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Complete the Quality Dimensions and Measures Table Worksheet. HCS/451 v9 Quality Dimensions Worksheet HCS/451 v9 Page 2 of 2 Quality Dimensions Worksheet Open your web browser and research quality dimensions/quality standards/quality indicators used by various health care organizations that work to improve the quality of health care. A list of suggested organizations has been provided below. You may also use other organizations that show up in your research. Health Care Organizations Health and Medicine Division (HMD) National Committee for Quality Assurance (NCQA) The Joint Commission Centers for Medicare & Medicaid Services Agency for Healthcare Research and Quality Select 6 quality dimensions/standards/measures used in the health care industry. Complete the table below by identifying the quality standard, the health care organization it is used in, and its purpose. An example has been provided for you. Cite at least 2 peer-reviewed, scholarly, or similar references and your textbook to support your information. Quality Standard Health Care Organization Purpose of Standard AHRQuality Indicators Agency for Healthcare Research and Quality (AHRQ) The Quality Indicators are used by acute care hospitals to highlight potential quality concerns, identify areas that need further investigation and study and track changes over time in their administrative data. Cite your sources below. References Copyright© 2019 by University of Phoenix. All rights reserved. Copyright© 2019 by University of Phoenix. All rights reserved. AHRQ Quality IndicatorsTM Quality Indicator User Guide: Prevention Quality Indicators (PQI) Composite Measures, v2021 Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 http://www.qualityindicators.ahrq.gov Contract No. HHSA290201800003G July 2021 http://www.qualityindicators.ahrq.gov/ AHRQ Quality IndicatorsTM Quality Indicator User Guide: Prevention Quality Indicators (PQI) Composite Measures, v2021 Version 2021 Page i July 2021 Table of Contents 1.0 Overview .......................................................................................................................................... 1 2.0 What Are the Composites? ............................................................................................................ 1 3.0 How Are the Composites Created?............................................................................................... 3 4.0 Steps for Creating the Composite ................................................................................................. 3 5.0 How Have the Composites Changed? .......................................................................................... 3 6.0 What Are the Current Uses of the Composites? ......................................................................... 3 7.0 Additional Resources ...................................................................................................................... 4 Index of Tables Table 1. AHRQ PQI Composite Measures, v2021 ........................................................................................ 2 AHRQ Quality IndicatorsTM Quality Indicator User Guide: Prevention Quality Indicators (PQI) Composite Measures, v2021 Version 2021 Page 1 July 2021 1.0 Overview The goal in developing the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators™ (QI) composite measures was to provide a measure that could be used to monitor performance over time or across regions and populations using a method that applied at the national, regional, state or provider/area level. Potential benefits of composite measures are to: summarize quality across multiple indicators, improve the ability to detect differences, identify important domains and drivers of quality, prioritize action for quality improvement, make current decisions about future (unknown) health care needs and avoid cognitive “shortcuts”. Despite these potential advantages there are concerns with composite measures, such as: masking important differences and relations among components, not being actionable, not being representative of parts of the health care system that contribute most to quality or detracting from the impact and credibility of reports. In weighing the benefits and concerns of composite measures there are also a number of potential uses to consider, such as: consumer use for selecting a hospital or health plan, provider use for identifying domains and drivers of quality, purchaser use for selection of hospitals or health plans to improve employee health and policymaker use for setting policy priorities to improve the health of a population. This document provides a technical overview for AHRQ QI users. 2.0 What Are the Composites? The Prevention Quality Indicators (PQI) are measures of potentially avoidable hospitalizations for Ambulatory Care Sensitive Conditions (ACSCs), which, though they rely on hospital discharge data, are intended to reflect issues of access to, and quality of, ambulatory care in a given geographic area. The PQI composites are intended to improve the statistical precision of the individual PQI, allowing for greater discrimination in performance among areas and improved ability to identify potentially determining factors in performance. An overall composite captures the general concept of potentially avoidable hospitalization connecting the individual PQI measures, which are all rates at the area level. Separate composite measures were created for acute and chronic conditions to investigate different factors influencing hospitalization rates for each condition. See Table 1 for the measures that comprise each of the four PQI composites. The PQI composites provide the following advantages: • Provide assessment of quality and disparity • Provide baselines to track progress • Identify information gaps • Emphasize interdependence of quality and disparities • Promote awareness and change AHRQ Quality IndicatorsTM Quality Indicator User Guide: Prevention Quality Indicators (PQI) Composite Measures, v2021 Version 2021 Page 2 July 2021 Table 1. AHRQ PQI Composite Measures, v2021 PQI 90 PREVENTION QUALITY OVERALL COMPOSITE PQI 01 Diabetes Short-Term Complications Admission Rate PQI 03 Diabetes Long-Term Complications Admission Rate PQI 05 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate PQI 07 Hypertension Admission Rate PQI 08 Heart Failure Admission Rate PQI 11 Community Acquired Pneumonia Admission Rate PQI 12 Urinary Tract Infection Admission Rate PQI 14 Uncontrolled Diabetes Admission Rate PQI 15 Asthma in Younger Adults Admission Rate PQI 16 Lower-Extremity Amputation among Patients with Diabetes Rate PQI 91 PREVENTION QUALITY ACUTE COMPOSITE PQI 11 Bacterial Pneumonia Admission Rate PQI 12 Urinary Tract Infection Admission Rate PQI 92 PREVENTION QUALITY CHRONIC COMPOSITE PQI 01 Diabetes Short-Term Complications Admission Rate PQI 03 Diabetes Long-Term Complications Admission Rate PQI 05 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate PQI 07 Hypertension Admission Rate PQI 08 Heart Failure Admission Rate PQI 14 Uncontrolled Diabetes Admission Rate PQI 15 Asthma in Younger Adults Admission Rate PQI 16 Lower-Extremity Amputation among Patients with Diabetes Rate PQI 93 PREVENTION QUALITY DIABETES COMPOSITE PQI 01 Diabetes Short-Term Complications Admission Rate PQI 03 Diabetes Long-Term Complications Admission Rate PQI 14 Uncontrolled Diabetes Admission Rate PQI 16 Lower-Extremity Amputation among Patients with Diabetes Rate AHRQ Quality IndicatorsTM Quality Indicator User Guide: Prevention Quality Indicators (PQI) Composite Measures, v2021 Version 2021 Page 3 July 2021 3.0 How Are the Composites Created? The composites were created through a workgroup1 that included discussion of conceptual issues related to the composite (e.g., single composite vs. separate composites) and analyses using 2003 State Inpatient Databases (SID) from the AHRQ Healthcare Cost and Utilization Project (HCUP). The PQI composites are calculated by summing the number of discharges that meet the inclusion and exclusion rules for the numerator in any of a composite’s component measures (i.e., a hospitalization for any of the component PQIs), because the components have a common denominator. Beginning in Version 4.3, PQI 05 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate and PQI 15 Asthma in Younger Adults Admission Rate have complementary denominators (age greater than or equal to 40; age less than 40) so the rationale still applies. Descriptive statistics for the PQIs were calculated as hospitalizations per 100,000 persons for the entire dataset and by county. Correlations and factor loadings for the county level rates (adjusted for age and gender) were examined. The relation between the composite and other area measures potentially related to access to care (e.g., hospital beds per population and primary care physician density) were examined. 4.0 Steps for Creating the Composite The composites are constructed by summing the hospitalizations across the component conditions and dividing by the population. Rates can optionally be adjusted for age, sex and socio-economic status when comparing across regions or demographic groups. 5.0 How Have the Composites Changed? The specifications of the PQI composite measures have changed in two ways since the initial release. First, PQI 10 Dehydration Admission Rate and PQI 13 Angina Without Procedure Admission Rate measures were retired in Version 2019 and removed from the composites containing them.2 Second, a fourth PQI composite measure, PQI 93 Prevention Quality Diabetes Composite, was added. There have also been changes to the specifications of component PQIs that constitute the composites, which can be found on the AHRQ QI website in the Log of Coding Updates and Revisions (https://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/v2021/ChangeLog_PQI_v2021.pdf). 6.0 What Are the Current Uses of the Composites? The PQI composites are intended to be used to provide national estimates that can be tracked over time and to provide State and county level estimates that can be compared with the national estimate and to each other. The following two questions were examined in the initial creation of the composite: 1 Agency for Healthcare Research and Quality (2006). Prevention Quality Indicators (PQI) Composite Measure Workgroup Final Report. The report is available at https://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/PQI_Composite_Development.pdf 2 PQI 10 was removed from PQI composites 90 and 91. PQI 13 was removed from PQI composites 90 and 92. https://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/v2021/ChangeLog_PQI_v2021.pdf https://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/PQI_Composite_Development.pdf AHRQ Quality IndicatorsTM Quality Indicator User Guide: Prevention Quality Indicators (PQI) Composite Measures, v2021 Version 2021 Page 4 July 2021 1. Does disease prevalence impact variability? As anticipated, areas with higher rates of diabetes and hypertension show higher hospitalizations, particularly in the chronic composite. However, for asthma the contrary relation is true suggesting other confounding factors. 2. Is variability driven by poverty status? Areas with low levels of poverty also show lower hospitalization rates for each of the PQI composites, which is independent of access to care. 7.0 Additional Resources See the AHRQ QI website for additional PQI resources and downloads http://www.qualityindicators.ahrq.gov/modules/pqi_resources.aspx Agency for Healthcare Research and Quality (2006). Prevention Quality Indicators (PQI) Composite Measure Workgroup Final Report. The report is available at https://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/PQI_Composite_Development.pdf http://www.qualityindicators.ahrq.gov/modules/pqi_resources.aspx https://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/PQI_Composite_Development.pdf Prepared for: 1.0 Overview 2.0 What Are the Composites? 3.0 How Are the Composites Created? 4.0 Steps for Creating the Composite 5.0 How Have the Composites Changed? 6.0 What Are the Current Uses of the Composites? 7.0 Additional Resources An official website of the Department of Health and Human Services Careers | Contact Us | Español | FAQs | Email Updates Search AHRQ Topics Programs Research Data Tools Funding & Grants News About Home Talking Quality Select Measures To Report Domains of Health Care Quality SHARE: Talking Quality Plan Your Reporting Project Translate Data Into Information Explain and Motivate Use Distribute Your Quality Report Promote Your Quality Report Assess Your Reporting Project Resources About TalkingQuality Select Measures To Report Domains of Health Care Quality Types of Quality Measures Data Sources Key Questions About Measures Measures in Different Settings Quality Measurement Resources Six Domains of Health Care Quality A handful of analytic frameworks for quality assessment have guided measure development initiatives in the public and private sectors. One of the most influential is the framework put forth by the Institute of Medicine (IOM), which includes the following six aims for the health care system. Safe: Avoiding harm to patients from the care that is intended to help them. Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively). Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care. Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy. Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. Existing measures address some domains more extensively than others. The vast majority of measures address effectiveness and safety, a smaller number examine timeliness and patient-centeredness, and very few assess the efficiency or equity of care. Frameworks like the IOM domains also make it easier for consumers to grasp the meaning and relevance of quality measures. Studies have shown that providing consumers with a framework for understanding quality helps them value a broader range of quality indicators. For example, when consumers are given a brief, understandable explanation of safe, effective, and patient-centered care, they view all three categories as important. Further, when measures are grouped into user-friendly versions of those three IOM domains, consumers can see the meaning of the measures more clearly and understand how they relate to their own concerns about their care. To learn more about grouping measures into categories, go to Organizing Measures To Reduce Information Overload. To learn more about selecting and reporting measures within categories that consumers understand, refer to: Hibbard J. Engaging Consumers in Quality Issues: While the road to engaging consumers is steep, it is fairly well marked. Washington, DC: National Institute for Health Care Management Foundation; October 2005. Available at http://www.nihcm.org/pdf/ExpertV9.pdf . Hibbard JH, Pawlson LG. Why Not Give Consumers a Framework for Understanding Quality? Joint Commission Journal on Quality Improvement 2004 June. 30(6); 347- 351. Pillittere D, Bigley MB, Hibbard J, et al. Exploring Consumer Perspectives on Good Physician Care: A Summary of Focus Group Results. New York: The Commonwealth Fund; January 2003. Available at https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2003_jan_exploring_consumer_perspectives_on_good_physician_care__a_summary_of_focus_group_results_pillittere_consumerperspectives_578_pdf.pdf Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press; 2001. Institute of Medicine (IOM). Performance Measurement: Accelerating Improvement. Washington, D.C: National Academy Press; 2005. Hibbard JH, Pawlson LG. Why Not Give Consumers a Framework for Understanding Quality? Joint Commission Journal on Quality Improvement 2004 June. 30(6); 347-351. Also in Select Measures to Report The Six Domains of Health Care Quality Types of Measures You Can Report Understanding Data Sources Selecting the Right Measures for Your Report Measures of Quality for Different Health Care Settings Quality Measurement Resources [1] [2] [3] [1] [2] [3] Page last reviewed November 2018 Page originally created February 2015 Connect With Us Sign up for Email Updates To sign up for updates or to access your subscriber preferences, please enter your email address below. Sign Up Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, MD 20857 Telephone: (301) 427-1364 Careers Contact Us Español FAQs Accessibility Disclaimers EEO Electronic Policies FOIA HHS Digital Strategy HHS Nondiscrimination Notice Inspector General Plain Writing Act Privacy Policy Viewers & Players U.S. Department of Health & Human Services The White House USA.gov Internet Citation: Six Domains of Health Care Quality. Content last reviewed November 2018. 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Department of Health and Human Services Health Resources and Services Administration April 2011 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 - Establish an Organizational Foundation for QI .............................. 6 The Role of Organizational Leadership .................................................................................. 7 Key Staff Roles in a QI Program ............................................................................................ 8 Readiness Assessment – Preparing for Change ...................................................................... 9 Part 3: QI Programs - The 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 - Keep the Momentum Going ......................................... 16 How Is Performance Tracked Over Time? ........................................................................... 16 Celebrating Success .............................................................................................................. 16 Part 5: References ........................................................................................................................ 17 Part 6: Additional Resources ....................................................................................................... 17 i Quality Improvement QUALITY IMPROVEMENT The purpose of this module is to provide a foundation and an introduction to quality improvement (QI) concepts and key topics for developing or improving a QI program within an organization. Part 1: Quality Improvement (QI) and the Importance 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, defines 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 defined by an organization’s efficiency 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 processes • Focus on patients • Focus on being part of the team • Focus on use of the data The next subsections describe these four QI principles in more depth. QI Work as Systems and Processes To make improvements, an organization needs 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 organization’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 http://www.iom.edu/About-IOM.aspx Quality Improvement Source: Donabedian (1980) Figure 1.1: Inputs, 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; however, 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 performs 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 resources to assist an organization that wants 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 to deliver optimal health care services. When these steps are tied to pertinent clinical guidelines, then optimal outcomes are achieved. These 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 critical pathway for a particular service, an organization gains a better understanding of what and how care is provided. When an organization compares its map to one that shows optimal care for a service that is congruent with evidence-based guidelines (i.e., idealized critical pathway), it sees 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. Changes 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 Quality Improvement The following illustrative example reinforces the benefits of understanding systems and key processes in approaching a performance improvement project: Focus on Patients An important measure of quality is the extent to which patients’ needs and expectations are met. Services that are designed to meet the needs and expectations of patients 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 other 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 the 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. Under 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 helps 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 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. More 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 organization’s available resources and its goal. Focus on Use of the Data 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 ensure that improvements are sustained  Indicates whether changes lead to improvements  Allows comparisons of performance across sites Both quantitative and qualitative methods of data collection are helpful in QI efforts. Quantitative methods involve the use of numbers and frequencies that 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 setting include: • Finding the average of a specific laboratory value • Calculating the frequencies of timely access to care • Calculating the percentages of patients that receive an appropriate health screening Qualitative methods collect data with descriptive characteristics, rather than numeric values that draw statistical inferences. Qualitative data 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. Common strategies for collecting 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 systems, satisfaction 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 Quality Improvement When an organization wants to narrow its focus on specific data for its QI program, one strategy is to adopt standardized performance measures. Since performance measures include specific requirements that define exactly what data is needed for each measure, they target the data to be collected and monitored from the other data that is available to an organization. The clinical quality measures identified in this toolkit are examples of standardized measures that an organization, such as a safety net provider, may consider for adoption. They are designed to measure care processes that are common to safety net providers and are relevant to populations served. They narrow an organization’s choices of what data to collect and measure. Additional information, including tools and resources to assist an organization with effective data collection, use, and analysis are found in the Performance Management and Measurement and Managing Data for Performance Improvement modules. Examples of specific data considerations for the clinical quality measures can be found in the modules below: • Breast Cancer Screening • Cervical Cancer Screening • Colorectal Cancer Screening • Diabetes HbA1c {Poor Control} • HIV Screening for Pregnant Women • Hypertension Control • Prenatal - First Trimester Care Access What Is a QI Program? A QI program involves systematic activities that are organized and implemented by an organization to monitor, assess, and improve its quality of health care. The activities are cyclical so that an organization continues to seek higher levels of performance to optimize its care for the patients it serves, while striving for continuous improvement. A QI program typically envelops all QI activities within an organization. Clinically-related QI initiatives and activities to improve an organization’s operations and finance are common examples. A QI program in a health care organization often begins with leadership considering these questions: • Why is a QI program important to an organization? • What does an organization need to know as it develops a QI program? • How does an organization start its development of a QI program? • How do QI processes work to support the success of the QI program? The rest of this module provides a high-level discussion that assists an organization with answering these questions. This important content highlights: • The importance of a QI program • Considerations for building an infrastructure that supports quality • Key components of the QI process 5 Quality Improvement The module provides additional information for specific topics and can be accessed by clicking on their links. Why Is a QI Program Essential to a Health Care Organization? An organization that implements a QI program experiences a range of benefits: • Improved patient health (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. Additional 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. • Avoided costs associated with process failures, errors, and poor outcomes. Costs are incurred when nonstandard 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 ensure that systems of care are reliable and predictable. A culture of improvement frequently develops in an organization that is committed to quality, because errors are reported and addressed. • Improved communication with resources that are internal and external to an organization, 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 often enhances communication and resolves critical issues. When an organization implements an effective QI program, the result can be a balance of quality, efficiency, and profitability in its achievement of organizational goals. Part 2: Before Beginning - Establish an Organizational Foundation for QI An effective QI program requires changes in an organization’s culture and infrastructure to overcome its traditional barriers and works 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 those that also include quality improvement. 6 Quality Improvement Each of these foundational topics needs to be discussed within the management team before beginning a quality program and then periodically thereafter. Assessing 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 leaders 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 demonstrates 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 experiences success in the development and implementation of its QI program understands that the organizations chief officer or senior leader creates 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 statements that define the organizations mission and values, and identify operational objectives, and short- and long-term expectations • Demonstrate continuous commitment to achieving the organizations 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 guidance for delivering safe and quality care. The plan is often updated annually by clinical, administrative, and executive leadership to ensure 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 effort • Is fact-based using indicators to measure progress • Includes systematic cycles of planning, execution, and evaluation • Concentrates on key processes as the route to better results • Focuses on patients and other stakeholders 7 Quality Improvement In addition to the vision and strategy, a leader needs 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 internal 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 Roles in a QI Program For quality to be effectively managed, individuals and groups in an organization should have a clear understanding of their roles and responsibilities relative to QI. Each staff member has a role in ensuring that QI objectives 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 the committee. Common roles within a QI team include: • Day-to-day leader organizes 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-to–day leader also serves as the “key contact” responsible for coordinating communication on the progress on a QI project to the overall organization, staff, and board of directors. • Data entry 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 to train a backup person, who also learns to aggregate monthly and quarterly 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 needs 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, social 8 http://www.healthcarecommunities.org/WorkArea/DownloadAsset.aspx?id=300 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 specialist collects and analyzes data, and uses QI tools. The person selected 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 engage in multiple roles. While the role of the team in a QI program is significant, total quality commitment involves all levels of an organizations structure. An organization needs to build ongoing training opportunities for staff and teams into its 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 resources to assist an organization with developing and supporting a QI team, can be found in the Improvement Teams module. Readiness Assessment – Preparing for Change Successful implementation of a QI program begins 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 organization may ask its staff to participate in the assessment process to determine their 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 routinely and systematically collect and analyze data to assess quality of care? • Does the organization have resources dedicated to QI activities? • 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 Quality Improvement When assessing an organization’s readiness to undertake organization-wide practice and culture changes for QI, consider traits fundamental to the success of QI, such as: • Organizational commitment to QI • Leadership’s knowledge of QI …