Building and Assessing Components for Successful Quality Improvement Programs

1. Building and Assessing Components for Successful QI Programs : The Organizational QI Assessment

2. The Organizational QI Assessment • Quality Philosophy - QI Principles • Elements of an Effective QI Program • Components of a Organizational QI Assessment • QI Infrastructure • Other Key Components • Performing an Initial Organizational QI Assessment • Questions - Discussion

3. Quality Philosophy Infrastructure

4. QI Principles • Performance data lays the foundation for quality improvement • Infrastructure permits systematic implementation of quality improvement activities • Improvements are made through a systematic process involving all staff applying proven QI methods

5. Focus on Systems of Care • Challenges for quality are usually found in processes and systems (and not in individuals) • Changes are sustained by improving processes and systems

6. Elements of an Effective Quality Program • Leadership • Infrastructure • Staff Buy-In • Resources

7. Organizational Assessment Components: • Quality Infrastructure • Quality Performance Measurement • Quality Improvement Activities • Consumer Involvement • Staff Involvement • Service Documentation and Clinical Information

8. INFRASTRUCTURE COMPONENTS • Written Quality Plan • Quality Committee and Teams • Information – DATA

9. INFRASTRUCTURE COMPONENTS, continued • Written Quality Plan • Quality statement (mission) • Annual quality goals • Performance measurement (indicators) • Description of the quality committee • Plan for evaluation

10. INFRASTRUCTURE COMPONENTS, continued • Quality Committee and Teams • Membership roles and responsibilities clearly defined • Meeting schedule • Communication and Documentation tools – agendas, minutes

11. INFRASTRUCTURE COMPONENTS,continued • Information – DATA • System for collecting data on monitored indicators and sharing with staff • Dissemination of regulatory requirements

12. Organizational Assessment Components: • Quality Infrastructure • Is there an organizational structure (Quality Committee) to assess and improve the quality of services? • Does the organization have a written quality management plan? • Who has responsibility for the quality plan? • Is the program area clearly integrated into the quality program or structure?

13. Organizational Assessment Components: • Quality Infrastructure, continued • Which staff is involved? • Does the program or division (depending on the size of organization) have a system in place to communicate with the overall organization about quality? • Does the organization’s leadership support the quality program and activities? • Is there a process in place to evaluate the effectiveness of quality activities?

14. Organizational Assessment Components: • Quality Performance Measurement • Does the Program arearoutinely measure the quality of care? • In addition to externally-required indicators, does the program use additional measures to assess the quality of services? • Are performance measurement findings used to identify and establish quality priorities for the program?

15. Organizational Assessment Components: • Quality Improvement Activities • Does the program routinely conduct quality projects? • Are QI teams structured and supported to successfully address needed improvements within the program area? • Are systems in place to sustain improvements within the program ? • Has the program conducted coordinated quality improvement projects across service areas or with external providers? • Has the program conducted coordinated projects to improve coordination with medical care such as to reinforce the primary care linkage?

16. Organizational Assessment Components: • Consumer Involvement • Does the program routinely seek client input into its quality improvement activities? (e.g. through satisfaction surveys, a consumer advisory board, other methods)

17. Organizational Assessment Components: • Staff Involvement • Is the staff routinely educated about quality? • Does the program routinely engage staff in quality improvement activities?

18. Organizational Assessment Components: • Service Documentation and Clinical Information • Does the program have an information system in place to track patient services? • Does the program have written instructions or guidelines for documenting services &/or collecting data? • How are databases used by the program? (e.g.External Reporting, Service Coordination, Progress Notes, Monitoring Units of Service, Outcomes Monitoring, QI)

19. Performing the Initial QI Assessment: Information Sources • Self-Report • Interview • Document/Systems Review Methods • On-Site • Telephonic • Off-Site Group Process

20. Organizational QI Assessments: Questions? - Discussion - Next Steps