Table of Contents
I. Getting Organized....
Abbreviations, Acronyms and Definitions
History and Philosophy
4 Step Improvement Cycle: Plan Do Study Act
Roles and Responsibilities
PI Program Policy/Plan
Drafting Policies and Procedures
II. Working with Departments/Services
Task Function
Interpersonal Function
Tips for Managing Conflict
II. Data Collection, Aggregation and Assessment
IV. Performance Reporting
V. Tips for Surviving Regulatory Surveys
VI. CAH Annual Evaluation
Getting Organized...... Introduction
I. Abbreviations, Acronyms and Definitions
Refer to the appendix at the back of this manual for a list of commonly encountered abbreviations, acronyms and the definitions of commonly used terms in quality/performance improvement.
II. Brief History and Philosophy of Continuous Quality and Performance Improvement
1950’s Dr. W. Edwards Deming, statistician, and post-WWII reconstruction in Japan
Quality = results of work
total cost
1965-1979 P.B. Crosby: “zero defects” at ITT
1980’s Outcomes-based management: achieving desired outcomes
1980’s Quality Assurance: achieving an acceptable failure rate
1990’s Total Quality Management (TQM): build quality into processes and systems
“Quality, after all, is not an end in itself, but the strategic method that the hospital uses to effectively and efficiently perform its mission.”
“Total Quality Management in a Hospital”, Wm J. McCabe; QRB April 1992. p 140.
Quality Improvement, JCAHO: continuous cycles of improvement
Performance Improvement, JCAHO: performance is more objectively measured than quality
Six Sigma: reduce the failure rate to less than 3.4 defects in a million opportunities
2000 Value of healthcare = quality
cost
2005 Institute of Medicine, Crossing the Quality Chasm: safe, effective, patient-centered, timely, efficient, equitable
Mar 2007 Secretary Leavitt, HHS: “right treatment to the right patient at the right time, every time”
The Distilled Quality/Performance Improvement Philosophy:
· The performance of any organization can and must be continuously improved;
· The quality of decision-making improves when it is based on objective information;
· Top leadership support is fundamental to success;
· Team work and cooperation are essential;
· To settle for anything less is an unacceptable management position.
· ... to settle for anything less in healthcare now is an unacceptable national position....
Getting Organized...... The 4 Step Improvement Cycle
Practice Scenario
1. Review of occurrence/incident reports reveals you have 15 falls in one month in your facility.
Is this acceptable performance, or do you have an opportunity for improvement?
2. What next steps do you take in planning for improvement?
3. What actions will you take to trial your improvement plan?
4. How will you know whether or not improvement has been achieved?
5. Is the improvement you achieved ‘enough’?
6. What steps will you take to permanently implement the improvement actions?
Getting Organized...... The Scope of our Work
Our work ranges from meeting and exceeding the needs and expectations of customers, to improving patient care process and systems and, indeed, to improving all of the hospital’s operations.
I. Customers
1. Internal Customers are the direct recipients of work. In healthcare, patients and their families, staff (including per diem staff and students), medical staff and Board members are all internal customers.
2. External Customers are the indirect recipients of work. In healthcare, regulatory surveyors (CMS, OSHA), insurance carriers, product vendors and members of the community can be external customers.
II. Patient Care Processes and Systems
The term quality improvement comes from the philosophy that health care workers should always be improving the quality of patient care.
A patient care process is ______.
A patient care system is ______.
Improving the quality of patient care processes and systems, then, can include:
· Improving clinical care delivery and clinical care support services
· Acquiring new patient care or testing technology
· Reducing the risk to a patient in the healthcare environment
· Identifying new health care markets and developing the ability to serve them
III. Hospital Operations
There are other processes and systems in the hospital which we don’t often think of as impacting patient care, but they do, and they also need continuous improvement. Because of this and the difficulty people were having defining quality, the terminology was broadened to ‘performance improvement’ and improvement efforts were realigned to evaluate for improvement non-clinical hospital departments, including:
· Financial performance (including billing practices)
· Building/Environment of Care (EOC)
· Human Resources
· Information Management (including electronic medical or personal health records)
· Materials Management (supply)
· Marketing/Community Relations
IV. The National Quality Agenda
1. Institute of Medicine (IOM): the care we deliver should be.....
· Safe – we do no harm
· Effective – we achieve the desired outcome
· Timely – without delay
· Efficient – without waste, without error
· Patient-centered – individualized
· Equitable- same for all patients
Crossing the Quality Chasm (2001
2. Centers for Medicare and Medicaid Services (CMS) http://www.cms.hhs.gov
“... the right care for every person every time.” Jan 2007, CMS vision statement,
HHS Sec Leavitt
a) Congressional mandates
· Omnibus Reconciliation Acts
· Tax Relief and Health Care Act of 2006
b) State Operations Manual (SOM) and the Medicare Conditions of Participation (CoP) http://www.cms.hhs.gov/manuals/downloads/som107ap_w_cah.pdf , 2009
c) CART & public hospital performance reporting; voluntary participation for CAHs
· Acute myocardial infarction
· Heart Failure
· Pneumonia
· Surgical Care Improvement Project
d) Hospital and Nursing Home Compare: performance data websites
hospitals: www.hospitalcompare.hhs.gov
nursing homes: http://www.medicare.gov/NHCompare
e) HCAHPS: Hospital- Comprehensive Assessment of Healthcare Providers Survey
For PPS hospitals only, at this time www.hcahpsonline.org
f) Value-based Purchasing: for PPS hospitals, only at this time
g) Outpatient Performance Measures, “Rural Measures” - see attached
http://www.qualitynet.org/dcs/ContentServer?cid=1191255879384&pagename=QnetPublic%2FPage%2FQnetTier2&c=Page (Quality Net Exchange)
3. Institute for Healthcare Improvement (IHI) www.ihi.org
· 100,000 Lives Campaign (Jan 2005 – June 2006)
o Deploy rapid response teams
o Deliver reliable, evidence-based care for AMI
o Prevent adverse drug events
o Prevent central line infections
o Prevent surgical site infections
o Prevent ventilator-associated pneumonia
· 5 Million Lives Campaign (Dec 2006- Dec 2008) http://www.ihi.org/IHI/Programs/Campaign/
o All of the 100,000 Lives interventions (see above)
o Prevent harm from high-alert medications
o Reduce surgical complications
o Prevent pressure ulcers
o Reduce MRSA infection
o Deliver reliable, evidence-based care for congestive heart failure
o Get Boards on Board
4. National Patient Safety Goals for Critical Access Hospitals (Joint Commission)
· Patient identification
· Communication
· Safe medication use
· Reduce risk of healthcare-associated infections
· Unanticipated death or major permanent loss of function
· Reduce harm from falls
· Encourage patient and family to report safety concerns
· Improve recognition and response to changes in patient condition
http://www.jointcommission.org/NR/rdonlyres/6B00286D-DB29-4237-98D5-0D57CF807098/0/CAH_2010_NPSG.pdf
Getting Organized...... Roles and Responsibilities
I. The Organization Chart Clarifies Roles and Responsibilities
A. Governing Board/Board of Directors Role
“ The CAH has a governing body that assumes full legal responsibility to provide quality health care in a safe environment.” Tag C-0241, Condition § 485.627(a)
According to the State Operations Manual for Medicare providers, the specific duties of the Board in Quality/Performance improvement include:
· Determine the eligibility of candidates for medical staff and appointment qualified providers
· Review and approve Medical Staff Bylaws
· Ensure the organization is in compliance with State and Federal laws, and the Medicare Conditions of Participation (CoP)
The Board also has a legally-recognized duty to the community to make decisions for them in trust (“fiduciary duty”), i.e., in their best interest. In order to make sound decisions on behalf of the community, the Board works to ensure there is a plan for how to go forward into the future (strategic plan). The plan always includes financial management plans, but also typically includes goals for improving:
· How the organization meets and exceeds its customer needs & expectations
· How to improve patient care systems
· How to improve hospital operations
Board members, in the course of meeting their trust obligations, should discuss and come to agreement about the need for the organization to continuously improve its performance. They will need to monitor the implementation of the strategic plan to ensure the organization is moving forward. Their monitoring should include routinely reviewing key objective measures of hospital-wide performance. The key measures are often presented in a dashboard report format for easy identification of areas where performance targets are being met, and where adjustments need to be made to reach performance goals.
B. Chief Executive Office/Administrator and other Senior Leaders Role
The role of senior leadership in a successful quality/performance improvement program cannot be overstated. Without leadership support within the facility, the program is doomed to a continuous cycle of collecting and reporting meaningless numbers. The data collected is meant to support informed, objective decision-making within the organization, at every level, in order to support the organization’s ability to achieve the specific strategic objectives established by the Board, and thereby attain its mission, continuing to provide necessary healthcare services to the community well into the future.
There are several specific actions senior leaders are responsible for which support these goals:
· Demonstrate commitment to the strategic objectives and QI/PI through its actions and decisions
· Convert the Board’s strategic objectives into measurable, short-term, operational goals (these are often called a work plan or initiatives). The short-term goals will clearly link back to the strategic objectives and focus in some way on improving:
o Meeting and exceeding internal and external customer needs and expectations
o Patient care systems
o Hospital operations
· Communicating established goals throughout the organization
· Providing education for staff and medical staff about quality/performance improvement
o This includes sharing learning from QI/PI projects, publishing and celebrating successes and “good tries”
· Supporting the QI/PI Coordinator and working cooperatively with that person to achieve real, significant improvement
· Providing through the budget system the needed resources to do QI/PI well
o Human resources
o Access to necessary information and data
o Technology
o Time to work through the improvement cycle
o Financial resources
o Environment
C. Medical Staff Role
“ The doctor of medicine or osteopathy provides medical direction for the CAH’s health care activities and consultation for, and medical supervision of, the health care staff.” Tag C-0257
According to the State Operations Manual, it is the responsibility of the medical director to perform the following QI/PI functions:
· Evaluate and improve the quality of patient diagnosis, treatment and patient outcomes. At a minimum, this includes:
o All patient care services
o Nosocomial infections
o Medication therapy (see tag C-0337)
· Evaluate and improve the quality of patient care provided by other members of the medical staff
· Evaluate and improve the quality of other patient care services and service providers (these services include dietary, the therapies, lab and blood utilization, radiology or imaging, anesthesia, etc)
· Evaluate and improve the quality of the medical record
· Evaluate and approve contracted patient care services
The medical staff’s work will include the peer review, utilization review and mortality review functions, as well as evaluating applicant and current provider applications for medical staff membership and privileges, and making recommendations to the Board about action on those requests.
Nothing makes life easier for a QI/PI Coordinator than a medical provider who understands and is engaged in the QI/PI program actively. A couple of words of caution, however: time really is a physician’s most valuable resource- spend it wisely. Focus your providers on the issues that are relevant to their work, and if possible, in areas where they have a personal interest.
Role Assessment Worksheet
Going Well Needs to be Worked On
Board and CEO/Administrator
______
______
______
______
Medical Staff
______
______
Quality Management Team
______
______
______
QI/PI Coordinator/Director
______
______
______
Dept/Service Leaders/Managers
______
______
______
D. The Quality Management Team and QI/PI Coordinator
The Quality Management Team (QMT)
If you have ever attempted to single-handedly change a process or system in your organization based on your well-intentioned desire to do so, but without the support of others in your organization, you understand the truth of what Dr. McCabe is saying in the quote above. Your authority to make changes unilaterally goes as far as your office or work space door. And without authority, it is grossly unfair to have delegated to you the responsibility to make needed changes.
So, how is the change needed to make improvement accomplished? Back to Dr. Deming’s 14 Points for Management- teamwork. You need to be able to meet and work with others in the organization to accomplish the necessary changes to propel your organization forward. One team is of primary importance- the team that will coordinate and support all of the different improvement efforts going on in the organization, whether the effort is to prepare for a regulatory survey, correct deficiencies, or develop a safer way to pass patient medications. That team, which we refer to as the Quality Management Team, is also sometimes called the Quality Council, or Performance Improvement Council, or similar such names.
The Quality Management Team varies in composition from organization to organization, usually based on the organization’s size, the complexity of services offered, and the extent to which QI/PI is integrated into the organization’s culture. Please note that the word “team” simply means more than one person is involved. You are one; if the only other person you work with on quality issues in your facility is your CEO, your team has 2 permanent members. It is still a team at that point. Other members of your Quality Management Team might include:
· Senior organization leaders
· Department/service heads
· Other QI/PI staff, if any
· Medical staff representative
· Governing Board member
· Line staff
· Community member
The first and foremost essential function of the Quality Management Team is to conduct the independent assessment of objective evidence concerning the hospital’s overall quality management system. Key characteristics of this assessment are that it:
· Is prevention-oriented and proactive. This team does not meet to ‘fight fires’.
· Is fact-based: hard data is the basis of assessment whenever possible
· Is independent, meaning that it is not constrained by organization structure and reporting relationships, but requires the entirely unbiased collection of relevant objective data from the entire organization about: