QUALITY ASSURANCE

1. Sandy Smith, Consultant Comprehensive Resources, Inc. (225) 751-9716 QUALITY ASSURANCE/PERFORMANCE IMPROVEMENT A TEAM PROCESS

2. OBJECTIVES The participants will be able to: Describe basic performance improvement concepts (includes statistical analysis) List 4 critical components to ensure effective teams List 5 methods for displaying data Describe 5 important components for effective data management

3. Critical Access HospitalRegulations C195 � Each CAH shall have an agreement with respect to quality assurance with at least (i) One hospital that is a member of the network (ii) One PRO; or (iii) One other qualified entity

4. Regulations C330 � Periodic evaluation and quality assurance review (annual evaluation of the total program) C336 � The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes

5. Requirements of the Quality Assurance Program Evaluation of all services affecting patient health and safety Nosocomial infections Medication therapy Quality and appropriateness of the diagnosis and treatment furnished by physicians

6. Components Collect data Analyze data Remedial action Evaluate actions

7. What is Quality? What one defines it to be

8. Leadership Responsibility Mission Vision Values

9. Quality Control �The performance of processes through which actual performance is measured and compared with goals, and the difference is acted on.� JCAHO

10. Quality Assurance/Improvement �An approach to the continuous study and improvement of the processes of providing health care services to meet the needs of individuals and others. Synonyms include continuous quality improvement, performance improvement, and total quality management.� JCAHO

11. Performance Improvement �The continuous study and adaptation of a health care organization�s functions and processes to increase the probability of achieving desired outcomes � This is the third segment of a performance measurement, assessment, and improvement system.� JCAHO

12. Key to Effective Teams Define the Quality/Performance Model Provide Team Training Define Team Expectations Provide Resources to the Team (Time, space, leadership support)

13. Stages of Team Development Forming Storming Norming Performing Source: The Team Handbook

14. Performance Improvement Model (FOCUS-PDCA) (F) ind a process to improve - Identification method: Feedback (Community, Patient, Physician, Staff) PI Data Regulations JCAHO Standard Practice Guideline Other _________ (O) rganize the Team that knows the process Persons who contribute to the improvement process (define roles) (C ) larify the current knowledge of the process Policy/Procedure Review Flow chart current process PI data - PI Tools (U) nderstand causes of process variation PI data Logs Fishbone diagram Surveys Flow chart Check sheets Graphs Pareto Charts Control charts (S) elect the process improvement Identify the process to be planned Prepare proposal

15. PDCA (P) lan - Revise or develop policy/ procedure Identify resources required (Staff, Equipment, Space, Supplies) Gantt Chart, Affinity Diagram, Story Board, Critical paths/guidelines - Identify PI indicators (D) o - Implement on a trial or pilot basis (C ) heck � Collect, aggregate, and analyze data (A) ct - Reevaluate, Replan, Implement

16. Statistical Data Variance � a measure of the differences in a set of observations Variation � The differences in results obtained in measuring the same phenomenon more than once (common and special causes) Source: JCAHO

17. Display of Data Run Charts Control Charts Bar Graphs Pie Charts Histograms

18. Bar Graph

19. Standard Deviation �A measure of variability that indicates the spread of a set of observations around a mean� Source: JCAHO

20. Data Management What data measurements are required? What data measures are important to the organization decision- making process? What data measures are important to day to day management?

21. Critical Components to Effective Data Management Define what data to measure? Define the process for data collection and reporting (allocate appropriate resources) Provide appropriate data analysis Define the responsibility for Action Plan Research products and process for managing data

22. Excel� Training Resource to enhance data management Data collection Measurement/Aggregation Assessment/Analysis Improvement

23. CAH QA/PI Resource for data collection, reporting, and benchmarking with other CAHs (Financial data, Transfers) Resource to enhance organization data management (Risk Management, Utilization Management, Infection Control, Medication Use, Restraint Use, Complaints, etc.) Provide Training Provide resources for use or purchase

24. FY 03 Indicators

25. Volume Indicators Patient Days Inpatient Observation Skilled Emergency Room Visits

26. Financial Indicators Debt to Asset Ratio (%) Donor & Government Support (%) Profit Margin (%) Medicare Inpatient Costs per adjusted discharge ($) # ARDs (Days)

27. Human Resource Indicators Total FTEs RN FTEs LPN FTEs CNA FTEs Unit Clerk FTEs Pharmacy FTEs RT FTEs Lab FTEs Social Service FTEs Dietitian FTEs Nursing Hours/ED Visit

28. Clinical Indicators # Transfers Reason for Transfers Equipment Staff Space/Bed availability Services (Imaging, Surgery, etc.) Patient/Family preference

29. Summation Description of QA/PI process Components to ensure effective teams Methods for displaying statistical data Components for effective data management

30. QA/PI RepresentativesAfternoon Agenda Group discussion of QA/PI processes in place � �What�s Working � What�s Not?� (Participants) Identify needs to enhance the current QA/PI processes

31. Evaluation