Designing a Successful Quality Improvement Program: Teambuilding and Writing a QI Plan

1. Designing a Successful Quality Improvement Program:Teambuilding and Writing a QI Plan Bureau of Primary Health Care Health Resources and Services Administration March 10, 2011

2. Introduction • Learning series on quality improvement planning • Current core and FTCA requirements as a starting point • Focus on implementation • Roadmap for getting there • Create a QI infrastructure • Seek resources and technical assistance • Third-party quality recognition • Build on partnerships with HRSA and the national cooperative agreements

3. Health Center Performance Calendar Year 2009 Among Health Center Patients: 67.3% entered prenatal care in the first trimester Rate of low birth weight babies (7.3%) continues to be lower than national estimates (8.2%) 68.8% of children received all recommended immunizations by 2nd birthday 63.1% Hypertensive Patients with Blood Pressure<= 140/90 70.7% Diabetic Patients with HbA1c <= 9 $600 Total Cost per Patient $131 per Medical Visit Source: Uniform Data System, 2009 For more information: http://www.bphc.hrsa.gov/about/performancemeasures.htm

4. FY 2011 HRSA Strategic Priorities • Improve Access to Quality Health Care and Services • Community/new site development • Expansion planning • Patient-centered medical/health home development • Meaningful use adoption • Strengthen the Health Workforce • Workforce recruitment and retention • Build Healthy Communities and Improve Health Equity

5. BPHC QI Strategy • Develop and enhance access points • Transform HC care delivery system • PCMHH • HIT Meaningful Use • Recruit, develop, retain skilled workforce • Integrate Health Centers into local health systems • Specialists, ER, Hospitals • ACOs • Public Health • Align policies and programs where possible

6. National & State Performance Profile Health Center Trend Report (National/State/Grantee) Health Center Summary Report (National/State/Grantee) Performance Profile (National/State) -- Number & Percent of Health Centers Meet Meaningful Use Standards Achieve National Quality Recognition Exceed Healthy People Goals (Core Clinical Measures) Increase in Cost/Patient Less than National Increase Increase in Patients Going Concern Issues FTCA Claims/Visit 60 or 30 Day Progressive Actions 1 year Project Periods

7. HRSA Program Requirements • Ongoing QI/QA Plan encompassing management and clinical services, maintaining confidentiality of patient records • Focused responsibility for QI • Periodic assessments of appropriate service use and quality

8. Benefits of an Effective QI Plan • Roadmap for HC organization • Leadership, focus, & prioritization • Efficient coordination of staff & resources • Better outcomes • Satisfy external requirements • HRSA, State • Third-party quality accreditation and recognition

9. QI Resources • Local • Your own staff • Other HCs • Academia • Health Departments • State/Region • PCAs & HCCNs • Medicaid, AHEC, PCOs

10. QI Resources • Federal/National • HRSA: BPHC, HRSA Offices • CMS, AHRQ, ONC, SAMHSA, CDC, NIH, VA • National Cooperative Agreements • Third party quality accreditation and recognition

11. Breathing Life into Your QI Plan…

12. Where Do We Start? OK Great!! So how do we actually do this when we are: • Short staffed • Busy with lots of complicated patients • Short on resources (shouldn’t all our money go for patient care?) • Lacking QI skills (not covered well in medical school, nursing school, business school)

13. Where Do We Start? Depends on where you are, who you are, when you began, how big you are… • One site 3 providers rural Alaska 2,000 users • 12 sites NYC 52 providers 100,000 users • 35 year history of organization, fully implemented EHR for 6 years • New start 2010 paper medical records

14. Where Do We Start? The Steps: • Create the Basic Structures • Evaluate & Determine Priorities • Select Performance Measures • Collect Data/Determine a Baseline • Analyze Data/Evaluate Performance • Plan & Implement Changes for Improvement • Monitor Performance Over Time

15. 1. Create the Basic Structures Q. What aspects of care does QI include? A. ALL! Q. What staff members are included? A. ALL!

16. 1. Create the Basic Structures • Quality as an integral part of the organization’s “culture”. • Buy-in at all levels—Board, management, staff and patients. • Resources—staff time, meetings, information systems. • Provide education

17. Role of the board Approve QI plan Receives reports at least quarterly BOD QI Committee 1. Create the Basic Structures

18. 1. Create the Basic Structures • Continuous resources (time, money, staff) dedicated for TA • You cannot afford not to do this!

19. 1. Create the Basic Structures • QI Committee • QI Plan & Health care plan • QI calendar • Clinical practice guidelines • Policies & procedures • Peer review • Chart audits • Patient satisfaction surveys • Tracking systems • Credentialing and privileging • Data sources

20. 2. Evaluate & Determine Priorities • Set aside a specific time/place where all essential staff plan how to develop your QI Plan • Remember this work will never be DONE--Continuous QI

21. 2. Evaluate & Determine Priorities • Focused areas • High risk • High volume • Low performing measures

22. 3. Select Performance Measures A Performance Measure is a quantitative tool that provides an indication of an organization’s performance in relation to a specified process or outcome.

23. 3. Select Performance Measures Set goals for measures: A SMART goal is a goal that is specific, measurable, attainable, relevant and time based. In other words, a goal that is very clear and easily understood.

24. 3. Select Performance Measures Outreach/Quality of Care Indicators Trimester of entry into perinatal care Childhood (2 year old) immunization rate Pap tests for adult (21 – 64 year old) women Health Outcomes and Disparities Infant birth weight (normal vs. low) Hypertension (controlled vs. uncontrolled) Diabetes (adequate control vs. inadequate control)

25. 3. Select Performance Measures Required two additional measures One Oral Health One Behavioral Health Supplemental measures

26. 3. Select Performance Measures • Working capital to monthly expense ratio • Liquidity in # of months - ability to pay bills on time - current financial condition • Long-term debt to equity ratio • Portion of net assets tied up in long-term debt - long-term financial condition • Change in net assets as a percent of expense • Financial results from operations in relationship to total expenses • Total cost per patient • Annual average cost per patient served - value of service provided based on costs • Medical cost per medical encounter • Average cost per billable medical encounter (less: lab & pharmacy) - cost efficiency

27. 4. Collect Data/Determine a Baseline

28. 4. Collect Data/Determine a Baseline • Define measurement population and delineate eligibility criteria. • Create a data collection plan to include: • Sampling strategy; • Determine method of data collection, i.e. chart abstraction, interviews

29. 4. Collect Data/Determine a Baseline • Create data collection tools: • Create instructions for data collection tools • Train personnel who will collect data • Conduct pilot test of tool • Establish process of communicating with staff about measurement process • Collect data

30. 5. Analyze Data/Evaluate Performance • Analyze data and review the results. • Identify areas where additional data is required. • If historical data are available, compare for trends. • Display and distribute data to communicate findings and results. • Identify areas for improvement and select a quality improvement project.

31. 5. Analyze Data/Evaluate Performance • How do we know if performance is satisfactory? • Benchmarks useful in setting feasible and challenging goals • The most important comparisons are internal • Most relevant when patient populations are similar • UDS data will reveal state and national trends over time, rural vs. urban, etc.

32. 5. Analyze Data/Evaluate Performance Healthy People 2010: www.healthypeople.gov National Quality Center—Improving HIV Care: http://www.nationalqualitycenter.org/index.cfm/22 AHRQ Effective Health Care: http://effectivehealthcare.ahrq.gov/ National Quality Forum: http://www.qualityforum.org/ State Primary Care Associations:http://www.bphc.hrsa.gov/technicalassistance/pcadirectory.htm

33. 6. Plan & Implement Changes for Improvement

34. 6. Plan & Implement Changes for Improvement • Discrepancy between goals or standards and reality • Solve the problem! • Can it be solved? • Is it worth solving? • Who should do it? • What is the goal? (MEASUREABLE) • How soon?

35. 6. Plan & Implement Changes for Improvement • Establish project-specific QI team that represents all staff integral to the service or issue. • Identify a team leader or sponsor. • Delineate specific goals for the team. • Allocate time and resources for the team. • Delineate team responsibilities. • Develop timeline for reporting findings and improvement strategies.

36. 6. Plan & Implement Changes for Improvement • Develop a time line or calendar of activities for the year. • Select a QI approach, such as PDSA or the Chronic Care Model. • Clarify QI responsibilities of staff.

37. 6. Plan & Implement Changes for Improvement • Utilize QI tools and techniques to understand the process, such as flow charts, facilitated brainstorming, cause and effect diagrams, etc. • Document and track progress by using activity logs, issue identification logs, meeting minutes, etc. • Report progress on a regular, defined basis.

38. 6. Plan & Implement Changes for Improvement • Identify potential solutions to make improvement to the systems of care. • Recognize quick fixes and longer term solutions. • Try a small test of change and analyze results. • Refine improvement plan. • Develop timeline for implementation of plan. • Delineate team responsibilities. • Implement changes. • Track changes and improvement actions.

39. 6. Plan & Implement Changes for Improvement Plan-Do-Study-Act (PDSA) : PDSA is a widely used framework for testing change on a small scale.

40. 7. Monitor Performance Over Time • Determine interval for remeasurement. • Remeasure indicator after change has been implemented. • Look for incremental improvement. • Communicate results to team, staff and leadership. • Determine need for and/or level of remeasurement on an ongoing basis. • Develop a plan for sustained improvement.

41. CHC Difficult Areas QI Improvement • Performance Measures • Data bases/Data Collection/Data Reliability • Identify/Use Benchmarks • Identifying/Documenting necessity for change in provision of services • Result in change being implemented—remeasure to assure improvement

42. A Real Life Example

43. Steps 1 - 4 XCHC Diabetes measure (HbA1C < 9%) was 83% (HDC participant for 6 yrs) HTN rate <140/90 was 52% (Healthy People 2010 goal 50%) Pap baseline rate of 20%—new measure for them

44. 5. Analyze Data/Evaluate Performance • Discrepancy between benchmarks (HP 1998 benchmark 79%; 2009 BPHC UDS 58%) and reality (20%) • Solve the problem!

45. 6. Plan & Implement Changes for Improvement Establish project-specific QI team that represents all staff integral to the service or issue. Scheduler, provider, nurse manager, medical records, IT Identify a team leader or sponsor. Chair of CQI program (COO) Set specific goals for the team. Initially wanted to improve to 25%... Verify baseline data Identify restricting & contributing factors

46. 6. Plan & Implement Changes for Improvement • Allocate time and resources for the team. • Initially meet weekly to monitor PDSA cycles • Delineate responsibilities. • Develop timeline for reporting findings and improvement strategies. • Report to next CQI meeting in one week then monthly

47. 6. Plan & Implement Changes for Improvement Processes… EHR now being implemented Staff training Patient education Plan to institute new consent form specific for women’s health and policy to ensure its use

48. 6. Plan & Implement Changes for Improvement Clinical practice guideline Review Pap guidelines and present to provider staff Access to care issue Many pts seek Paps at State Health Department Hispanic patients prefer female provider Many mobile migrant patients with multiple providers Outcomes data Incomplete because only queried practice management system which did not include transferred records Tracking No consistent mechanism for obtaining records from other providers Have meeting with health dept staff to assure cooperation

49. 6. Plan & Implement Changes for Improvement Pt. satisfaction survey?—are they happy with the system? Will consider in the future to explore attitudes regarding various interventions Documentation of process Plan to keep meeting minutes, goals, outcomes

50. 6. Plan & Implement Changes for Improvement Analyze data and review the results. Monthly review of women seen for Pap status Identify areas where additional data is required. Data collection method did not capture all Paps done If historical data are available, compare for trends. Not previously measured Display and distribute data to communicate findings and results. Plan to inform CQI committee and staff of results Graphic presentation of data readings over time