Quality Management Presentation by Susan Traynor

Goals of Presentation• Attendee will have a brief yet understandable

history regarding quality improvement

• Attendee will have a basic definition and concept of quality improvement

• Attendee will have a basic understanding of HRSA requirement for quality

• Attendee will have an enhanced awareness of organizations devoted to quality improvement

• Attendee will have an understanding of how quality improvement relates to RW & DSHS funded HIV services

CONTINUOUS QUALITY  IMPROVEMENT

CQI is a management philosophy which contends that most things can be improved 

Continuous Quality Improvement Definition:

An approach to quality management that builds upon traditional quality assurance methods by emphasizing the organization and systems: focuses on “process” rather than the individual; recognizes both internal and external “customers”; promotes the need for objective data to analyze and improve processes 

Source:  Graham, N.O. Quality in Health Care (1995)

Quality

It is a set of concepts, principles and methods developed from quality principles proposed by early quality gurus, W. Edwards Deming, Joseph Juran, Philip Crosby, Brian Joiner, and others

Ultimate Purpose of QA/QI/PI

What are we getting for the bucks?

1. Treatment/Service Delivered

2. Treatment/Service Result (Outcome)

3. Cost of Treatment

Ryan White funds

Ryan White funds are distributed by looking at 2 issues: a formula based on the number of cases in Texas and a competitive process(Texas is looked at how well it is delivering QUALITY services and compared to other geographic locations/states)

Quality impacts funding $?Example: Hospitals receive Medicaid funds

Who was W. Edwards Deming

Dr. W. Edwards Deming is known as the father of the Japanese post-war industrial revival and was regarded by many as the leading quality guru in the United States. He passed on in 1993

Trained as a statistician, his expertise was used during World War II to assist the United States in its effort to improve the quality of war materials

He was invited to Japan at the end of World War II by Japanese industrial leaders and engineers-changed perception that Japan produced cheap, shoddy imitations to one of producing innovative quality products

Deming's business philosophy is summarized

in his famous "14 Points," listed below

1. Constancy of purpose2. The new philosophy3. Cease dependence on mass inspection4. End lowest tender contracts5. Improve every process6. Institute training on the job 7. Institute leadership8. Drive out fear9. Break down barriers10. Eliminate exhortations11. Eliminate arbitrary numerical targets12. Permit pride of workmanship13. Encourage education14. Top management commitment and action

CONTINUOUS QUALITY  IMPROVEMENT

These CQI principles, tools, and techniques have been found to work effectively in manufacturing industries.  They have been found to also effectively work in human service industries, including healthcare

At the core of CQI is serial experimentation (the scientific method) applied to everyday work to meet the needs of those we serve and improve the services we offer

Who was Joseph Juran?

Joseph Juran is an internationally acclaimed quality guru, similar to Edwards Deming, strongly influencing Japanese manufacturing practices. Joseph Juran’s belief that “quality does not happen by accident” gave rise to the quality trilogy:

Quality planning

Quality control

Quality improvement

In the 1980’s Joseph Juran recognized that the common approach to total quality management…believes quality must start at the top

The key steps in implementing company-wide strategic goals are: Identify customers and their needs – both internal and external – and work to meet those needs

Create measures of quality, establish

optimal quality goals and organize to meet them

Create processes capable of meeting quality goals in “real” operating conditions

HRSA supports Quality Improvement

The CARE Act was signed into law on August 15, 1990 to improve the quality and availability of care for people with HIV/AIDS and their families

(Taken from the HRSA website)

In serving people and families affected by HIV/AIDS, the Bureau,

headed by HRSA Associate Administrator Deborah Parham,

Ph.D., RN,

has identified four factors that have significant implications for HIV/AIDS

care, services and treatment:

(Taken from the HRSA website)

• The HIV/AIDS epidemic is growing among traditionally underserved and hard-to-reach populations

• The quality of emerging HIV/AIDS therapies can make a difference in the lives of people living with HIV

• Changes in the economics of health care are

affecting the HIV/AIDS care network

• Policy and funding increasingly are determined by outcomes

(Taken from the HRSA website)

Who is Philip Crosby?

Known as The Fun Uncle of the Quality Revolution

Where Phil Crosby excelled was in finding a terminology for quality that mere mortals could understand. (Dr. Deming and Dr. Juran were the great brains of the quality revolution)

He popularized the idea of the "cost of poor quality", that is, figuring out how much it really costs to do things badly

Mr. Crosby defined quality as a conformity to certain specifications set forth by management and not some vague concept of "goodness." These specifications are not arbitrary either; they must be set according to customer needs and wants

The CARE Act Amendments of 2000 require all CARE Act programs to establish

quality management programs to:

1. Assess the extent to which HIV health services are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infections

(Taken from the HRSA website)

and

2. Develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV services

(Taken from the HRSA website)

The overall purpose of a quality management program is to ensure that:

• Services adhere to PHS guidelines and established clinical practice

• Program improvement includes supportive services linked to access and adherence to medical care, and

• Demographic, clinical and utilization data are used to evaluate and address characteristics of the local epidemic. (Taken from the HRSA website)

In order to be effective, quality management programs should include five key characteristics:

Systematic process Benchmarks FocusAdaptabilityImproved Outcomes

(Taken from the HRSA website)

1. Systematic process

A systematic process for assessing and monitoring quality should be established with identified leadership and accountability, and dedicated resources to support the activities.

(Taken from the HRSA website)

2. Benchmarks

Data and measurable outcomes should be used to determine progress toward relevant, evidence-based benchmarks.

(Taken from the HRSA website)

(Need to start with a baseline measure)

3. Focus

Linkages, efficiencies, and provider and client expectations should be a primary focus for addressing outcome improvement

(Taken from the HRSA website)

4. Adaptability

The process should be continuous, adaptive to change and be able to fit within the framework of other programmatic quality assurance and quality improvement (QI) activities (i.e. JCAHO, Medicaid, and other HRSA programs)

(Taken from the HRSA website)

5. Improved Outcomes Data collected should be fed back into the quality management process (especially to providers) to assure that goals are accomplished and improved outcomes are realized.

(Taken from the HRSA website)

Who was Brian JoinerKnown for showing how statistics and statisticians are important in generating quality improvements. Agency/Company success is because of:

1. obsession with quality, 2. achieving a feeling among employees that they

are one big family, and 3. identifying and correcting problems by means of

data, not opinion or emotion

The key to improved quality is improved processes. Quality is improved through improvement in process, not by inspection.. (Deming has said that more than 94% of problems appear to be system related)

Quality for HIV/AIDS• The National Quality Center (NQC) partners with

Institute for Healthcare Improvement (IHI) with the goal of improving the quality of HIV/AIDS care across the United States

• NQC is funded by the Health Resources and Services Administration (HRSA) under the New York State AIDS Institute to provide state-of-the-art quality improvement technical assistance to Ryan White CARE Act grantees of all Titles

QI Organizations cont.• The Institute for Healthcare Improvement

(IHI) is a Boston-based, independent, non-profit organization working since 1991 to accelerate improvement in healthcare systems in the United States, Canada, and Europe

• Agency for Healthcare Research and Quality (AHRQ) is part of the U.S. Department of Health and Human Services

• The Joint Commission on the Accreditation of Healthcare (JAHCO) organizations is a nationally recognized accreditation agency for hospitals, managed care entities and other types of healthcare facilities

QI Organizations Continued• The National Committee for Quality Assurance

(NCQA) is an independent, non-profit organization devoted to assessing and reporting on the quality of managed care plans

• The National Association for Healthcare Quality (NAHQ)-is dedicated to the continuous improvement of quality in healthcare and to supporting the development of professionals in healthcare quality

QI Organizations Continued• IPRO-an independent, not-for-profit New York

corporation whose clients include federal and state agencies, providers, managed care organizations, commercial insurers, Fortune 500 companies, business coalitions and unions across the country

• CARF-Commission on Accreditation of Rehabilitation Facilities, provides accreditation status for substance abuse, etc.

HRSA Goals(Taken from the HRSA Program Guidance Fiscal Year

2006)

1. Improve access to health care

2. Improve health outcomes

3. Improve the quality of health care

4. Eliminate health disparities

5. Improve the public health and health care systems

6. Enhance the ability of the health care system to respond to public health emergencies

7. Achieve excellence in management practices

DSHS HIV/STD Goal:

To Improve the Health of HIV Positive Texans

Quality Indicators for HIV• HIV is in the process of establishing evidence

based quality indicators (outcomes)• NCQA set up national research based studies

(now called evidence based) to determine quality indicators and outcomes for specific programmatic areas > focus studies

• Quality indicator examples from focus studies:Pregnant women seen in the 1st trimester have babies

with higher birth weight and fewer days in neonatal intensive care

Mental Health established quality outcome measures-examples: inpatient readmission rates length of stay

Summary of QI Elements• Quality Improvement Plan

(Contract Compliance-this is in the AA contract) establish goalsmeasurable objectivesactivity list to achieve objectives

• Quality improvement committee – diverse membership, physician representation, integrated with management (provide accountability and oversight)

• Provider feedback loop-get the information to the front lines!

Summary of QI Elements cont.

• Plan, collect, and use data for effective decision making, define formula, establish baseline, bench marks, monitor utilization and penetration rates, etc.)– Outcomes/ Results for the bucks$– What are you measuring – access, availability,

effectiveness, efficiency, retention, client perception of quality, etc.

– Data validation– Keep up with the research

• Quality work plan

Summary of QI Elements cont.• Availability of Services (network adequacy,

etc.)

• Accessibility to Services

• Continuity of Care

• Client Satisfaction Surveys

• Provider Satisfaction Surveys

• Complaint Tracking System (client, family, providers, etc.)

• Documentation of all QI Activities

• Contractor Oversight Process

Summary of QI Elements cont.• Compliance with Public Health Service

guidelines for the treatment of HIV disease and related opportunistic infections, DSHS Public Health Standards, laws, etc.- usually done through record reviews (data verification needed if using electronic system)

• Focus Studies-need to establish for HIV services

Very Important Thoughts About Improvement Efforts

• Before you try to solve a problem, define it

• Before you try to control a process, understand it

• Before trying to control everything, find out what is important, and work on the most important or on that process having the biggest impact

• Recognize that we can learn from failures, so respect  “meaningful failures”

http://www.dshs.state.tx.us/hivstd/conference/2006/presentations/B9_QM.ppt#34