Continuous Quality Continuous Quality Improvement 101Improvement 101Amelia Broussard, PhD, RN, Amelia Broussard, PhD, RN,

MPHMPH

broussardco1@msn.combroussardco1@msn.com

WHY DO WE NEED TO KNOW WHY DO WE NEED TO KNOW ABOUT CQI?ABOUT CQI?

• Provision of Quality Care• CQI tools and techniques work in

healthcare.  • Bureau of Primary Health Care

requires quality improvement• New process relates health care plan,

QI, UDS info, needs assessment• Focus on Core Clinical Measures

A Few Questions to Ask…A Few Questions to Ask…

Services provided in timely manner?Was necessary care provided?Efficient provision of care?Was the expected outcome

achieved? Are patients, clients and customers

satisfied with provided services?

Success is achieved through Success is achieved through meeting the needs of those we meeting the needs of those we

serveserve..

Quality Assurance vs. Quality Quality Assurance vs. Quality ControlControl

Quality assurance and quality control are often used interchangeably to refer to ways of ensuring the quality of a service or product.

The terms, however, have different meanings.

Quality AssuranceQuality Assurance

“The planned and systematic activities implemented in a quality system so that quality requirements for a product or service will be fulfilled.”

American Society for Quality

Examples of Quality Assurance Examples of Quality Assurance ActivitiesActivities

Activities that are based on public health standards, licensing standards, institutional policies, etc.

• Annual infection control and safety training• Review medication closet for outdated meds• Review emergency chart once a week for supplies

and outdated meds

Can help identify a problem, but are more often used to comply with the standards.

Quality ControlQuality Control

“The observation techniques and activities used to fulfill requirements for quality.”

American Society for Quality

Examples of Quality ControlExamples of Quality Control

• Infection control training sign-in sheets cross-referenced with staff roster

• Review sheet of emergency cart

• Direct observation of counseling session

Quality ImprovementQuality Improvement

“Continuous improvement is an ongoing effort to improve products, services or processes. These efforts can seek “incremental” improvement over time or “breakthrough” improvement all at once.”

American Society for Quality

Philosophy of CQIPhilosophy of CQI

• Based on concept of balance between quality improvement & performance measurement

• QI programs are built upon foundation of program support & infrastructure

• Emphasizes development of systems & processes to support QI

Guiding PrinciplesGuiding Principles

• Ongoing QI activities improve patient care

• Performance measurement lays foundation for QI

• Infrastructure supports systematic implementation of QI

• Indicators are based on clinical guidelines & formal group-decision making

Core Clinical Measures for Core Clinical Measures for Health Care PlanHealth Care Plan

• Diabetes• Cardiovascular

Disease• Prenatal Care• Perinatal Care

• Child health• Behavioral Health• Oral Health• Other x2

Goals of Quality Goals of Quality ImprovementImprovement

• The goals of QI – to understand process, reduce

unintended variation in care, eliminate errors, remove unnecessary steps, and improve communication and accountability.

– process is designed toward outcomes.– Quality improvement depends on

measurement.

Core Concepts of CQICore Concepts of CQI

• Quality defined as meeting and/or exceeding expectations of customers.

• Success is achieved through meeting the needs of those we serve.

• Most problems are found in processes, not in people. 

• CQI does not seek to blame, but rather to improve processes. 

CORE CONCEPTS OF CQICORE CONCEPTS OF CQI

• Unintended variation in processes can lead to unwanted variation in outcomes

• Possible to achieve continual improvement through small, incremental changes using the scientific method. 

• CQI most effective when it becomes natural part of way everyday work is done.

Comparison of QA & QIComparison of QA & QIQA QI

Motivation Measuring compliance with standards

Continuously improving processes to meet standards

Means Inspection Prevention, monitor over time

Attitude Required, defensive Chosen, proactive

Focus Outliers or “bad apples”, individuals

Processes, systems, majority

Players Selected departments

Organization wide, benchmarking

Disciplines Within profession Multidisciplinary approach

Scope Medical profession focused

Patient care focused

Responsibility

Few All

QA versus QIQA versus QI

Exercise on QualityExercise on Quality

• What is the benefit for:– Patients– Staff– Organization

Putting It All TogetherPutting It All Together

QA + CQI + Peer Review + Consumer Satisfaction = QM

Process Indicator:

Are we doing what we said we’d do?

Outcome:

Is it working for the clients?

GUIDING VALUES of CQIGUIDING VALUES of CQI

• Most problems are found in processes, not in people. 

• If you “focus” on everything, you can’t focus on anything.

• The best solutions are staff designed.

Roles and ResponsibilitiesRoles and Responsibilities

• Leadership/Board/Consumers: Oversight and resources. Help set priorities.

• QI Committee: Review data, pick projects and goals, review results of tests.

• Project Team: Brainstorm ideas and design tests.

• All Staff: Help perform tests and collect data.

PITFALLS OF CQIPITFALLS OF CQI

• The paperwork can bury you

SET PRIORITIESSET PRIORITIES

PITFALLS OF CQIPITFALLS OF CQI

• Staff view it as a ball and chain, hindering their daily work

PITFALLS OF CQIPITFALLS OF CQI

• The Process can tie you up in knots

Lessons LearnedLessons Learned

• “The shorter the timeframes between test cycles, the more tests can be conducted and therefore, more opportunities for learning will emerge.” - HIVQUAL Workbook

• “Let’s be as opportunistic as a virus!” - Anonymous

• Improvement is about learning– trial and error (scientific method)– improvements requires change, however not all changes are an

improvement• Measure your progress

– only data can tell you whether improvements are made– integrate measurement into the daily routine

• Improvements thru continuous cycles of changes– Plan-Do-Study-Act approach– changes are initiated on a small scale to test them before

implementation• Leadership is needed

– establish organizational commitment and support staff and activities

Common Themes among QI Common Themes among QI ModelsModels

One MODEL FOR One MODEL FOR IMPROVEMENTIMPROVEMENT• Model consists

of:– three questions

(aim, measure, change) to form context for improvement

– Plan-Do-Study-Act (PDSA) Cycle to structure tests

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Act Plan

Study Do

Model for ImprovementModel for Improvement

Model for

Improvement

What are we trying to accomplish?

How will we know that a change is an

improvement?

What change can we make that will result in

improvement?

Model for ImprovementModel for Improvement

What are we trying to accomplish?

How will we know that a change is an

improvement?

What change can we make that will result in

improvement?

Model for ImprovementModel for Improvement

What are we trying to accomplish?

How will we know that a change is an

improvement?

What change can we make that will result in

improvement?

Model for ImprovementModel for Improvement

PDSA CYCLEPDSA CYCLE

• Plan - Plan a change• Do - Try it out on a

small-scale• Study - Observe the

results• Adopt, adapt, or

abandon -Refine the change as necessary

PRINCIPLES OF PDSA PRINCIPLES OF PDSA CYCLESCYCLES

Short cycles of changes to accelerate rate of improvement small scale tests (“What can you test till next Tuesday”) collect just enough information

Create flow of ideas, then emphasize implementation increase frequency of tests build knowledge sequentially - use multiple cycles to adapt a

change to your system Adopt existing knowledge (‘not more research but

more application of existing knowledge’) ‘Steal shamelessly, Share senselessly’ Promote peer learning

Tips for PDSA CyclesTips for PDSA Cycles

- formulate question and predict results

- test first in ‘safe zones’ (with team members, volunteers)

- ‘Just-do-it’ mentality- collect useful just

enough data, not perfect data

- think a couple of cycles ahead

- scale down size of test (# of patients, clinics)

- be innovative to make test feasible

PDSA Cycles: Testing a pap PDSA Cycles: Testing a pap Cuing PlanCuing Plan

Use of flowsheet

will improve care to known

standards

Improved Decision Support

A PS D

APS

D

D SP A

DATAD SP A

Cycle 1A: On Mon., prescreen Fred’s Tues. pts, mark appointment sheet for those who are due for paps.

Cycle 1B: Debrief staff; did it help, how long did it take? Test with Dr. Strange’s patients for a full week.

Cycle 1C: Test with all patients for a full week, document feedback and time required.

Cycle 1D: Implement thruout clinic and monitor the impact.

Smaller Scale Tests: Smaller Scale Tests: Scale Down TimeframeScale Down Timeframe

• Years• Quarters• Months• Weeks• Days• Hours• Minutes

Reduce your timeframe to plan Test Cycle!

Analysis Tools: FlowchartsAnalysis Tools: Flowcharts

• Flowchart is picture of any process,• Flowcharts help visualize process • Easier to understand and easier to

improve. • Identifies potential sources of

problems and solutions

FLOWCHARTFLOWCHART

• Flowchart symbols

• Oval: shows beginning or ending step in a process

• Rectangle depicts particular step or task

• Arrow: shows direction of process flow

• Diamond: indicates a decision point

FLOWCHART EXAMPLEFLOWCHART EXAMPLE

Patient arrives at front desk

Receptionist asks for patient’s name & searches database for his/her file

Patient in system?

Receptionist asks patient to complete paperwork for new clients

and return it to front deskNO

Ask patient to be seated in the Waiting room

YES

Medical assistanttakes patient into

exam room

ETC.

CAUSE-AND-EFFECT CAUSE-AND-EFFECT DIAGRAMDIAGRAM

• Used to map variables that may influence a problem, outcome, or effect

• Also called:– Ishikawa diagram– Fishbone diagram

CAUSE-AND-EFFECT CAUSE-AND-EFFECT DIAGRAMDIAGRAMCAUSESCAUSES

• The four M’s– Methods, Materials, Machines, Manpower

• The four P’s – Place, Procedures, Policies, People

• The four S’s– Surroundings, Suppliers, Systems, Skills

CAUSE-AND-EFFECT CAUSE-AND-EFFECT DIAGRAMDIAGRAMSAMPLESAMPLE

Low show ratefor appointments

Procedures People

Patients

Patient unawareof appointment

Computer

System downfor routinemaintenance

Skeleton

EquipmentEnvironme

nt

ExerciseExercise

• Construct Cause and Effect Diagram with staff

Performance Performance Measurement and Measurement and

DataData

Why Measure?Why Measure?

• Separates what you think is happening from

what is really happening

• Establishes a baseline

• Helps to avoid putting ineffective solutions in

place

• To monitor improvements and prevent slippage

What is a good indicator?What is a good indicator?

• Relevance. Does the indicator relate to a condition that occurs

frequently or have a great impact on the patients at your

facility?

• Measurability. Can the indicator realistically and efficiently be

measured given the facility’s finite resources?

• Accuracy. Is the indicator based on accepted guidelines or

developed through formal group-decision making methods?

• Improvability. Can the performance rate associated with the

indicator realistically be improved given the limitations of your

clinical services and patient population?