Quality Improvements Steps

1. Dr Bruno Bouchet Regional Quality of Care Director Quality Improvements Steps

2. OBJECTIVE • To implement a logical sequence of activities that will lead to improved quality of care to patients, through identification of issues, understanding of their causes, and interventions to address them.

3. 3 Main Quality Improvement Steps • Express the improvement objective or quality issue to address • Get information • Implement interventions/changes

4. Quality Improvement Methods (1) • Many “small” methods promoted by various organizations • Many acronyms: PI, FOCUS-PDCA, COPE, etc. • Lots of confusing jargon: team-based problem solving, permanent process improvement, reengineering, quality design, rapid improvement cycle, etc.

5. Quality Improvement Methods (2) • The name of the method does not really matter as long as you follow a logical sequence of steps. • All methods have their own little sub-steps and differences but follow the same logic/sequence of 3 main steps: express objective, get information, implement intervention

6. First: Express your Improvement Objective (1) • Identify an opportunity for improvement or a quality of care issue • Criteria: • Frequency (high volume) • Seriousness (high risk) • Difficulty to manage (problem-prone) • Costly (high cost)

7. Criteria: Frequency (high volume) Seriousness (high risk) Difficult to manage (problem-prone) Costly (high cost) Examples: 25% of adult population has arterial hypertension 80% of women with pregnancy-induced hypertension develop eclampsia 60% of patients with myocardial infraction die within the first 48 hours at the hospital 50% of newborns are hospitalized for 2 months for neonatal infections, for an average cost of $2000. Express your Improvement Objective (2)

8. Express your Improvement Objective (3) • Sources of information: • Routine Health Information System • Health Statistics Reports • Performance Monitoring Systems • Supervision/Visits/Inspection System • Health Surveys (DHS, etc.) • Burden of Diseases Surveys • Providers’ opinions • Patients’ opinions

9. Express your Improvement Objective (4) • Examples of general quality improvement objective statements: • To improve the quality of care to adult patients with arterial hypertension • To improve the performance of the healthcare system for women of reproductive age with anemia • To improve the quality of care to children according to IMCI clinical care standards

10. Express your Improvement Objective (5) • Subsequent main steps: • Define what is meant by system performance or quality of care in each particular situation* (health topic, level of the health system, stakeholders’ perspectives) • Identify indicators that would reflect improved quality of care or overall system performance • Setup a Quality Performance Monitoring System *When evidence-based clinical care standards are not available, use common-sense standards for the first improvement cycle

11. Second: Get Needed Information (1) • Identify the information you need: • To know more about the topic for improvement (knowledge of the content of care) • To know more about the magnitude and types of quality issues • To know more about the consequences of poor performance/quality

12. Get Needed Information (2) • Identify the information you need: • To understand the causes of poor performance and factors influencing quality • To identify who is involved in the healthcare system and processes to improve • To know the opinions of the stakeholders on the topic for improvement

13. Get Needed Information (3) • Identify the information you need: • To know more about the current organization of healthcare services for the particular topic • To understand the referral patterns between levels of the system • To identify the components that need to be part of the healthcare system for a particular health condition/issue

14. Get Needed Information (4) • Get the information you need: • Review of existing data (many sources) • Collection of more data (direct observation, review of records, interviews, focus group discussions, inspections) • Through the Quality Performance Monitoring System • Transform data into meaningful information (indicators, qualitative, costs, etc.)

15. Third: Implement Interventions/Changes (1) • Make sense of the information you got • Use the information to suggest/identify interventions • Be creative • Focus on interventions that change/redesign some or all components of the healthcare system involved in the particular topic

16. Consider Interventions as ideas to test, and implement them as an operational research, following the Shewhart cycle: Plan-Do-Study-Act Implement Interventions/Changes (2)

17. A P S D D S P A A P S D Repeated PDSA to increase compliance with standards 3% Performance Indicators 8% Cycle 4: Assessment of providers’ performance 15% 25% Cycle 3: Pharmacist checks relation treatment/diagnosis A P Cycle 2: Define job-aids for IRA S D Cycle 1: Remind IRA treatment standards 30%

18. Chart illustrating the effect of changes on performance Change 3 Change 1 Change 4 Change 2

19. The Overall Management of a Quality Improvement Project (1) • Before the QI steps: • Obtain consensus/agreement • Discuss ideas • Expose stakeholders to Quality management concepts • Planning meeting • Setup different teams • Inform everybody

20. The Overall Management of a Quality Improvement Project (2) • During the QI/Steps: • Reconsider the team composition and needs for new teams • Maintain team cohesion • Facilitate communication • Sustain enthusiasm • Encourage/Motivate • Provide technical assistance • Ensure quality of work processes

21. The Overall Management of a Quality Improvement Project (3) After the QI steps: • Draw lessons and conclusions • Celebrate/reward • Document • Present/Communicate • Replicate, expand changes/results • Institutionalize an improvement dynamic

22. Conclusion • Pilot Quality Improvement Projects in Ferghana have the potential to significantly influence the design of the health sector reform through increasing our knowledge of more effective clinical practices and better organization of healthcare services