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Quality Improvement Contents Part 1: Quality Improvement (QI) and the Importance of QI .. 1 Quality Improvement (QI) 1 Principles of QI .. 1 What Is a QI Program? .. 5 Why Is a QI Program Essential to a Health Care Organization? .. 6 Part 2: Before Beginning РEstablish an Organizational Foundation for QI 6 The Role of Organizational Leadership . 7 Key Staff Roles in a QI Program .. 8 Readiness Assessment ΠPreparing for Change . 9 Part 3: QI Programs РThe Improvement Journey .. 10 What Are the Desired Improvements? . 10 How Are Changes and Improvements Measured? . 11 How Is Staff Organized to Accomplish the Work? .. 12 How Can QI Models Be Leveraged to Accomplish Improvements Effectively and Efficiently ? 13 How Is Change Managed? . 14 Part 4: Supporting the QI Program РKeep the Momentum Going .. 16 How Is Performance Tracked Over Time? 16 Celebrating Success .. 16 Part 5: References 17 Part 6: Additional Resources . 17 i

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Quality Improvement QUALITY IM PROVEMENT The purpose of this module is to provide a foundation and an introduction to q uality improve ment (QI) concepts and key topics for developing or improving a QI program within an organization. Part 1: Quality Improvement (QI ) and t he Importanc e of QI Quality Improvement (QI) Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups . The Institute of Medicine (IOM) , which is a recognized leader and advisor on improving the Nation™s health care, defin es quality in health care as a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations. 1 Principles of QI When quality is considered from the IOM™s perspective , then an organization™s current system is defined as how things are done now, whereas health care performance is defin ed by an organization™s efficien cy and outcome of care , and level of patient satisfaction. Quality is directly linked to an organization™s service delivery approach or underlying systems of care . To achieve a different level of performance (i.e., results) and improve quality, an organization™s current system needs to change. While each QI program may appear different, a successful program always incorporates the following four key principles: 2 QI work as systems and pro cesses Foc us on patients Focus on being part of the team Focus on use of the data The next sub sections describe the se four QI principles in more depth. QI Work as Systems and Processes To make improvements, an organization need s to understand its own delivery system and key processes . The concepts behind the QI approaches in this toolkit recognize that both resources (inputs ) and activities carried out ( processes ) are addressed together to ensure or improve quality of care ( outputs/outcomes ). A health service delivery system can be small and simple, such as , an immunization clinic , or large and complex, like a large managed -care organization. QI can assume many forms and is most effective if it is individualized to meet the needs of a specific organi zation™s health service delivery system. Figure 1.1 shows how a health care delivery system consists of resources, activities, and results; these key components are also called inputs , processes , and outputs/ outcomes : 1

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Quality Improvement Source: Donabedian (1980) Figu re 1.1: Input s, Processes and Outputs/Outcomes Activities or processes within a health care organization contain two major components: 1) what is done (what care is provided), and 2) how it is done (when, where , and by whom care is delivered). Improvement can be achieved by addressing either component; h owever, the greatest impact for QI is when both are addressed at the same time. Process mapping is a tool commonly used by an organization to better understand the health care processes within its practice system . This tool gained popularity in engineering before being adapted by health care . A process map provides a visual diagram of a sequence of events that result in a particular outcome. By reviewing the steps and their sequence as to who perform s each step , and how efficiently the process works, an organization can often visualize opportunities for improvement. The process mapping tool may also be used to evaluate or redesign a current process. Additional information , including tools and resour ces to assist an organization that want s to adopt process mapping as an improvement strategy, can be found in the Redesigning a System of Care to Promote QI module. Specific steps are required t o deliver optimal health care service s. When these steps ar e tied to pertinent clinical guidelines , then optimal outcomes are achieved . The se essential steps are referred to as the critical (or clinical) pathway. The critical pathway steps can be mapped as described above. By mapping the current c ritical pathway for a particular service, an organization gains a better understand ing of what and how care is provided. When an organization compare s its map to one that shows optimal care for a service that is congruent with evidence -based guidelines (i.e., idealized c ritical pathway), it see s other opportunities to provide or improve delivered care. In this module, improvement strategies are presented based on what has worked for other health care organizations. C hanges are applied throughout an existing critical pathway so it works more effectively. QI strives to enable an organization to achieve the ideal critical pathway, which is one that allows the care team and patient to interact productively and efficiently to achieve optimal health outcomes. 2

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Quality Improvement The follow ing illustrative example reinforces the benefits of understanding systems and key processes in approaching a performance improvement project: Focus on Patient s An important measure of quality is the extent to which patient s™ needs and expectations are met . Services that are designed to meet the needs and expectations of patient s and their community include: Systems that affect patient access Care provision that is evidence- based Patient safety Support for patient engagement Coordination of care with othe r parts of the larger health care system Cultural competence , including assessing health literacy of patients, patient -centered communication , and linguistically appropriate care A health care facility decided to target the accuracy of its medication lists as a way to improve patient safety. Based on its research, the facility staff understood the benefits of implementing information technology as an input or resource to improve t he consistency and completeness of its medical documentation. The staff noted that technology adds more value when the focus also includes key processes or activities , such as, developing an effective workflow and staff proficiency in using the technology . The health care facility purchased an electronic medical record (EMR) system as its key component for input and also focused on processes ; i.e., how the staff uses the system to improve the quality of medication documentation ( outcome ).Focus on Being Part of the Team At its core, QI is a team process. Unde r the right circumstances, a team harnesses the knowledge, skills, experience, and perspectives of different individuals within the team to make lasting improvements. A team approach is most effective when : The process or system is complex No one person in an organization knows all the dimensions of an issue The process involves more than one discipline or work area Solutions require creativity Staff commitment and buy -in are needed In other words, virtually all QI projects involve a team process. Whether an organization is seeking to improve patient wait times, telephone service, diabetes care, or other goals it deems important, a team effort help s an organization to achieve significant and lasting improvements. It is the responsibility of each individual to be an active and contributing member of the team. Each person on a team brings a unique perspective to the process; i.e., how things work; what happens when changes are made, and how to sustain improvements during daily work. 3

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Quality Improvement Contributions are made from each individual™s skill set and the team™s synthesis of ideas. Additional information , including tools and resources to assist an organization in developing and supporting a QI team within its organization, can be found in the Improvement Teams module. In addition to staff, a key component of a well- functioning QI team is an effective infrastructure , such as , leadership , and policies and procedures to organize and facilitate the work of the team. Infrastructure support affords the team with tools, resources, clear expectations , and a forum for communication. M ore detail is provided in The Role of Organizational Leadership section of this module . This level of infrastructure helps a team to stay on a clear path, while being mindful of an organizat ion™s available resources and its goal . Focus on Use of the D ata Data is the cornerstone of QI. It is used to describe how well current systems are working ; what happens when changes are applied, and to document successful performance. Using data: Separates what is thought to be happening from what is really happening Establishes a baseline (Starting with a low score is acceptable) Reduces placement of ineffective solutions Allows monitoring of procedural changes to en sure that improvements are susta ined Indicates whether changes lead to improvements Allows comparisons of performance across sites Both quantitative and qualitative methods of data collecti on are helpful in QI efforts. Quantitative methods involve the use of numbers and frequencies tha t result in measurable data . This type of information is easy to analyze statistically and is familiar to science and health care professionals. Examples in a health care setti ng include: Finding the average of a specific laboratory value Calculating t he frequencies of timely access to care Calculating the percentages of patients that receive an appropriate health screening Qualitative methods collect data with descri ptive characteristics , rather than numeric values that draw statistical inferences. Qualitative d ata is observable but not measurable, and it provides important information about patterns, relationships between systems , and is often used to provide context for needed improvements. C ommon strategies for collect ing qualitative data in a health care setting are: Patient and staff satisfaction surveys Focus group discussions Independent observations A health care organization already has considerable data from various sources, such as , clinical records, practice management system s, satisfac tion surveys, external evaluations of the population™s health , and others. Focusing on existing data in a disciplined and methodical way allows an organization to evaluate its current system, identify opportunities for improvement, and monitor performance improvement over time. 4

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Quality Improvement The module provid es a dditional information for specific topics and can be accessed by clicking on the ir links. Why Is a QI Program Essential to a Health C are Organization? An organization that implement s a QI program experiences a range of benefits : Improved patient he alth (clinical) outcomes that involve both process outcomes (e.g., provide recommended screenings) and health outcomes (e.g., decreased morbidity and mortality ). Improved efficiency of managerial and clinical processes. By improving processes and outcomes relevant to high-priority health needs, an organization reduces waste and costs associated with system failures and redundancy. Often QI processes are budget -neutral , where the costs to make the changes are offset by the cost savings incurred. Additiona l information , including tools and resources to assist an organization with improving processes and outcomes can be found in the Redesigning a System of Care to Promote QI module. Avoid ed costs associated with process failures, errors, and poor outcomes. Costs are incurred when non standard and inefficient systems increase errors and cause rework. Streamlined and reliable processes are less expensive to maintain. Proactive processes that recognize and solve problems before they occur e nsure that systems of care are reliable and predictable. A culture of improvement frequently develops in an organization that is committed to quality , because e rrors are reported and addressed. Improved communication with resources that are internal and external to an organiza tion , such as , funders, civic and community organizations. A commitment to quality shines a positive light on an organization, which may result in an increase of partnership and funding opportunities. When successfully implemented, a QI infrastructure oft en enhances communication a nd resolves critical issues. When an organization implements a n effective QI program , the result can be a balance of quality, efficiency , and profitability in its achievement of organizational goals. Part 2: Before Begin ning – Establish an Organizational Foundation for Q I An e ffective QI program require s change s in an organization™s culture and infrastructure to overcome its trad itional barriers and work s toward a common goal of quality. This occurs when all staff embraces the philosophy of QI and understands their roles in supporting an organization-wide focus on QI. Hierarchical roles that are important in clinical settings , and include licensure and appropriate supervision, are different from roles that support effective QI. Therefore, a paradigm shift is needed from their standard care -team roles to th ose that also include quality improvement. 6

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Quality Improvement Each of these foundational topics needs to be discussed within the management team before beginning a quality program and then periodically thereafter. Assess ing leadership support of quality, staff engagement in the quality process, and the ability of an organization to manage change, provides the context for an effective QI program that may evolve over time. An organization may step back to reflect on these topics annually or, at minimum , conduct a biennial review. The Role of Organizational Leadership The leader’s role in promoting and developing QI begins with creating and sustaining a personal and organizational focus on the needs of internal and external customers. Through actions, a leader demonstrate s a clear commitment to the organizational mission, values, goals, and expectations that promote quality and performance excellence. The customer -oriented mission, vision, values, and goals of an organization are best integrated into all aspects of management through effective leadership. An organization that experience s success in the development and implementation of its QI program understands that the organization’s ch ief officer or senior leader create s energy, synergy, and focused leadership for the QI program. Under his or her leadership, all other managers or leaders work together to: Set the direction for QI by creating a strong patient focus Create clear stateme nts that define the organization’s mission and values, and identify operational objectives, and short – and long- term expectations Demonstrate continuous commitment to achiev ing the organization’s QI goals Achieving high levels of performance requires that an organization ™s leaders develop a strategic quality plan to fulfill the mission of integrating QI into their organization. A strategic quality plan provides guid ance for delivering safe and quality care. The plan is often updated annually by clinical, administrative , and executive leadership to en sure the organization is continuously making improvements to meet the needs of its patients and families. The strategic quality plan: Identifies clear goals that define expected outcomes of the overall QI eff ort Is fact -based using indicators to measure progress Includes systematic cycles of plan ning, execution, and evaluation Concentrate s on key processes as the route to better results Focus es on patients and other stakeholders 7

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Quality Improvement In addition to the vision and strategy, a leader need s to create and support an infrastructure that organizes and supports the work. Successful leaders found these actions helpful in creating their quality infrastructures : Become a QI champion and actively support the team; i.e., strong endorsement, support, participation , and resources from organizational leadership to facilitate ongoing QI activities Cultivate a spirit of QI within the organization that encourages continuous improvement of services and programs Identify interna l experts or external consultants with experience and training in QI to help get teams started Develop staff members’ skills in data collection and analysis Develop staff members’ skills in information retrieval, such as, conducting literature searches and accessing databases Key Staff Role s in a QI Program For quality to be effectively managed, individuals and groups in an organization should have a clear understanding of their role s and responsibilities relati ve to QI. Each staff member has a role in ensuring that QI objective s set by the organization are met. Ideally, all contributions are equally valued on the QI team. Although the medical assistant may be supervised by the physician when providing patient care, the medical assistant™s perspective and input within the context of the QI team are very important. Since individuals on the QI team work in fundamentally different ways when doing improvement work compared with actual patient -care delivery, it is important to formalize their roles within t he committee. Common roles within a QI team include: Day -to-day l eader organize s and drives the ongoing work, measurement, and team. This person needs to work effectively with the executive leadership and members of the improvement team. The day -toŒday leader also serves as the fikey contact fl responsible for coordinating communication on the progress on a QI project to the overall organization, staff, and board of di rectors. Data e ntry person carries out the data-entry function, and needs sufficient time and computer access to enter data and submit reports regularly. It is often recommended t o train a backup person, who also learns t o aggregate monthly and quarter ly reports, so that reporting is not interrupted for vacations, illnesses, or other unexpected events. Provider champion is an essential member of the QI team due to the clinical nature of the work. The provider champion works regularly with those patients whose care is directly affected by QI efforts. As a leader to help drive change, the provider needs to be an individual who is well- respected and influential among the medical staff, works well with management, and is open to change and new approaches. Operations person is integrally involved in current processes and need s to be part of the team , because much of the innovative work involves designing new processes and streamlining old ones. Operations personnel may include: nurses, nutritionists, socia l 8

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Quality Improvement workers, pharmacists, or others. The appropriate specialty of the operations person becomes apparent when areas for improvement in the current processes are identified. Data s pecialist collects and analyzes data, and uses QI tools. The person selecte d does not necessarily need to work in a QI department or hold a specific title as long as he or she is well -versed in QI concepts and tools. Depending on the focus of improvement, other individuals in an organization may bring valuable insight to the process. Any individual may be considered a candidate for a QI team if he or she is willing to be part of a team that is committed to improving quality. In a smaller organization, one person may en gage in multiple roles. While the role of the team in a Q I program is significant, total quality commitment in volves all levels of an organization’s structure. An organization needs to build ongoing training opportunities for staff and teams into it s QI framework to sustain and advance its QI efforts. Quality patient care services are achieved through positive interactions among departments that work together to build a dynamic mechanism for continuously improving processes and outcomes of health care services. Additional information , including tools and resour ces to assist an organization with developing and supporting a QI team , can be found in the Improvement Teams module. Readiness Assessment Œ Preparing for Change Successful implementation of a QI program begin s with an honest and objective assessment of an organization™s current culture, and its commitment to improving the quality of its care and services. An o rganization may ask its staff to participate in the assessment process to determine the ir level of understanding about its existing QI processes . Understanding an organization™ s strengths and weaknesses around QI is a good starting point to assess its readiness for change. Questions that an organization may want to consider in determining its readiness are: Does the organization have a structure to assess and improve quality of care? Do providers and staff have a basic understanding of QI tools and techniques? Do providers and staff understand their roles, responsibilities , and expectations regarding QI activities? Does the organization routinel y and systematically collect and analyze data to assess quality of care? Does the organization have resources dedicated to QI activi ties? Has the organization identified barriers to fully implement a QI program? The questions above are provided as examples to demonstrate the assessment process; however, a team may list others specific to its organization. A key point is for an organization to understand that assessing readiness for change increases its ability to support its identified QI goals . 9

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