29 Jul Performance Improvement in Health Care? Assignment Content Based on the information you have acquired this semester, as well as through conducting some additional r
Performance Improvement in Health Care
Assignment Content
Based on the information you have acquired this semester, as well as through conducting some additional research, please complete 2 of the 3 questions below. Each response should be 3/4 of a page to 1 page in length.
A. Develop a SWOT (strengths, weaknesses, opportunities and threats) analysis of the QI plan for a health care facility, Select a hypothetical facility/agency of your choice.
B. As the new QI Director of an 800 bed Acute Care Hospital, you have been asked to develop a strategic plan to assess the current QI program and determine any required revisions or updates. Please complete a hypothetical assessment and a plan to address any required updates. Additionally develop a brief QI work plan of proposed topics for the remainder of 2022.
C. Quality tools are not those found in our toolbox at home, but assist in analysis of a potential issue or concern in a process.
- 1). Discuss what quality tool you think would be most efficient for analyzing a patient elopement from a Nursing Home. What measures would you use to drill down to the possible contributing factors?
- 2). Discuss the importance of benchmarking with other facilities/programs/plans and provide an example of how you can do this (remember the 1st discussion).
- 3). Discuss the importance of launching an effective quality action team.
- 4). How would you handle conflicts in a quality action team?
- 5). How would you recommend rewarding achievements of a quality action team.
D. Develop a plan for survey readiness as a new Quality Director with 3 months until the New York State Department of Health or a CMS survey.
Please respond as completely and comprehensively as possible.
Total of 2 pages: APA Format and References.
Chapter 7: The Role of the Patient in Continuous Quality Improvement
Contents
Introduction and background
Patient involvement in healthcare improvement overview
Rationale for Patient Involvement in CQI
Methods for Involving Patients in CQI
Factors Affecting Patient Involvement
The MAPR Model of Patient Involvement
Partners to Owners
Conclusion
Introduction
The primary function of health systems is to care for the health and wellbeing of populations in an effective and efficient way.
A range of mechanisms exist for measuring the quality of care provided by health systems
The role of the patient, family, and caregivers is much less clear
History, policy, and causality are conflicted on the role of and outcomes from the patient in CQI
Background
Most CQI systems value the involvement of the client in systemic change and development
Patient safety inquiries show that patients and carers often flagged problems first but were ignored
These inquiries were not isolated to one part of the health system – problems are diverse in type and location of occurrence
How can CQI help avoid these problems, halt their recurrence and improve systemic approaches?
Patient Involvement in Healthcare Improvement Overview
Patients are expected to be involved in health care as health systems have developed – CQI is a part of this
Social and health sector changes have contributed to the call for patient involvement
The dominance of medicine has been questioned by patients, advocates and health practitioners
The HIV/AIDS epidemic has been a major force for change in traditional health system approaches
Technological shifts have/are having a huge impact e.g. knowledge base, global contacts, volunteers for trials etc.
Rationale for Patient Involvement in CQI
Greater knowledge of health has increased knowledge of errors in the media and public domains
High profile cases continue to get major news coverage e.g. The Shipman Inquiry in the U.K.
Health systems have been forced to acknowledge the patient/client/carer perspectives
CQI is part of the shift to patient-centered health care e.g. Insurance systems, co-payments etc. also make patients customers
Methods for Involving Patients in CQI
Three important levels of patient involvement in CQI:
Micro-level involvement – active patient involvement as acknowledged in the concept of the self-managing patient;
Meso-level involvement – patients involved in health service or even whole system planning, management and evaluation;
Macro-level involvement – here patients are involved in national/international safety activities e.g. The WHO London Declaration
Factors Affecting Patient Involvement
The evidence base for patient involvement is small but growing
Patient willingness to participate is affected by several factors e.g. self-efficacy in the role, health literacy, shift/changes required in role
Inhibitory factors include e.g. type/severity of condition, SES factors (minority social position), the health setting and issues around power relations
Clinician attitudes are also a factor including training, personal beliefs and organizational issues such as time
Measuring Patient Involvement in CQI
Patient satisfaction surveys (like customer satisfaction surveys) have become widespread in healthcare
Satisfaction is a problematic measure for a range of reasons e.g. Individual patient/carer reactions to error versus health care provider/system responses
Data collection needs to more closely reflect the kind of knowledge we are trying to produce in patient safety CQI – not just surveys because surveys are the common tool
The MAPR Model of Patient Involvement
The MAPR model aims to canvas all three levels of patient involvement and span most types of health system
Two dimensions of involvement are addressed – (1) active-proactive and (2) passive-reactive
Dimension 1 involves direct patient involvement in identifying, confronting and addressing the sources of error prior to events
Dimension 2 involves responses from patients after error events have occurred e.g. Complaint letters, participation in root cause analysis etc.
The MAPR Model
Dimension of Patient Involvement in Quality Improvement: The M-APR Model
The MAPR Model (continued)
Dimension of Patient Involvement in Quality Improvement: The M-APR Model
Partners in Health: Kaiser Permanente
The program is now more than 10 years old with a focus on chronic disease self-management
Based on the Stanford CDSMP model and research on patient outcomes
The Healthwise Handbook and related resource supports both low and high intensity interventions
Research and RCTs showed a range of positive outcomes for both patients and providers
Kaiser indicated that many of these interventions could be implemented by smaller organizations lacking Kaiser’s resource base
National Patient Safety Goals in the United States
The Joint Commission (TJC) accreditation agency has National Patient Safety Goal 13 to involve patients in their own (safe) care; in 2010 this goal became part of TJC’s standards for accreditation
In 2007 TJC published a Patients as Partners toolkit to support patients and carers in identifying safety issues
TJC has emphasised the role of diversity as a key issue in safety e.g., meeting patient/staff language needs and effective communication more broadly
Patients as Partners Program
Impact British Columbia, an NFP, implemented a patients as partners program based on the BC Health Charter
The focus was chronic disease patients who are English-speaking emphasising diversity effects on health care design and provision
Outreach activities target both health care recipients and health care providers
From Partners to Owners
The SouthCentral Foundation (SCF) in Alaska took on management of all Native health services in its area in 1999
Ownership and control caused a shift in the design and delivery of services
Native people were consulted about their ideas for service delivery and fit
This new model shifted from patient-centered to patient-owned
Conclusion
Patient involvement is now an accepted part of health systems development
In spite of this, error rates have not yet fallen much The key issue is to identify how patient involvement can have a positive impact on this situation
Each system in each country is likely to have a unique response to this problem
The important thing is, whether exclusively unique or similar, that effective responses have a positive impact through CQI
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Chapter 1: The Global Evolution of Continuous Quality Improvement: From Japanese Manufacturing to Global Health Services
Outline
Introduction
Definitions
Characteristics / Elements of CQI
Evolution of CQI in Health Care
Broad-Based Approaches to CQI
Introduction
Continuous quality improvement (CQI) has evolved over time and across countries
Substantial progress has been made in the diffusion of CQI in health, e.g., in public heath
The need for greater diffusion of CQI continues, particularly due to greater complexity in health care systems
Quality and safety problems persist in health care and new techniques are available to address these
Definition of Quality in Health
The WHO definition of quality of care is “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered.”
Components of Health (WHO)
Safe. Delivering health care that minimizes risks and harm to service users, including avoiding preventable injuries and reducing medical errors.
Effective. Providing services based on scientific knowledge and evidence-based guidelines.
Timely. Reducing delays in providing and receiving health care.
Efficient. Delivering health care in a manner that maximizes resource use and avoids waste.
Equitable. Delivering health care that does not differ in quality according to personal characteristics such as gender, race, ethnicity, geographical location or socioeconomic status.
People-centered. Providing care that takes into account the preferences and aspirations of individual service users and the culture of their community
Quality Assurance(QA)
QA focuses on conformance quality, which is defined as “conforming to specifications; having a product or service that meets predefined standards” (McLaughlin & Kaluzny, 2006, p. 37).
QA is sometimes the primary goal of accreditation processes.
Definition of CQI in Health Care
CQI is defined as a structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations
Common Characteristics of CQI
• a link to key elements of the organization’s strategic plan;
• a quality council made up of the institution’s top leadership;
• training programs for personnel;
• mechanisms for selecting improvement opportunities;
formation of process improvement teams;
• staff support for process analysis and redesign;
• personnel policies that motivate and support staff participation in process improvement;
• application of the most current and rigorous techniques of the scientific method and statistical process control.
Societal Cost of Poor Quality
Crosby: Cost of quality (“Quality is free”, 1979)
Cost of (poor) quality = cost of nonconformance
Poor quality care has an impact on the patients directly affected, the services which provide that care, and society at large
unnecessary costs associated with waste and wasted effort when work is not done correctly the first time.
includes the costs of identifying errors, correcting them, and making up for the customer dissatisfaction that results.
This view leads naturally to a broadening of the definition of quality by introducing the concept of adding value, in addition to ensuring the highest quality of care.
Quality/Accountability/Value
Improving quality involves three aims (“The triple aim: Care, health, and cost”: Berwick et. al, 2008: 759):
Improving the experience of care
Improving the health of populations
Reducing the per capita costs of health care
At a more micro level, improving quality also involves professional responsibility and development
An example of the evolution continuing in the 21st Century
These concepts have evolved further in the second decade of the 21st century to include a fourth aim directed at ensuring the well being of health care providers
See Chapter 2 (Bodenheimer & Sinsky, 2014)
Rationale for Implementation of CQI in Health Care
Health care organizations embark on CQI for a variety of reasons, including:
Engagement in true process improvement
Give customers (patients) the quality care they deserve
AND / OR
Accreditation requirements,
Cost control,
Competition for customers, and
Pressure from employers and payers
Characteristics/Functions of Health Care CQI
(1) Understanding and adapting to the external environment;
(2) empowering clinicians and managers to analyze and improve processes;
(3) adopting a norm that the term customer includes both patients and providers and that customer preferences are important determinants of quality in the process;
(4) developing a multidisciplinary approach that goes beyond conventional departmental and professional lines;
Characteristics/Functions of Health Care CQI
(5) adopting a planned, articulated philosophy of ongoing change and adaptation;
(6) setting up mechanisms to ensure implementation of best practices through planned organizational learning;
(7) providing the motivation for a rational, data-based, cooperative approach to process analysis and change; and
(8) developing a culture that promotes all of the above.
CQI: Philosophy and Process
CQI is simultaneously two things: a management philosophy and a management method.
It is distinguished by the recognition that customer requirements are the key to customer quality and that customer requirements ultimately will change over time because of changes in evidence-based practices and associated changes in education, economics, technology, and culture.
In health care such changes, in turn, require continuous improvements in the administrative and clinical methods that affect the quality of patient care and population health.
Elements of CQI in Health Care
Philosophical Elements
Structural Elements
Health Care Elements
Philosophical Elements of CQI
Strategic Focus
Customer Focus.
Systems View
Data-driven (evidence-based) Analysis
Implementer Involvement
Multiple Causation
Solution Identification
Process Optimization
Continuing Improvement.
Organizational Learning
Structural Elements of CQI
Use of process improvement teams
Use of CQI tools
Creation of parallel organization (Quality Council) to monitor CQI
Gain commitment from top management
Utilize statistical analysis
Develop and review customer satisfaction measures
Use benchmarking
Engage in redesign of processes
Examples of CQI Tools
Flow charts
Run charts
Control charts
Cause and effect diagrams
Frequency
charts
Checklists
Pareto charts
Healthcare Elements of CQI
Use of epidemiological and clinical studies (evidence based medicine)
Involvement of staff in governance and peer review
Use of risk-adjusted outcome measures
Use of cost-effectiveness analysis
Use of quality assurance and risk management data and techniques
Evolution of CQI
From Japan(post-WW II) to US (1960s) to the World (21st century)
Most recently: to low and middle income countries
From TQM to CQI
Pioneers
Deming (14 points)
Shewhart
Juran
Feigenbaum
Crosby
Donabedian
Continuing Evolution in Japan
Taguchi
Ishikawa
Deming’s 14 Points
Deming’s 14-Point Program
Reprinted from The New Economics for Industry, Government, Education by W. Edwards Deming by permission of MIT and W. Edwards Deming. Published by MIT, Center for Advanced Engineering Study, Cambridge, MA 02139. Copyright © 1993 by W. Edwards Demig.
Cross Disciplinary Thinking
Cross-Disciplinary Strategic Thinking
Industrial Versus Health Care Quality
Cons
Ignores complexities patient-practitioner relationship;
Downplays competencies and motivation of the practitioner;
Ignores quality-cost trade-offs;
Gives less to clinical activities than to supportive ones;
Limited perspective on mechanisms for influencing professional behavior such as “education, retraining, supervision, encouragement and censure”
Pros
Importance of health care quality traditions.
Greater attention to consumers
Greater attention to system designs and processes
Expansion of self-monitoring, self-governing tradition to all staff
Greater role by management in CQI
Development of appropriate applications for health care monitoring.
Greater education and training in CQI for all staff
Evolution of CQI in Health Care
From hospitals to all segments of healthcare
From doctors and managers to all staff
From specialized knowledge to generalized competencies
From localized activities to national and international regulatory and accrediation agencies
The Big Bang of CQI
Institute of Medicine
To Err is Human (2000)
Crossing The Quality Chasm (2001)
Data already know, but these report galvanized the press, the public, professional groups and regulators
Increased demands for accountability and professional responsibility
Transfer of concerns from managerial responses, to across the board responsibility
Revised Boynton & Victor Model for Health Care From Industrialization to Personalization
Revised Boynton and Victor Model for Health Care
Mass Personalization
Personalization must not be mixed up with customization. While customization relates to changing, assembling or modifying product or service components according to customers’ needs and desires, personalization involves intense communication and interaction between two parties namely customer and supplier. Personalization in general is about selecting or filtering information objects for an individual by using information about that individual (the customer profile) and then negotiating the selection with the individual….
(Tseng and Piller, 2003, p.7)
Examples of Personalization in Health Care
Increased accessibility of data and information leading to increased patient and family participation in decision making
Possibility of personalized medicine – right drug at the right dose at the right time
Focus on individual rather than (chronic) condition, including evidence based medicine and self management
Recent Evolutionary Trends in CQI
The integration of CQI into public health activities
The integration of CQI into nursing education (QSEN)
The expanding role of accreditation.
The global spread of CQI across countries and health services
Greater understanding and use of broad–based applications and methods
PDSA/PDCA
PDSA Plan-Do-Study-Act
Shewhart (PDSA) cycles “provide a structure for iterative testing of changes to improve quality of systems…The pragmatic principles of PDSA cycles promote the use of a small scale iterative approach to test interventions, as this enables rapid assessment and provides flexibility to adapt the change according to feedback to ensure fit-for-purpose solutions are developed” (Taylor et al. 2014, pp.290-291).
PDCA is an alternate definition of PDSA
Used interchangeably
C:Check is equivalent to S:Study
Shewhart (PDSA) Cycle
Shewhart (PDSA) Cycle
Reprinted from The New Economics for Industry, Government, Education by W. Edwards Deming by permission of MIT and W. Edwards Deming. Published by MIT, Center for Advanced Engineering Study, Cambridge,
MA 02139. Copyright © 1993 by W. Edwards Demig.
Key Features of PDSA
The use of repeated iterative cycles
Prediction-based test of change (developed in the plan stage)
Small-scale testing (build as confidence grows – adapting according to feedback and learning)
Use of data over time (to understand the impact of change)
Documentation (to support local learning and transferability to other settings)
Source: Taylor et al. 2014, p.293.
FOCUS-PDCA
The FOCUS–PDCA Cycle
FOCUS-PDCA
FOCUS-PDCA creates common language and an orderly sequence for implementing CQI. It focuses on the answers to 9 questions (Batalden and Stoltz, 1993):
1. What are we trying to accomplish?
2. How will we know when that change is an improvement?
3. What changes can we predict will make an improvement?
4. How shall we pilot test the predicted improvements?
5. What do we expect to learn from the test run?
6. As the data comes in, what have we learned?
7. If we get positive results, how do we hold onto the gains?
8. If we get negative results, what needs to be done next?
9. When we review the experience, what can we learn about doing a better job in the future?
Model for Improvement
Model for Improvement
Reproduced from Langley, G.L., Nolan, K.M., Nolan, T.W., Norman, C.L. and Provost, L.P. (2009), The
Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed., Jossey Bass, San Francisco.
Guidelines for Strengthening PDSA Applications
Four questions to ask when applying or reviewing PDSA applications:
Is the quality improvement study pertinent and relevant?
Are the results valid?
Are appropriate criteria used to interpret the results?
Will the study help you with your practice or organization of care?
(Source: Speroff et.al., 2004, p.36)
Conclusions
Since the advent of the new millennium CQI has continued to evolve in an exponential manner
Globally and across sectors of health care, leading to innovations and paradigm shifts
Examples
Broader applications in low and middle income countries
Institutionalization of CQI in Public Health
Broad-based CQI approaches/methods continue to be used successfully and help account for these trends
PDCA/PDSA
Focus PDCA
The Model for Improvement
However, continued success in using these methods requires care
Recommendations have been presented for greater emphasis on the fidelity of the applications and fuller understanding, and consideration of the context, in which project-specific results are obtained and generalized
Conclusions
The need for greater diffusion of CQI continues, particularly due to greater complexity in health care systems
Quality and safety problems persist in health care and new techniques are available to address these
The evolution of CQI will continue in a broader manner
Future health improvement models will address the questions of quality and cost and the issues of “value-added” care.
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Chapter 3: Integrating Implementation Science Approaches into Continuous Quality Improvement
Outline
Introduction
Implementation Science Defined
Integrating Implementation into QI: The Model for Improvement and Implementation
Implementing Well: Using Frameworks for Implementation
Introduction
Most consistent challenges to continuous quality improvement (CQI) in health care:
Ensuring broadest adoption of evidence-based improvements in practice
Motivating research into further improvements of processes and outcomes
Implementation science represents a next step in the evolution of CQI in health care.
Implementation Science Defined
Implementation
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