Continuous Quality Improvement, Risk Management

Clinton (1993) (health care reform) Six principles basic to Security Act:
1. security: guaranteeing comprehensive benefits to everyone 2. Simplicity : cutting red tape and consequently simplifying the system

3. savings: controlling the costs of health care 4. Quality: making health care better 5. Choice: preserving and increasing the options available 6. Responsibility: making everyone responsible for health care

Choice - the right to choose ones health care provider to protect the doctorpatient relationship

Quality standards are often set by professional bodies and promulgated through:
A. Codes of ethics Standards of care Standards of performance Practice guidelines

Monitored through:
1. accreditation Peer review Certification processes

Outlines standards of care 1. Assessment 2. Diagnosis 3. Identification of outcomes 4. Planning 5. Implementation 6. evaluation

Standards of professional performance 1. Quality of care 2. Performance appraisal 3. Education 4. Collegiality 5. Ethics 6. Collaboration 7. Research 8. Resource utilization

Deming (1982)
Total Quality Management (TQM) Continuous Quality Improvement (CQI) Plan-do-check-act (PDCA)

Chain reaction:

a. Improve quality b. Decrease costs with fewer mistakes, less rework, fewer delays, better use of time and materials c. Improve productivity d. Capture the market with better quality at lower prizes e. Stay in business f. Provide jobs

1. 2. 3. 4. 5. 6.

7.

cause-and-effect chart Flow chart Pareto chart Histogram Run (trend) chart Scatter diagram Control chart

Others:
Checklist Pie charts Time charts Decision matrices Affinity charts Tree diagrams Relationship diagrams Force-field analysis Bar graphs

Vilfredo Pareto, contains both bars and a line graph, where individual values are represented in descending order by bars, and the cumulative total is represented by the line.

a histogram is a graphical representation showing a visual impression of the distribution of data

Plan:
Plan the change Identify the opportunities Develop vision statement Collect data to define problems and opportunities Use CQI tools to organize data and thinking Decide on improvement initiatives

Do
Implement the planned change Implement initiatives Test with a trial run Identify costs, people and materials Educate staff and management about changes in the process

Check:

Observe the effect of change Monitor progress of initiatives Meet with staff to discuss changes Delegate staff to monitor results Compare new data with original data, using CQI tools Use CQI tools to monitor results

Act:
Adjust as necessary Incorporate changes into department policies Inform and educate all involved Distribute new policies to key individuals Look for new opportunities

Quality planning:

1. Determine who the customers are 2. Determine the needs of the customers 3. Develop product features that respond to customers needs 4. Develop the processes that produce those product feature 5. Transfer the resulting plans to the operating forces

Quality Control:
1. Evaluate actual quality performance 2. Compare actual performance with quality goals 3. Act on the difference

Quality Improvement:
1. Establish the infrastructure needed to secure annual quality improvement 2. Identify the specific needs for improvement, which become the improvement projects

3. Establish a project team with responsibilities for bridging the project to successful closure 4. Provide the resources and training needed by teams to diagnose the problems, develops a remedy, and establish controls to maintain the gains

14 Steps: 1. Commitment from management 2. Use of quality improvement teams composed of people with process knowledge and commitment

3.

4.

5.

Quality measurement to identify the areas that need improvement and change Measuring the cost of quality and nonquality Quality awareness by all personnel

6.

7.

8.

Corrective actions through opportunities for improvement Zero defects planning do it right the first time Employee education for quality improvement

9.

10. 11. 12.

Zero defect day as demonstration of commitment to quality Goal setting toward zero defects Error-causal removal by removing barriers Recognition for meeting goals

13.

14.

Quality councils to assist people in quality improvement Do it all over again

Defines quality as: conformance to requirements Believes that the system for creating quality is prevention of errors instead of appraisal

Donabedian:
Known for his structure, process and outcome criteria for quality assessment

Berwick:
Stresses the importance of improving process toward quality improvement

10 rules of Redesign
1. care is based on continuous healing relationships 2. Care is customized according to client needs and values 3. Client is the source of control 4. Knowledge is hared and information flows

5. Decision making is evidence based 6. Safety is a system issues 7. Transparency is necessary 8. Needs are anticipated 9. Waste is continuously decreased 10. Cooperation among clinicians is a priority

Challenges of redefined imperatives:

1. Reengineered care processes 2. Effective use of information technologies 3. Knowledge and skills management

4. Development of effective teams 5. Coordination of care across patient conditions, services and sites of care over time

Quality Assurance:
a. b. c. d. e. f. g. h. i. Detection oriented Reactive Narrow focus Getting by Tradition and safety Busyness Leadership not vested Leader as director Employee as expendable

Quality Improvement:
a. b. c. d. e. Prevention oriented Proactive Cross-functional Raising standards Experimentation and risk f. Productivity g. Leadership leading h. Leader as empowerer i. Employee as customer

Quality Assurance:
j. Responsibility of few k. Problem solving by authority l. We-they thinking m. Cynicism

Quality Improvement:
j. Responsibility of all k. Problem solving by all l. Organizational perspective m. New optimism

Standards are written value statements that define a predetermined level of expected performance:
a. Structure b. Process c. Outcome

Structure standards: physical environment, structure or management Process standards: related to delivery of care Outcome standards: results of the care or administration

Nursing audits: are basic form of data collection

1. Structure audits: done with check list ->that can note the presence and absence of policies, procedures, medical records, physical facilities, equipment, organizational structure, caregivers knowledge and experience, adequate staffing

2. Process audits: related to care -> implementing physicians orders, observing symptoms, implementing nursing procedures, discharge planning, teaching and charting

3. Outcome audits: observe the result of the care or how the patients health status changed as a result of the interventions -> related to physical health status, mental health status, physical function, health behaviors, utilization of services and satisfaction with the service received

Bar graph: series of bars representing successive changes in value of a variable or different data sets

Benchmarking: process of identifying best practices and comparing them with the agencys practices to improve performance

Brainstorming: process of creating a free flow of ideas without fear of criticism and then thinking about the good in the wild ideas that were generated

Cause-and-effect diagram: (fishbone diagram) used to identify the root causes of a problem or outcome

Check sheets: used to collect and classify raw data Process flow chart: helps analyze how a task is being performed

Decision matrix: grid that helps prioritize options Histogram: bar graph that can be used to compare patterns of occurrence over time

Radar charts: circular displays of beforeand-after data to demonstrate progress made or lost

Run chart: line graph that displays the variations in data over time. Quick assessment of patterns and trends

Scatter diagrams: determine relationships between two variables

- Reflects correlations but do not explain causation