designing a successful quality improvement program

Designing a Successful Quality Improvement Program:

Teambuilding and Writing a QI Plan

Bureau of Primary Health CareHealth Resources and Services Administration

March 10, 2011

Replay info: 888-568-0877, passcode 3255

Introduction

• Learning series on quality improvement planning

• Current core and FTCA requirements as a starting point

• Focus on implementation• Roadmap for getting there

• Create a QI infrastructure• Seek resources and technical assistance• Third-party quality recognition• Build on partnerships with HRSA and the national

cooperative agreements

Health Center Performance Calendar Year 2009

Among Health Center Patients:

• 67.3% entered prenatal care in the first trimester• Rate of low birth weight babies (7.3%) continues to be lower

than national estimates (8.2%)• 68.8% of children received all recommended immunizations by

2nd birthday• 63.1% Hypertensive Patients with Blood Pressure<= 140/90• 70.7% Diabetic Patients with HbA1c <= 9• $600 Total Cost per Patient • $131 per Medical Visit

Source: Uniform Data System, 2009

For more information: http://www.bphc.hrsa.gov/about/performancemeasures.htm

http://www.bphc.hrsa.gov/about/performancemeasures.htm

FY 2011 HRSA Strategic Priorities

• Improve Access to Quality Health Care and Services• Community/new site development• Expansion planning• Patient-centered medical/health home development• Meaningful use adoption

• Strengthen the Health Workforce• Workforce recruitment and retention

• Build Healthy Communities and Improve Health Equity

BPHC QI Strategy

1. Develop and enhance access points 2. Transform HC care delivery system

• PCMHH• HIT Meaningful Use

1. Recruit, develop, retain skilled workforce2. Integrate Health Centers into local health

systems• Specialists, ER, Hospitals• ACOs• Public Health

1. Align policies and programs where possible

National & State Performance Profile

Health Center Trend Report (National/State/Grantee) Health Center Summary Report (National/State/Grantee) Performance Profile (National/State) -- Number & Percent of

Health Centers Meet Meaningful Use Standards Achieve National Quality Recognition Exceed Healthy People Goals (Core Clinical Measures) Increase in Cost/Patient Less than National Increase Increase in Patients Going Concern Issues FTCA Claims/Visit 60 or 30 Day Progressive Actions 1 year Project Periods

HRSA Program Requirements

• Ongoing QI/QA Plan encompassing management and clinical services, maintaining confidentiality of patient records

• Focused responsibility for QI• Periodic assessments of appropriate

service use and quality

Benefits of an Effective QI Plan

• Roadmap for HC organization• Leadership, focus, & prioritization• Efficient coordination of staff &

resources• Better outcomes

• Satisfy external requirements• HRSA, State• Third-party quality accreditation and

recognition

QI Resources

• Local• Your own staff• Other HCs• Academia• Health Departments

• State/Region• PCAs & HCCNs• Medicaid, AHEC, PCOs

QI Resources

• Federal/National• HRSA: BPHC, HRSA Offices• CMS, AHRQ, ONC, SAMHSA, CDC,

NIH, VA• National Cooperative Agreements• Third party quality accreditation and

recognition

Breathing Life into Your QI Plan…

Where Do We Start?

OK Great!! So how do we actually do this when we are: • Short staffed• Busy with lots of complicated patients• Short on resources (shouldn’t all our

money go for patient care?)• Lacking QI skills (not covered well in

medical school, nursing school, business school)

Where Do We Start?

Depends on where you are, who you are, when you began, how big you are…• One site 3 providers rural Alaska 2,000

users• 12 sites NYC 52 providers 100,000

users• 35 year history of organization, fully

implemented EHR for 6 years• New start 2010 paper medical records

Where Do We Start?

The Steps:1. Create the Basic Structures2. Evaluate & Determine Priorities3. Select Performance Measures4. Collect Data/Determine a Baseline5. Analyze Data/Evaluate Performance6. Plan & Implement Changes for

Improvement 7. Monitor Performance Over Time

1. Create the Basic Structures

Q. What aspects of care does QI include?A. ALL!

Q. What staff members are included?A. ALL!


• Quality as an integral part of the organization’s “culture”.

• Buy-in at all levels—Board, management, staff and patients.

• Resources—staff time, meetings, information systems.

• Provide education


Role of the board• Approve QI plan• Receives reports at

least quarterly• BOD QI Committee


• Continuous resources (time, money, staff) dedicated for TA

• You cannot afford not to do this!


• QI Committee • QI Plan & Health care plan• QI calendar • Clinical practice guidelines• Policies & procedures• Peer review • Chart audits• Patient satisfaction surveys• Tracking systems• Credentialing and privileging• Data sources

2. Evaluate & Determine Priorities

• Set aside a specific time/place where all essential staff plan how to develop your QI Plan

• Remember this work will never be DONE--Continuous QI

2. Evaluate & Determine Priorities

• Focused areas• High risk• High volume• Low performing

measures

3. Select Performance Measures

A Performance Measure is a quantitative tool that provides an indication of an organization’s performance in relation to a specified process or outcome.


Set goals for measures:A SMART goal is a goal that is specific, measurable, attainable, relevant and time based. In other words, a goal that is very clear and easily understood.


Outreach/Quality of Care Indicators

• Trimester of entry into perinatal care• Childhood (2 year old) immunization

rate• Pap tests for adult (21 – 64 year old)

women

Health Outcomes and Disparities

• Infant birth weight (normal vs. low)• Hypertension (controlled vs.

uncontrolled)• Diabetes (adequate control vs.

inadequate control)


• Required two additional measures• One Oral Health• One Behavioral Health

• Supplemental measures


• Working capital to monthly expense ratio Liquidity in # of months - ability to pay bills on

time - current financial condition• Long-term debt to equity ratio

Portion of net assets tied up in long-term debt - long-term financial condition

• Change in net assets as a percent of expense Financial results from operations in relationship to total

expenses• Total cost per patient

Annual average cost per patient served - value of service provided based on costs

• Medical cost per medical encounter Average cost per billable medical encounter (less: lab &

pharmacy) - cost efficiency

4. Collect Data/Determine a Baseline


• Define measurement population and delineate eligibility criteria.

• Create a data collection plan to include:• Sampling strategy;• Determine method of data collection,

i.e. chart abstraction, interviews


• Create data collection tools:• Create instructions for data collection tools• Train personnel who will collect data• Conduct pilot test of tool

• Establish process of communicating with staff about measurement process

• Collect data

5. Analyze Data/Evaluate Performance

• Analyze data and review the results.• Identify areas where additional data is

required.• If historical data are available, compare for

trends.• Display and distribute data to communicate

findings and results.• Identify areas for improvement and select a

quality improvement project.


• How do we know if performance is satisfactory?

• Benchmarks useful in setting feasible and challenging goals

• The most important comparisons are internal

• Most relevant when patient populations are similar

• UDS data will reveal state and national trends over time, rural vs. urban, etc.


• Healthy People 2010: www.healthypeople.gov

• National Quality Center—Improving HIV Care: http://www.nationalqualitycenter.org/index.cfm/22

• AHRQ Effective Health Care: http://effectivehealthcare.ahrq.gov/

• National Quality Forum: http://www.qualityforum.org/

• State Primary Care Associations: http://www.bphc.hrsa.gov/technicalassistance/pcadirectory.htm

http://www.healthypeople.gov/

http://www.nationalqualitycenter.org/index.cfm/22

http://effectivehealthcare.ahrq.gov/

http://www.qualityforum.org/

http://www.bphc.hrsa.gov/technicalassistance/pcadirectory.htm

6. Plan & Implement Changes for Improvement

depicts a process flowchart for quality improvement. • Step 1 is evaluating organizational priorities. • Step 2 is choosing performance measures. • Step 3 is determining a baseline. • Step 4 is evaluating performance. If performance is evaluated to

be satisfactory, Step 4a depicts an arrow indicates that the organization can start a new QI cycle with Step 1 and determining new organization priorities. If performance is evaluated to be less than desired, Step 4b depicts that the QI cycle should continue. Step 4.b.1 is establishing goals for a performance measure.

• Step 5 is developing a plan and making changes. • Step 6 is monitoring performance. The two possible outcomes

are the goal being reached, and the goal not being reached. If the goal is not reached, an arrow directs the organization back to Step 5, developing a plan and making changes. If the goal was reached, the QI cycle was successful.


• Discrepancy between goals or standards and reality

• Solve the problem!• Can it be solved?• Is it worth solving?• Who should do it?• What is the goal? (MEASUREABLE)• How soon?


• Establish project-specific QI team that represents all staff integral to the service or issue.

• Identify a team leader or sponsor.• Delineate specific goals for the team.• Allocate time and resources for the team.• Delineate team responsibilities.• Develop timeline for reporting findings and

improvement strategies.


• Develop a time line or calendar of activities for the year.

• Select a QI approach, such as PDSA or the Chronic Care Model.

• Clarify QI responsibilities of staff.


• Utilize QI tools and techniques to understand the process, such as flow charts, facilitated brainstorming, cause and effect diagrams, etc.

• Document and track progress by using activity logs, issue identification logs, meeting minutes, etc.

• Report progress on a regular, defined basis.


• Identify potential solutions to make improvement to the systems of care.

• Recognize quick fixes and longer term solutions.

• Try a small test of change and analyze results.

• Refine improvement plan.• Develop timeline for implementation of

plan.• Delineate team responsibilities.• Implement changes.• Track changes and improvement actions.


Plan-Do-Study-Act (PDSA) : PDSA is a widely used framework for testing change on a small scale.

7. Monitor Performance Over Time

• Determine interval for remeasurement.• Remeasure indicator after change has

been implemented.• Look for incremental improvement.• Communicate results to team, staff and

leadership.• Determine need for and/or level of

remeasurement on an ongoing basis.• Develop a plan for sustained improvement.

CHC Difficult Areas QI Improvement

• Performance Measures• Data bases/Data Collection/Data Reliability• Identify/Use Benchmarks• Identifying/Documenting necessity for

change in provision of services• Result in change being implemented—

remeasure to assure improvement

A Real Life Example

Steps 1 - 4

• XCHC Diabetes measure (HbA1C < 9%) was 83% (HDC participant for 6 yrs)

• HTN rate <140/90 was 52% (Healthy People 2010 goal 50%)

• Pap baseline rate of 20%—new measure for them


• Discrepancy between benchmarks (HP 1998 benchmark 79%; 2009 BPHC UDS 58%) and reality (20%)

• Solve the problem!


• Establish project-specific QI team that represents all staff integral to the service or issue. • Scheduler, provider, nurse manager, medical

records, IT• Identify a team leader or sponsor.

• Chair of CQI program (COO)• Set specific goals for the team.

• Initially wanted to improve to 25%...• Verify baseline data• Identify restricting & contributing factors


• Allocate time and resources for the team.• Initially meet weekly to

monitor PDSA cycles• Delineate

responsibilities.• Develop timeline for

reporting findings and improvement strategies.• Report to next CQI

meeting in one week then monthly


Processes…• EHR now being implemented• Staff training• Patient education• Plan to institute new consent form

specific for women’s health and policy to ensure its use


• Clinical practice guideline • Review Pap guidelines and present to provider staff

• Access to care issue• Many pts seek Paps at State Health Department• Hispanic patients prefer female provider• Many mobile migrant patients with multiple providers

• Outcomes data• Incomplete because only queried practice management

system which did not include transferred records• Tracking

• No consistent mechanism for obtaining records from other providers

• Have meeting with health dept staff to assure cooperation


Pt. satisfaction survey?—are they happy with the system?

• Will consider in the future to explore attitudes regarding various interventions

• Documentation of process • Plan to keep meeting minutes, goals,

outcomes


• Analyze data and review the results.• Monthly review of women seen for Pap status

• Identify areas where additional data is required.• Data collection method did not capture all Paps done

• If historical data are available, compare for trends.• Not previously measured

• Display and distribute data to communicate findings and results.• Plan to inform CQI committee and staff of results• Graphic presentation of data readings over time

7. Monitor Performance Over Time

•Communicate results•Reports to BOD, staff

•Congratulate team•Newsletter article

•Select a new project and begin with a new measure.

•Oral health for pregnant women

Additional Webinars in This Series

• Implementing your QI plan• How to choose specific strategies• How to evaluate• Connection to risk management, peer review,

accreditation and PCMH• How to use data that you are already collecting

to fuel your QI process• Setting goals and performance metrics• Increasing data reliability• Using HIT

Discussion and Questions

• Please share your quality improvement successes, challenges, and training and technical assistance needs

• Contact your HRSA Project Officer or the Office of Quality and Data at [email protected] or

(301) 594-0818

mailto:[email protected]

designing a successful quality improvement program

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