Quality Improvements Steps

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Quality Improvements Steps

• Dr Bruno Bouchet
• Regional Quality of Care Director

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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.

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3 Main Quality Improvement Steps

• Express the improvement objective or quality
  issue to address
• Get information
• Implement interventions/changes

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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.

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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

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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)

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Express your Improvement Objective (2)

• 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.

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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

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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

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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

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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

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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

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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

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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.)

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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

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Implement Interventions/Changes (2)

• Consider Interventions as ideas to test, and
  implement them as an operational research,
  following the Shewhart cycle Plan-Do-Study-Act

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Repeated PDSA to increase compliance with
standards
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Performance Indicators
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Cycle 4 Assessment of providers performance
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Cycle 3 Pharmacist checks relation
treatment/diagnosis
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A
P
Cycle 2 Define job-aids for IRA
S
D
Cycle 1 Remind IRA treatment standards
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Chart illustrating the effect of changes on
performance
Change 3
Change 1
Change 4
Change 2
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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

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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

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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

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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