____/____ Contact person:_______________ Phone: __________ Topic/goal: ___________________________________ Project Title: _______________________________ Facilitator: ___________________________________

Team Leader: _________________________________

Team Members: _______________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

UNIVERSITY CORRECTIONAL HEALTHCARECORRECTIONAL MEDICAL SERVICES

NEW JERSEY DEPARTMENT OF CORRECTIONS

PI FAIR REGISTRATION FORM

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DOCUMENTING MEETING MINUTES

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Copy page, fold on lines and cut.

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QI HELP LINE

609-771-8014 ext. 24QI DirectorCarl Ausfahl

CMS

609-943-4373Psychiatric Nurse Practitioner

Linda Adler

609-984-4188HSM SupervisorDebbie Raab

DOC

609-341-9383FMHC TrainerMechele Morris

609-341-3178Administrator Magie Conrad

973-465-0068AdministratorMitch Abrams

856-225-5753AdministratorMarci Masker

609-984-6474AdministratorRich Cevasco

609-341-3093Secretary IShirley Lee

609-341-3093QI CoordinatorLisa DeBilio

UCHC

732-235-7587Data Control ClerkKim Wilson

732-235-3921Secretary IISheila Jackson

732-235-4253Administrative Coordinator

Dorothy Hutty

732-235-3921Professor of PsychiatryMike Gara

732-235-5003Director of QI Shula Minsky

UBHC

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