Implementing a Robust Quality Program - ECRI...12/14/2016 1 ©2016 ECRI INSTITUTE Barbara G. Rebold, BSN, RN, MS, CPHQ Director, Engagement and Improvement December 22, 2016 Implementing

12/14/2016

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©2016 ECRI INSTITUTE

Barbara G. Rebold, BSN, RN, MS, CPHQ

Director, Engagement and Improvement

December 22, 2016

Implementing a Robust

Quality Program


• Power Point Slides viewed here• Today’s session is recorded• Today’s slides and recording will be

posted to the ECRI website.

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This activity has been approved for up to 1.0 California State Nursing contact hours by the

provider, Debora Simmons, who is approved by the California Board of Registered Nursing,

Provider Number CEP 13677. Credit will only be issued to individuals that are individually

registered and attend the entire program.

All faculty members involved in this December 22, 2016, live webinar, Implementing a Robust

Quality Program, have disclosed that there are no conflicts or financial affiliations.

To be eligible for credit:

Credit will only be issued to individuals that are individually registered and attend the entire

program. Each individual participant must log on prior to the start of the program and remain on

the line for the entirety of the program. This is how individual timed attendance is verified. In

addition you must complete an attestation survey included in the postwebinar evaluation at the

conclusion of the webinar. Once all that information is verified, qualified attendees will receive a

certificate via e-mail within 60 days of today’s program.

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About ECRI Institute

Independent, not-for-profit applied research institute focused on patient safety, healthcare quality, risk management

Nearly 50 years of experience, 400+ person staff

■ AHRQ Evidence-Based Practice Center (since 1997)

■ Federally designated Patient Safety Organization (since 2005)

ECRI Institute website resources about quality and safety

■ Obtain username and password access by contacting us at [email protected] with name and contact information

■ Search or browse for topics you need

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mailto:[email protected]

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Learning Objectives

Describe the integration of quality, risk management, and

patient safety

Identify key steps in developing a quality program

Recognize how to determine the structure and purpose of

a quality committee

Recall how to develop a quality plan

Identify methods for collecting and analyzing data

Identify methods for monitoring quality improvement (QI)

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What Is Quality?

Health and Medicine Division of

the National Academies of

Sciences, Engineering, and

Medicine*

*formerly the Institute of Medicine

High-quality care

Safe

Effective

Patient centered

Timely

Efficient

Equitable

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Overlap of Quality, Risk, and Patient Safety

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Why Focus on Quality?

Serious and widespread quality problems of underuse,

overuse, and misuse (Chassin)

Frequent harm and infrequent delivery of full benefits

■ Institute of Medicine

■ For 30 clinical conditions, evidence-based care provided 55% of

the time (McGlynn et al.)

■ For 11 clinical areas in pediatric settings, adherence to quality

indicators occurred 47% of the time (Mangione-Smith et al.)

Evidence that commitment to QI principles leads to

improved patient care and better outcomes (Asch et al.)

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Focus on Value

Increase quality

Decrease costs

Align with Patient Protection and Affordable Care Act

■ Delivery system reform

Paying for quality/accountable care

Improving healthcare

Participate in Quality Payment Program

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Key Steps in Developing a Quality

Improvement Program

Organize a QI committee

Develop a QI plan

Assess quality, patient safety, and risk issues

Set performance improvement goals

Identify performance measures

Collect and analyze data/evaluate progress toward goals

Develop and implement corrective actions

Report QI data to leadership

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Structure and Purpose of Quality Committee

The quality committee oversees the quality plan

Designate a chair and vice chair

Quality committee should be a multidisciplinary team

including administration, providers, and frontline staff

(e.g., executive director, nursing director, physicians,

nurses, administrative assistants, dentists, pharmacists)

Members of the committee may be permanent or rotating

(e.g., 1- or 2-year term) with some staff members invited

to participate temporarily (e.g., dentist invited to

participate during dental QI initiative)

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Quality Committee Meetings

The committee should meet on a

regular basis (e.g., monthly)

Agenda

■ Reviewing QI data/

progress toward goals

■ Analyzing trends/identifying problem areas

■ Brainstorming strategies for improvement

■ Developing improvement plans

Develop, revise, and implement QI plans

Document meeting minutes and keep on file

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Quality Committee

Meeting Agenda

Template

Use clear titles for

agenda items

Identify the individual

responsible for each

agenda item (if

applicable)

Set a budgeted time for

each item and stick to it

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Quality Committee Meeting Agenda Template

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Quality Meeting

Minutes Template

Include:

■ Attendees

■ Agenda items

■ Discussion topics

■ Recommendations

■ Action items

Clearly label with

consistent titles

Provide sufficient

detail

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Quality Meeting Minutes Template

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Quality Improvement Plan

Structure and purpose of quality committee

Clinical, financial, or administrative areas addressed in

QI activities (e.g., continuity of care, chronic disease

management, credentialing, patient/staff education,

patient satisfaction, access/availability)

Assessments/identification of risk areas

Improvement plans

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Quality Improvement Plan (cont.)

Data collection

Monitoring progress and improvements

Communicating results to senior

leadership

Communicating results to departmental

leadership

Communicating results to staff members

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Assess Quality, Safety, and Risk Issues

Patient satisfaction surveys

Administrative data

■ Demographic data, census logs,

patient flow data, wait times in

emergency department

Employee reports/surveys

■ Employees should be encouraged to

report quality concerns

Event reports

Medical record reviews

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Set Performance Improvement Goals

Focus on three main questions:

■ Set aims: What are we trying to accomplish? (e.g., reduce wait

times for patients in the emergency department)

■ Establish measures: How will we know we are improving?

■ Select changes: What changes will result in improvement?

Set SMART goals:

■ Specific

■ Measurable

■ Actionable

■ Realistic

■ Timely

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Organize a Team

Organize teams responsible for

improving processes/performance

Designate a team leader

Ensure representation from all who

are familiar with the particular

process

■ Administration

■ Medical staff

■ Nursing

■ Therapists

■ Frontline staff

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Identify Performance Measures

Select performance measures based on identified

high-risk areas, clinical importance, feasibility, and

needs

■ Percentage of emergency department patients who wait less

than 15 minutes to be seen by a provider

Measures should relate to processes, performance,

outcomes, decision appropriateness, patient/staff

satisfaction

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Quality Measures Sources

National Quality Forum Performance Measures

http://www.qualityforum.org/Measures_List.aspx

National Quality Measures Clearinghouse

https://www.qualitymeasures.ahrq.gov/

National Committee for Quality Assurance HEDIS

Measures: http://www.psninc.net/blog/accreditation-

preparation/ncqa-accreditation/hedis-measures-national-

committee-for-quality-assurance-ncqa/

Quality Payment Program website: https://qpp.cms.gov/

Joint Commission Core Measure Sets:

https://www.jointcommission.org/core_measure_sets.aspx

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Collect and Analyze Data

Make sure practitioners routinely document needed

information (e.g., information related to quality measures)

Consider using checklists or standardized forms during

patient care activities to document quality information

Use electronic information systems to track and trend

data; plot data over time to identify trends and progress

Designate a staff member to compile trended data for

analysis during quality committee meetings

Compare data to benchmarks to determine what areas

need improvement

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http://www.qualityforum.org/Measures_List.aspx

https://www.qualitymeasures.ahrq.gov/

http://www.psninc.net/blog/accreditation-preparation/ncqa-accreditation/hedis-measures-national-committee-for-quality-assurance-ncqa/

https://qpp.cms.gov/

https://www.jointcommission.org/core_measure_sets.aspx

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Implement Change or Corrective Action

Education and training

■ Clinical skills training

■ Communication

Revise policies/procedures

■ Scheduling procedures

■ Medication reconciliation

Develop and implement

QI initiatives

■ Immunization reminders

■ Hand hygiene campaign

■ Falls prevention

■ Reduction in central line infections

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Strength of Corrective Actions

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Plan, Do, Study, Act

Plan: Plan your test or observation

■ State your objective, make predictions

■ Initiate a plan that addresses the who? what? where? when? and

why?

Do: Carry out a test

■ Document problems encountered, unexpected results

Study: Analyze data and results

■ Compare data to predictions, determine what lessons were

learned

Act: Refine your change based on lessons learned

■ Determine if any changes need to be made

■ Plan additional tests

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Plan, Do, Study, Act—in Action

Scenario: Hospital X realizes many people are being

discharged without review of the results of laboratory work

done on day of discharge.

Plan: A team consisting of the medical director, providers,

laboratory staff, and information technology staff brainstorms

ideas. The team researches modifications to the electronic health

record (EHR) to improve test result communication.

Do: The team selects and implements EHR modifications.

Study: The new EHR system is piloted over a 6-month period.

Periodic medical record audits are completed.

Act: Both patients and staff are satisfied with the new system; test

result communication is improved. The system is rolled out in the

hospital; staff education is provided.

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Six Sigma

Define: Identify steps of a process, individuals involved

Measure: Determine the ability to make changes within

current processes

Analyze: Identify areas of high variability and causes of

variability

Improve: Make changes to minimize variability

Control: Take steps to sustain improvements

(Sources: Mistry et al.; Revere et al.)

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Reporting to Leadership

Governing or appropriate oversight authority responsible for quality of

care

■ Vote and take action on quality issues

■ Provide guidance, oversight, approval of activities

■ Review and approve policies (e.g., credentialing and privileging

policies, QI plans)

■ Review and approve credentialing/privileging information

Prepare regular (i.e., quarterly) quality reports for leadership

■ Prepare reports in a format that is easy to understand, such as

by using graphs or tables

Designate a member of the QI committee (e.g., chair, vice chair) to

present to leadership on results, QI activities, and recommendations

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Monitoring Quality Improvement

Review QI activities regularly and revise processes when

necessary

Use QI data to identify areas for improvement and

develop strategies or initiatives to address these areas

(e.g., education campaign, policy and procedure changes)

Involve staff members in improvement strategies; solicit

input and ideas

Communicate progress toward goals and improvements

made to providers and staff

Celebrate and recognize success

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Case Study: Care Rounds Improve Quality

Inpatient oncology unit analyzed adverse patient

outcome

Poor communication identified as contributing factor

A team was organized to develop

and implement initiatives to

improve communication:

■ Daily care planning

■ Care rounds

Studied results of initiatives

through the use of staff

questionnaires (Source: Blough and Walrath)

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Quality Management

Resource Page

Webinars

Guidance articles

Self-assessment

questionnaires

Online education

Industry news

Toolkits

Policies

Technology overviews

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Quality Improvement Toolkit

Sample quality plan

Quality committee meeting agenda templates

Quality committee meeting minutes templates

Quality committee formation worksheet

Quality measure sources

Improvement project planning form

Worksheet for testing changes

Patient/employee satisfaction questionnaires

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References

Asch SM, McGlynn EA, Hogan MM, Hayward RA, Shekelle P, Rubenstein L,

Keesey J, Adams J, Kerr EA. Comparison of quality of care for patients in the

Veterans Health Administration and patients in a national sample. Ann Intern

Med 2004 Dec 21;141(12):938-45.

Blough CA, Walrath JM. Improving patient safety and communication through

care rounds in a pediatric oncology outpatient clinic. J Nurs Care Qual 2007

Apr-Jun;22(2):159-63.

Chassin MR, Galvin RW. The urgent need to improve health care quality:

Institute of Medicine National Roundtable on Health Care Quality. JAMA

1998 Sep 16;280(11):1000-5.

Institute of Medicine (IOM). Crossing the quality chasm: A new health system

for the 21st century. Washington (D.C.): National Academies Press; 2001.

Institute for Healthcare Improvement. How to improve. 2016 [cited 2016

Nov 1]. http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx

Mangione-Smith R, DeCristofaro AH, Setodji CM, Keesey J, Klein DJ, Adams

JL, Schuster MA, McGlynn EA. The quality of ambulatory care delivered to

children in the United States. N Engl J Med 2007 Oct 11;357(15):1515-23.

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References (cont.)

McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA.

The quality of health care delivered to adults in the United States. N Engl J

Med 2003 Jun 26;348(26):2635-45.

Mistry KP, Jaggers J, Lodge AJ, Alton M, Mericle JM, Frush KS, Meliones JM.

Using Six Sigma® methodology to improve handoff communication in high-

risk patients. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances

in patient safety: new directions and alternative approaches. Vol. 3:

Performance and tools. Rockville (MD): Agency for Healthcare Research and

Quality; 2008 Aug. https://www.ncbi.nlm.nih.gov/books/NBK43658/

Revere L, Black K. Integrating Six Sigma with total quality management: a

case example for measuring medication errors. J Healthc Manag 2003 Nov-

Dec;48(6):377-91.

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http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx

https://www.ncbi.nlm.nih.gov/books/NBK43658/

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Upcoming Webinar Dates and Topics

Date* Topic

January 26, 2017 Data-Driven Quality

Improvement

February 23, 2017 Global Trigger Tool

March 23, 2017 Healthcare Resolution and

Disclosure

* All webinars are held the fourth Thursday of the month from 1–2 p.m.

eastern.

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Questions?

Please contact ECRI Institute at [email protected] or

(610) 825-6000, ext. 5800

Thank You

mailto:[email protected]

Documents

Implementing a Robust Quality Program - ECRI...12/14/2016 1 ©2016 ECRI INSTITUTE Barbara G. Rebold, BSN, RN, MS, CPHQ Director, Engagement and Improvement December 22, 2016 Implementing