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3/21/2014
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Illinois Critical Access Hospital Network (ICAHN) Presentation
Rural Hospital Performance Improvement Project (RHPI)National Rural Health Resource Center
Annual Quality Plan
Patient Safety
Continuous Survey Readiness (TJC/IDPH)
Planning a QI Meeting & QI Teams
Core Measures
Meaningful Use
Risk Management
Infection Control
FPPE/OPPE – Peer Review
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Required by TJC, licensing and regulatory agencies
QI Council – defined
Flow of QI Information: committee structure
QI Model used – PDCA, Six Sigma, Lean, etc.
What will you be working on?
Prioritizing Opportunities
New items?
Standard items –Falls
Blood Utilization Review
Medical Record Review
Medication Use Review
Operative/Invasive Procedure Review
Mortality Review
Patient Safety Plan (FMEA every 18 months)
Medical Staff Peer Review
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Create a safe event reporting culture
Use Near Miss event reports for process improvement opportunities
A true safety culture will increase Near Miss reports & a decrease of events
Most adverse events are related to a flaw in the process
Initiate corrective actions after an investigation
Be proactive, not reactive!
Daily Safety Huddles
Engage physicians
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TJC Survey Activity Guide
Intra-cycle Monitoring (ICM)-formerly PPR
Survey Binder
Mock Survey Tracers
Checklists
Accreditation Manual Update Review Meetings
Survey Readiness Plan
Environment of Care Rounds
Leadership Commitment
Environment of Learning
Teamwork
Communication
Board & Physician Involvement
Mock Surveys
Data Driven Processes
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Start meeting on time
Make sure it has real value
Conduct the meeting efficiently
Make sure you have a plan for the meeting
Include the right people
Respect people’s time
Provide food (if possible)
Call to Order/attendance/approval of last meeting’s minutes
Department Quality monitoring results
Sentinel Event Review
RCA/FMEA Review or Update
Process Improvement team(s) status reports
Order Set review
Policy review
Risk Management issues
Safety Issues (Patient & EOC)
Infection Control Issues
Adjournment
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Beginning a process improvement with a predetermined, but not proven, idea of the proper improvement or solution
Underestimating the difficulty of conducting a thorough planning phase
Skimping on the plan, thoughtful data collection, and investigation
Underestimating the time commitment and, sometimes interpersonal challenges in leading a team
Having difficulty developing creative approaches that improve performance and efficiency (value) simultaneously
American Society for Quality- www.asq.org
Failing to challenge the team with literature, benchmarks, and best practices from others
Failing to provide adequate team support for data analysis and use of creative and possibly unfamiliar methodologies, such as FMEA or LEAN.
Being in too much of a hurry for thoughtful analysis and design
Being too slow and allowing the team to lose momentum amid other priorities
Failing to monitor the revised process design for unintended results
Failing to allocate adequate resources to sustain the improvement over the long term
American Society for Quality- www.asq.org
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QI Teams Small group usually 6-10 members
Preferably contain facilitator with QI trainingPDCA – Plan | Do | Check | Act
Individuals with first hand knowledge of processes
Multi-disciplinary
Cooperative & open-minded
“Can-do” spirit: action-oriented
Consensus building
Have a charter and summary
TARGET CONDITION• Diagram of the proposed new process• Countermeasures noted as fluffy clouds• Measurable targets (quantity, time)
IMPLEMENTATION PLAN
• What will be the main actions and outcomes in the implementation process and in what sequence?• What support and resources will be required?• Who will be responsible for what, when, and how much?• How will you measure effectiveness?• When will progress be reviewed and by whom?• Use a Gantt chart (or similar diagram) to display actions, steps, outcomes, timelines, and roles.
METRICS/FOLLOW-UP• Identify a follow-up item for each implementation plan item• Describe how and when you will check• Evaluate if the results are as anticipated.• Countermeasures noted as fluffy clouds• Measurable targets (quantity, time)
Action Owner J F M A M J J A S O N D
<PROJECT NAME><date><author><version>
THEME• What are we trying to do?
STAKEHOLDERS• Customers – Identify all internal and external stakeholders.• Team Members –
BACKGROUND• Background of the problem• Context required for full understanding• Importance of the problem
CURRENT CONDITION• Diagram of current situation (or process)• Highlight problem(s) with storm bursts.• What about the system is not IDEAL• Extent of the problem(s) (i.e., measures)
ANALYSIS• List problem(s)• Most likely direct (or root) cause• Why why why why?
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When Measurement Might Lead to a Process Improvement Effort
Performance fails to meet the target, threshold, or goal consistently
Performance becomes variable as well as inconsistent
Patients express dissatisfaction, although performance has been stable (perhaps their needs have changed although your process has not)
Benchmarks or research suggest that better performance is achievable
The measure represents an important aspect of care or service for patients so that you are willing to allocate resources and priorities to its improvement
American Society for Quality- www.asq.org
Inpatient MeasuresAMI, HF, PN, SCIP, Stroke, & VTE
1.0 hour per record average
IMM/ED15 minutes with an above chart
Outpatient MeasuresAMI, Chest Pain, Stroke, Pain Management, & Surgery
30 minutes per record
Concurrent AbstractionChecklists for staff
1.5 hours per day
Audit Process
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CMS Data Reporting Electronic Submissions in 2014
Stroke, VTE & ED Throughput
Performance rates reported as of Spring 2013
Patient Safety
Process Improvements/Efficiency
Penalties
Stage 1 & Stage 2 of Meaningful Use National Provider Call 7.24.2013
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Stage 1
14 Core Objectives
5 of 10 Menu Items
19 Total Objectives
Stage 2
16 Core Objectives
3 of 6 Menu Items
19 Total Objectives
Electronic Submission of CQM’s Required in 2014
Report 16 of 29 CQM’s
3 Month Reporting Period fixed to fiscal year quarter
May qualify for Case Threshold Exemptions
Stage 1 & Stage 2 of Meaningful Use National Provider Call 7.24.2013
Stage 1 & Stage 2 of Meaningful Use National Provider Call 7.24.2013
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Identification & prevention of risk exposures
Event Reports
Root Cause Analysis (RCA)
Serious Safety Events/Sentinel Events
Failure Mode Effects Analysis (FMEA)
Potentially Compensable Events (PCE)/Claims
Certificates of Insurance (COI)
Director of Quality Role –
Regulations ExpertCMS Conditions of Participation
Joint Commission Standards
Center for Disease Control (CDC)
IDPH
Federal Law and RegulationOSHA
Champion of IC Program
Ensure ICP performs surveillance activities timely & provides meaningful data to applicable committees
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Loss of accreditation
Loss of funding/reimbursement
Loss of licensure
Fines
Significant NEGATIVE press
Morbidity and mortality of patients
Risk to employees and the community at large
Ensure quality care that meets professionally recognized standards
Reviews are on-going, objective, fair & consistent
Lead by medical staff, not quality/risk mgmt.
May require external review
Shift from review of adverse events to on-going performance review
Data now required to show competence
Peer Review/FPPE/OPPE kept in physician’s quality file
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Focused Professional Practice Evaluation
The time-limited evaluation of a practitioner competence in performing a specific privilege. FPPE is implemented for:
Initially requested privileges;
a newly requested privilege;
whenever a question arises regarding a practitioner’s ability to provide safe, high-quality care (practitioner exceeds OPPE triggers)
Determination made:Outcome acceptable, move into OPPE
Extend period of FPPE
Recommend to limit or suspend the privilege
On-Going Performance Practice EvaluationOngoing process of data collection to assess clinical competence & professional behavior
Data/information gathered is used to assist credentialing committee with decision to maintain, revise, or revoke existing privilege prior to or at time of re-credentialing.
Reported every 3-6 months, but no less than 9 months
Includes medical staff identified indicators and thresholds/triggers (may trigger FPPE)
Select 3-5 specialty specific indicators
Select several general indicators that apply to all practitioners
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Don’t get overburdened with too many indicators
go over 3 months for FPPE if possible
forget about CRNA’s, AHP-NP’s, PA’s-all must have an individual scorecard
forget to include all FPPE/OPPE/Peer Review information in the physician’s quality file
forget to have meeting minutes of outcomes of these reviews
forget the medical staff reviews and approves all decisions of the committee, triggers, & process
Forget to follow the medical staff bylaws to ensure consistency
Clarify Leadership roles related to the quality strategy
Assure “active” participation by the senior leaders (Leadership)
Determine the Quality language
Quality Management (QM)
Peer review
Quality Improvement (QI)
Quality Assessment and Improvement (QA & I)
Regulatory
Continuous Quality Improvement (CQI)
Quality Resource Management (QRM)
AKA‐Quality and Risk Management
Performance Improvement (PI)
Core measures, Teams
Quality and Patient Safety (QPS)
Others?
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Create one Accountability Structure for Quality:
Ask: Which body/committee/group will decide how to
set priorities and determine which quality projects
related to improving organization‐wide processes and
Building a Quality Program organization performance receive staff, timeand financial support.
Could be:Quality Council
Quality/performance improvement committee
Performance improvement committee
Others?
Develop a Quality information (or PI) flow chart
Include all councils/teams/committees/forums as a way to diagram communication of QI/PI information.
Develop clarify confirm or revise and INTEGRATE all
Develop, clarify, confirm, organization policies and guiding statements
concerning patient safety, quality of care and service, and performance improvement efforts.
Determine the systematic, organization‐wide approaches (methodology) to be used for performance improvement. (Model for improvement)
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Governing Board
Of Directors
Med Executive
Committee
Quality
Council
Occ Health
Committee
Incident
& Safety
Life Safety/Safety
Hazardous Materials
Equip/Utilities Mgt
Security/Emerg Prep
Staff/Visitor Incidents
Credentials Committee
Corporate Compliance
Committee
Quality Improvement
Teams
Utilization
Review
Risk/Peer
ReviewQuality Assurance
Infection
Control
Committee
Pharmacy &
Therapeutics
Blood UtilizationMedical Record/Clinical PertinenceCase Management
Mortality
Review/Autopsy
Invasive
Procedure
Review
Radiology Peer
Review
Medical/FP Peer
Reviews
Sentinel Events
ED Reviews
Core Measures
Dept PI
PI teams
Survey
Readinesss
Core Measures
Patient
Satisaction
QHI measures
Adverse Drug
Reactions
PI Review
Formulary
Medication Errors
Drug Recalls/
Shortages/
Releases
Policy &
Procedure Review
Pt. Falls
Procedure Variances
Sentinel Events/FMEA
Patient Safety P&Ps
Hospital Acquired
Infections
Multidrug Related
Organisms
MRSA Report
Flu Vaccinations
Core Measures/NHSN
Code Blue
Disaster Planning
Construction
Forms, ICD 10, IT Steering
Nursing Care, Pt Rounds,
Policy & Procedures
ChargeMaster-Rev Cycle
Shewhart PDCA‐Plan‐Do–Check–Act or Deming Plan‐Do‐Study‐Act
FOCUS PDCA
Six Sigma Strategy
Lean Thinking Approach
IHI Model for Improvement
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Shewhart PDCA‐Plan‐Do–Check–Act or Deming Plan‐Do‐Study‐Act
Plan: Plan the change, Study a process by collecting necessary data, evaluate the results, formulate a plan for improvement
Do: Implement the plan on a small scale, educate and train as needed
Check (Shewhart) Study (Deming): Determine degree of success of action taken
Act: Implement the change on a full scale, abandon the plan and rework the cycle
FOCUS PDCA (Assumes a process already in place)
F‐Find a Process to improve
O‐Organize a team that knows the process
C‐Clarify current knowledge of the process
U‐Understand the variables and causes of process variation
S‐Select the process improvement
P‐Plan the necessary action steps
D‐Do all that is necessary to implement the action plan (pilot) and collect data to evaluate
C‐Check the results
A‐Act to fully implement
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Six SigmaStarted in Manufacturing – Toyota
Reduction of common cause variation
Business Strategy Focused on:Customer needs
Customer expectations
Customer requirements or specifications
Six sigma is the near elimination of defects3.4 defects per million opportunities
↑ Sigma ↓ Defects ↑ Quality ↓ Costs
As sigma Increases (1 sigma→ 6 sigma) the product is less variation.
With less variation there is a decrease in DPMO (Defects per million opportunities) and increase in Quality Yield (the % of quality standards achieved).
With improvement in Quality Yield there is a decrease in COQ (Cost of Quality; costs to measure, data) and COPQ (Cost of Poor Quality; rework, malpractice, risk)
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LEAN ‐ Customer FocusEliminating or preventing waste
Reducing lead timeJust in Time
Cost Reduction
Reduction of WASTEOverburden (MURI)
Unevenness or Inconsistency (MURA)
Wasteful Activity (MUDA)
Lean (Cont.)Value – Customer focus
Value added vs non‐value added –
Value added the customer would pay for it
Non‐value added
Non‐value added but necessary
Value Stream‐ Process MapWaste
Flow
Pull
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Defects
Over-Production
Waiting
Non-utilized Sources/Talent
Transportation
Inventory
Motion
Excess Processing
Kaizen‐Continuous, Incremental Improvement event
4‐5 days
Process Analysis
Processing MappingCurrent Process
Future Process
Small Tests of Change
Measure, measure, measure
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Establish an organization wide QM/PI reporting structure, process and calendar
Organize the reporting, sets up accountability
Determine Team Structure multidisciplinary teamsWorks well for some depts.
Prepare a written plan for the organization wide Quality Strategy (QA Plan from earlier)
Identify any educational needs (ongoing and yearly evaluation)
Train teams (facilitators) for quality improvement methods…(handouts at end)
FY 2013-14 July August Sept Oct Nov Dec Jan-14Feb Mar April May June
Accounting X X X XAdmitting -Registration X X X XCardiac Rehab X X X XCardiopulmonary X X X XCentral Supply X X X XSafety X X X XChildcare X X X XCommons IL X X X XCommons AL X X X XCorporate Compliance X X X XEHS-Housekeeping X X X XEmployee Health X X X XLaundry X X X XFood Service X X X XHIM X X X XNursing Hospital X X X XNursing ER X X X XHuman Resources X X X XInfection Control X X X XIn-Patient Pharmacy X X X XIT X X X XLaboratory X X X XMAPBO X X X XMarketing X X X XMedical Imaging X X X XNursing Home X X X XPhysician Offices X X X XPlant Services X X X XPT-Rehab X X X XRetail Pharmacy X X X XRev Cycle - Pt Accts X X X XSecurity X X X XSurgical Services X X X XAnesthesia X X X XVascular X X X XWellness Center X X X X
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Data Inventory
What is being collected, used, submitted to external sources?
By whom?
Is there duplication of efforts?
What are the reasons for the data? Are the reasons valid?
Sources of data; Internal vs. External
Can it be captured electronically?
Is additional data needed?
Does the data produce useful information?
Is data Reliable, Valid?
Validity‐The capability of the indicator or collection tool to measure what it is supposed to measure; its predictive value as a measure of quality.
Example: What would be a valid measure or indicator to collect if looking at CHF readmissions?
Weight gain, follow up appointments, reason for readmission
Reliability‐ the ability of the indicator or collection tool to measure in a reproducible way what it is supposed to measure (inter‐rater reliability).
Example: Reliability – Temperature, weight
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Does data being collected align with strategic initiatives of the organization?
Is the data linked appropriately to the organizations balanced scorecard or dashboard?
Is it based on established performance measures?
Is it trended over time???
Displayed in the appropriate format?
Is it shared with others in the organization?
I: Identify Opportunity for Improvement –What is the Performance Improvement Goal
D: Determine Causes
E: Explore Solutions
A: Activate Action Plan for Improvement
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QI Opportunity/Problem Referral form
QI Priority Scoring Grid
QI Team Interim Report
QI Team Assignment
