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Quality Improvement/ Quality Assurance. Amelia Broussard, PhD, RN, MPH Christopher Gibbs, JD, MPH. Understanding Quality Improvement and Quality Assurance. Quality Assurance and Quality Improvement are often confused as the same process Terms used interchangeably but not the same - PowerPoint PPT Presentation


Quality Improvement and Quality Assurance

Quality Improvement/ Quality Assurance

Amelia Broussard, PhD, RN, MPHChristopher Gibbs, JD, MPH

Understanding Quality Improvement and Quality AssuranceQuality Assurance and Quality Improvement are often confused as the same processTerms used interchangeably but not the sameOne is focused on observations only and one time opportunityOther is continuous process documenting improvement Both based on standards for performanceBoth important to organizationBoth focus on quality services to patients2

Definition of Quality AssurancePlanned systematic activities implemented in quality systemQuality requirements for product or service fulfilledActivities typically based on standards of practiceCan help identify problem but no solutionCompliance with standards goal3

Public health departments, JACHO, or other groups such as licensing groupsExamples include annual infection control and safety training for staffReview of sample medications to assure current expiration date

3Definition of Quality ImprovementQI is continuous ongoing process designed to improve patient outcomes, services or processFocus is ongoing rather than one time reviewTeam is multidisciplinary with representatives from all departmentsFocus on process or service not individualProactive rather than reactive4

Focus is more often on processDoes not single out individuals but looks at methods of providing servicesInvolves whole organization in development of activities4Goals of QIGoals of Quality ImprovementUnderstand processReduce & eliminate errorsImprove efficiencyImprove communicationRequires measurementFocuses on outcomes


Core Concepts of Quality ImprovementExceed expectations of patients or clientsProcess usually problem not peopleDoes not seek to blame but to improve processMost effective when part of everyday workFocus on everything, you can not focus on anything6

QI based on achieving success through measuring specific outcomes that are related to patient care or financial stabilityThis also includes patient satisfaction, if patients are satisfied with care, then organization will continue to improve finances, etc.Quality Assurance often focuses on individuals in a certain discipline rather than the processFocusing on process reduces staff resistance and finger pointing which can be non-productiveFocus attention on one small part of the process rather than massive overhauls that may not be necessary

6Quality Improvement and FTCAQI plan integrates all departments in activitiesOne QI plan for organizationMinutes document QI activitiesPlan should have certain components outlining process of committee


Expectation is that one QI committee will be established for the organization. This committee will be responsible for all QI activities. There should not be individual departmental QI committees but one that deals with all QI concernsMinutes should include information on all QI projects conducted during the month with information on status of project. More to come on this topicPlan should have a strong outline of how the committee functions and information is reported to the organization as a whole and to the Board of Directors. 7Quality Improvement Plan ComponentsStatement of Purpose or Intent of PlanScope of PlanAdministrative ResponsibilityRisk Management Systems (some make this separate plan)Role of Peer Review in QICommittee CompositionCommittee AccountabilityMethods for conducting QI activitiesTracking of QI ActivitiesApproval and Review 8

Details for each of these areas will be discussed separatelyEach area must be addressed in a successful QI planPlan must be approved by Board of Directors within the last three years to be acceptable. A signature page with appropriate signatures from Board and CEO and dates signed must be included as part of the QI planPlan does not have to 20 pages as long as all of the required information is in place

8Statement of PurposePlan includes statement of purpose or intentExampleThe purpose of the Quality Improvement Program is to support improved health care delivery and outcomes for the patient population receiving care. Objective is to promote continuous Quality Improvement within the organization and support the objectives and scope of Quality Improvement Program. 9

The main idea is to indicate the overall function of the QI plan and program and its role within the organization. This statement indicates that the organization supports improved patient care and the QI program in designing projects to improve that care. It also focuses on outcomes for patient care

9Scope of PlanScope refers to what the QI committee will doIncludes monitoring of select measures, evaluation of performance and improvement in organizational performanceDiscusses which activities are applicable to QIIncludes risk management tracking as reported to QI, results of peer review and measures to be followed during yearAreas of consideration include medical/clinical, operational/administrative, governance and financeResources available in notes section10

In the scope, the QI committee defines what they will be monitoring on a general scale. It also indicates what type of measures will be monitored during the course of the year. These should include at a minimum the HRSA clinical measures and financial measures as reported in the most recent grant application.Other areas that may be included relate to administrative processes such as personnel policies/proceduresQI committee may be responsible for development, implementation and monitoring of practice guidelines or new policies/proceduresHRSA PAL 2012-01: http://bphc.hrsa.gov/policiesregulations/policies/pal201201.html. National Quality Forum Performance Measures: http://www.qualityforum.org/Measures_List.aspx. AMA Physician Consortium for Performance Improvement: http://www.ama-assn.org/ama/pub/physician-resources/physician-consortium-performance-improvement/pcpi-measures.page. AAFP Performance Measurement and Pay-for-Performance: http://www.aafp.org/online/en/home/practicemgt/quality/qitools/perfmeasure.html.

10Administrative ResponsibilityHealth center identifies by title individual with overall responsibility for QI programApproval requirements are stated (who must approve plan)Individual consulted in development of QI/QA Plan and activitiesIdentification of who will receive information about decisions and activities of QI/QA program11

This includes all QI/QA activities and projects conducted to improve organizational performance. This is typically the Board of Directors who in turn delegate this authority to the CEO and CMO for implementationHRSA has an expectation that the authority for the QI/QA program will be delegated to the CMO who in turn may delegate day to day operation to a QI coordinatorWho give approval for the implementation of the QI program at the organizational levelThis may include a QI coordinator who actually does most of the monitoring and runs the QI meetings with the approval of the CMOTypically, there is some provision of reporting to the Board of Directors on a regular basis. 11Risk Management SystemsHealth center identifies the following:Policies/procedures regarding appropriate supervision of clinical and non-clinical staffPolicies/procedures to identify and document system process or breakdownPolicies/procedures for addressing and investigating medical malpractice claimsResources available in Notes section of slides12

Straight forward statement that defines who supervises who and under what circumstanceA procedure should be in place to track certain indicators defined by the organization that would indicate a system breakdown. This may be something like a patient complaint, incident that occurred during the course of patient care, lack of patient care services that were identified by the staffInvestigation of medical malpractice claims is a very important part of risk management. A process must be in place and described within the QI plan. Results of the investigation may be reported to the QI committee if it is related to patient outcomes and processes that could have avoided potential claimshttp://www.ecri.org/clinical_rm_program (ECRI Risk Management Website)Event Reporting Toolkit: https://members2.ecri.org/Components/HRSA/Pages/EventReportToolkit.aspx. Patient Satisfaction Questionnaire: https://members2.ecri.org/Components/HRSA/Pages/PSRMPol2.aspxSafety Attitudes Questionnaire: https://members2.ecri.org/Components/HRSA/Pages/PSRMPol1.aspxAHRQ Medical Office Survey on Patient Safety Culture: http://www.ahrq.gov/qual/patientsafetyculture/mosurvindex.htm

12Role of Peer ReviewPeer review is the process of all providers reviewing a peers medical records Specific time frame for review is defined (i.e. quarterly, monthly, bi-monthly)Results of peer review should be communicated in aggregate form to QI committee for possible QI projects to improve patient careReview should consist of two partsMedical care reviewReview for completion and documentationResources in Notes section 13

Peer review is often overlooked in QI programsAll medical providers should participate, including physicians, nurse practitioners and physician assistantsShould be done at least quarterly to assure continuous monitoringBased on practice guidelines for most common diagnosis and clinical measuresReview for completion and documentation assures that patient care information is being documented in the correct location to improve access to data in EMRNCCHCA Healthcare Plan Chart Audit Tool: http://ncchca.affiniscape.com/associations/11930/files/Copy%20of%20bphc_data_entry_tool.xls. Physician Practice Risk Management Self-Assessment Questionnaire: https://members2.ecri.org/Components/HRSA/Pages/SAQ2.aspx

13Committee CompositionEstablishes QI committe


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