1. Quality Improvement Justine Strand, MPH, PA-C Patricia Castillo, MS, PA-C Victoria Kaprielian, MD

2. Goal: Apply principles and practices of Quality Improvement.

3. What is QI?

4. QI Opportunities and Benefits QI can give you the opportunity to ….. • Look at things differently • Come up with new options and solutions • Eliminate things that make you crazy

5. QI: A Historical Perspective • based on the theories of Deming and Juran • 1980s – Japanese auto industry • 1990s – American manufacturers and health care industry

6. Health Care: Cost and Access • Improvements in technology • Higher prices • Greater demand • Integrated medical delivery systems

7. Perspectives on Quality • Providers • Payers • Employers • Consumers

8. QI is a “Hot Topic” • “…The quality of health care received by the people of the United States falls short of what it should be.” IOM, 2001

9. US Health System Rankings • 37th place overall (out of 191) because of significant health disparities • Tied for 82nd place (out of 171) on polio vaccination rate • Number 1 on both dollars spent per capita, and proportion of GDP spend on health care

10. Medical Errors • How extensive is the problem of medical errors? • More people die in a year from medical errors than from motor vehicle accidents, breast cancer, or AIDS

11. “Crossing the Quality Chasm” IOM 2001 • Under use – helpful services not delivered • Overuse – useless interventions • Mistakes – inevitable human error

12. Medical Errors • Not the fault of individuals • Lessons from industry

13. QI in Health Care • How can you measure quality in health care? • What do you want to measure? • How can you do it? • What are the challenges?

14. Issues in Measurement • Structure • Process • Outcome

15. Process vs. Outcome • Process: • How health care is provided • How the system works • Outcome: • Health status • Does it make a difference?

16. Proxy Measures • Used when you can’t exactly measure what you want or need • Measure something that is close enough to reflect similarly

17. Information Systems • Can be a valuable tool • Can facilitate quality efforts • Examples: • Databases • Disease registries

18. Convenience Samples • Takes a limited number • Extrapolates to the whole population • Not necessarily randomized

19. QI: Issues in Measurement • Process vs. Outcome • Proxy measures • Information systems • Convenience samples

20. “FADE” Methodology • FOCUS • ANALYZE • DEVELOP • EXECUTE/EVALUATE

21. The FADE model

22. Example 1 The state child health report indicates no well child care is being done in your primary care clinic. What do you do?

23. Quality Improvement vs. Performance Improvement • Quality Improvement focuses on quality of care • Performance Improvement focuses on administrative systems • The goal is improvement in quality

24. The Diagnostic Process

25. Example 2 An audit shows your immunization rate for well children to be 45% What do you do?

26. Evaluation results About 18 months later, your immunization rate is now 82% What would you do now? Is 82% good enough?

27. QI: Rapid Cycle Improvement • EVALUATE • FOCUS • ANALYZE • DEVELOP • EXECUTE • EVALUATE

28. “PDSA” Methodology • PLAN • DO • STUDY • ACT

29. “PDSA” Methodology • PLAN • DO • STUDY • ACT

30. Example 3 Improving a phone message system PLAN DO STUDY ACT

31. QI: Confidential Existing standard of care Improving care No IRB approval needed Research: Publish/present Tests new methods Creating new generalizable knowledge Needs IRB approval QI vs. Research

32. Summary • Improving health care quality is our responsibility • Identify the cause before making changes • Be creative in developing solutions THINK OUTSIDE THE BOX!