Basic Skills Competency Education for New PI Directors

1
Basic Skills Competency EducationforNew PI
Directors Coordinators

• Session One
• January 10, 2007
• Sponsored by MT Rural Healthcare PI Network
• Co-Sponsored by Mountain Pacific Quality Health

2
Session One Learning Goals

• To discuss basic PI theory and history
• To show how PI supports strategic plan
  implementation
• To identify key organization structures for
  successful PI programs
• To describe the different PI program roles and
  responsibilities
• To identify the key elements of a PI Program
  policy

3
Terminology

• Quality Control (QC)
• Quality Assurance (QA)
• Quality Improvement (QI)
• Performance Improvement (PI)
• Quality Management (QM)
• State Operations Manual (SOM)
• Medicare Conditions of Participation (CoP)

4
PI Theory and History

• Dr. W. Edwards Deming statistician
• Reconstruction of industrial Japan post-WWII
• 1947, 1950s
• A management statistical process control
  consultant
• Quality results of work
• total cost

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Demings14 Points for Management (1993)

• Create constancy of purpose for improvement
• Adopt a philosophy of win-win cooperation
• Rely on statistical evidence that quality is
  built into a process, not mass inspection of
  outcomes
• Dont award business contracts based on cost
  alone focus on quality, build loyalty and trust

6
Demings14 Points for Management

• Improve constantly, and forever, the system of
  production, service, planning of any activity
• Institute training for staff skill building
• Adopt leadership aim help people, machines,
  gadgets do their jobs better
• Drive out fear and build trust so people can work
  more effectively

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Demings14 Points for Management

• Break down barriers between departments
• abolish competition between departments
• Eliminate slogans, targets asking for zero
  defects or new levels of productivity
• creates adversarial relationships
• Eliminate numerical goals, quotas and management
  by objectives
• substitute leadership

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Demings14 Points for Management

• Remove barriers that rob people of joy in their
  work
• Institute vigorous education and self-improvement
  program
• Put everybody in the company to work on
  accomplishing the culture transformation
• create a structure from the top down that
  supports pushing every day on the other points.

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Other Quality Movements

• J. M. Juran Quality circles coaches, 1979
• P.B. Crosby zero defects at ITT, 1965-1979
• A.V. Feigenbaum total quality control, 1980s
• Outcomes-based management, 1980s
• Total Quality Management (TQM), early 1990s
• Performance Improvement, late 1990s- JCAHO

10
The Distilled Philosophy

• The performance of any organization can and must
  be continuously improved
• The quality of decision-making improves when it
  is based on objective information
• Team work and cooperation are essential
• To settle for anything less is an unacceptable
  management position.

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PI and the Strategic Plan
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Strategy and PI

• Quality, after all, is not an end in itself, but
• the strategic method that the hospital uses
• to effectively and efficiently perform its
  mission.

Total Quality Management in a Hospital, Wm J.
McCabe QRB April 1992. p 140.
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Strategic Plans

• Customer Needs and Expectations
• Patient Care Systems, Processes
• Hospital Operations

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Strategic Plans

• Customer Needs and Expectations
• Internal Customers direct recipients of work
• Patients their families, staff, medical staff,
  Board
• External Customers indirect recipients of work
• Regulatory surveyors, vendors, community

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Strategic Plans

• Patient Care Systems
• Identification of new health care markets and
  developing the ability to serve them
• Clinical care delivery
• New technology
• Patient safety

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Strategic Plans

• Hospital Operations
• Financial performance
• Building/Environment of Care (EOC)
• Human Resources
• Information Management (EHR, EMR, PHR)
• Materials Management
• Marketing/Community Relations

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Strategic Plans

• Why Should We Care?
• Types of performance data collected
• Data sources
• Measure definitions
• Availability of benchmarks
• Rigor of statistical analysis
• Performance reporting

18
Organization Structure

• For a Successful
• Performance Improvement Program

19
Organization Structure

• What kinds of org structures are needed to
• Ensure everyone is working on same strategies?
• Link strategic and operational goals?
• Clarify responsibilities for PI from top to
  bottom?
• Who is responsible for doing something with the
  data?

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Organization Structure

• Bring the PI approach into all decision-making
  processes (objective, data-based)?
• Provide for the independent and objective
  measurement of performance across the org in
  support of objective decision-making?
• Provide access to needed data?

21
Organization Structure

• Provide the PI Dept/Director/Coordinator with the
  relationships, tools and resources it needs to do
  its work?
• Find opportunities for improvement and work as a
  team to address them?
• Coordinate the plans for multiple PI projects and
  their resource utilization?

22
Common PI Program Structure
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Roles and Responsibilities
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Roles and Responsibilities
Adapted from Health Care Quality Outcomes
Management Aspen Publishers. 1999. pg 145.
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Roles and Responsibilities
Medical Staff/ Director
Adapted from Health Care Quality Outcomes
Management Aspen Publishers. 1999. pg 145.
26
Roles and Responsibilities
Adapted from Health Care Quality Outcomes
Management Aspen Publishers. 1999. pg 145.
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Roles and Responsibilities
Medical Staff
MS Committees P T, IC, Credentialing
Adapted from Health Care Quality Outcomes
Management Aspen Publishers. 1999. pg 145.
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Roles Responsibilities Board

• 485.627(a) C-0241
• The CAH has a governing body that assumes
• full legal responsibility to provide
• quality health care in a safe environment.
• Medical Staff eligibility and appointments
• Medical Staff Bylaws review and approval
• Compliance with State and Federal law, and CoPs

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Roles Responsibilities Board

• Duty to the community (fiduciary)
• Monitors implementation of the strategic plan
• Routinely reviews key measures of hospital-wide
  performance (dashboard report)
• Customer needs expectations
• Patient care systems
• Hospital operations

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Roles Responsibilities Leadership

• Demonstrates its commitment to the strategic
  objectives and PI in its actions and decisions
• Converts strategic objectives into measurable
  operational improvement goals (work plan)
• Customer needs and expectations,
  internal/external
• Patient care systems
• Hospital operations

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Roles Responsibilities Leadership

• Communicates up, down across the org
• Deploys goals to the rest of the organization
• Educates staff and medical staff about PI
• Shares learning from PI projects, successes,
  good tries
• Provides needed resources to do PI
• human, information, time, financial, environment

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Roles Responsibilities Leadership

• Eliminates barriers and empowers staff,
  departments, teams to act to improve
• Routinely reviews evaluates progress
  objectively, making operational and strategic
  adjustments as necessary
• Holds others accountable for achieving
  operational and strategic improvement goals.

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Roles Responsibilities Providers

• 485.631(b)(1) C-0257
• The doctor of medicine or osteopathy provides
  medical direction for the CAHs health care
  activities and consultation for, and medical
  supervision of, the health care staff.

34
Roles Responsibilities Providers

• Time is a physicians most valuable resource,
  and in most cases, it is volunteered.
• Physician time must be directed toward those
  patient care processes in which the physician has
  a personal interest.

Total Quality Management in a Hospital, Wm J.
McCabe QRB April 1992. pg 139.
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Roles Responsibilities Providers

• Evaluate and improve the quality of patient
  diagnosis, treatment and patient outcomes
• Evaluate and improve the quality of patient care
  provided by other members of the medical staff
• Evaluate and improve the quality of other patient
  care services and service providers

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Roles Responsibilities Providers

• Evaluate and improve the quality of the medical
  record
• Evaluate and approve contracted patient care
  services

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Roles ResponsibilitiesQuality Management Team

• Composition Team more than one
• Senior organization leaders
• Department/service heads
• PI Director/Coordinator/staff
• Medical staff representative
• Governing Board member
• Line staff and/or community member

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Roles Responsibilities Quality Management Team

• Conducts the independent assessment of objective
  evidence concerning the hospitals overall
  quality management system
• Is prevention-oriented, proactive
• Is fact-based hard data whenever possible
• Uses continuous assessment and improvement cycles
  to improve all aspects of the organizations
  performance

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Roles ResponsibilitiesQuality Management Team

• Independent Assessment requires the unbiased
  collection of and gaining information from
  relevant objective data about
• Critical system, process outcome measures
  related to strategic and operational goals
• The work of interdisciplinary PI teams
• Department/service-level PI activities

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Roles ResponsibilitiesThe Quality Management
Team

• Assessment always ends with decision-making, a
  plan for moving forward
• Primary team decision-making method is consensus
  manages conflict
• Coordinates resource utilization and allocation
  for PI activities
• Eliminates barriers to improvement

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Roles ResponsibilitiesThe Quality Management
Team

• Educates the organization staff about PI
• Educates the community
• Annual community report
• Periodically evaluates the soundness of the
  organizations approach to quality management
• Annual progress and program evaluation

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Roles ResponsibilitiesPI Dept./Director/Coordi
nator

• Supports the organizations strategic plan
• Provides data for plan development as requested
• Supports the organizations operation work plan
• Provides data for plan development as requested
• Provides leadership and guidance for the Quality
  Management Team (QMT)
• Assists in developing the organization-wide
  approach to performance improvement

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Roles ResponsibilitiesPI Dept./Director/Coordi
nator

• Leads the development and definition of relevant
  measures of performance
• Strategic measures
• Operational measures
• Others
• Independently collects and analyzes objective
  data for use by the quality management team
• Resolves data quality issues
• Independently reports performance

44
Roles ResponsibilitiesPI Dept./Director/Coordi
nator

• Supports and facilitates medical staff,
  department, service and/or PI team efforts to
  improve performance
• Provides PI education and training
• Identifies and requests needed resources to
  support, promote, advance the program

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Roles ResponsibilitiesPI Dept./Director/Coordi
nator

• It is extremely important that quality
  management
• is not assigned solely to this department,
• which has neither the authority nor the
  resources
• to change the system it should not assume,
• or have delegated to it,
• the lines responsibility for managing quality.

Total Quality Management in a Hospital, Wm J.
McCabe QRB April 1992. pg 140.
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Roles ResponsibilitiesDepartments and Services

• Support the organizations strategic plan
• Obtain education about performance measurement
  and improvement
• Gain competence in the use of PI tools
• Process and systems analysis
• Data collection and assessment

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Roles ResponsibilitiesDepartments and Services

• Work cooperatively with senior leaders to
  identify and deploy relevant annual operational
  goals for each department
• Goals may be converted into specific projects
• Leaders provide necessary resources
• A time frame for completion/achievement is
  clearly established

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Roles ResponsibilitiesDepartments and Services

• Responsibility for achieving goals and/or
  completing projects is clearly assigned
• Relevant measures of performance are developed
  and defined for each important goal/project
• Responsibility for regularly reporting
  performance is clearly assigned

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Roles ResponsibilitiesDepartments and Services

• Work cooperatively with other departments,
  services and staff to improve performance
• Discuss progress and performance data with
  leaders regularly
• Discuss progress and performance data with
  department staff regularly

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Roles ResponsibilitiesDepartments and Services

• Educate staff about PI
• increase staff competence in the use of PI
  methods and tools
• Identify and remove improvement barriers
• Celebrate successes and great tries
• Commit to continuous improvement

51
PI Program Policy or Plan
52
PI Program Policy/Plan

• Three key components
• Policy statement
• Purpose of the program
• Procedure, or approach, for implementing the
  policy

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Policy Statement

• States that the PI Program exists and why
• XXX Hospital will maintain an effective
• performance improvement program to
• continuously evaluate and improve the quality and
  
• appropriateness of patient care services and
  other
• services affecting patient health and safety.

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Policy Statement

• If focus is only clinical quality and CAH regs
• XXX Hospital will maintain an effective
• quality assurance program to continuously
• evaluate and improve the quality and
• appropriateness of the diagnosis and treatment
• furnished in the CAH and of the treatment
• outcomes.

SOM, May 2004 485.641 (b) C-0336
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Purpose Statements

• Identifies the few, critical functions of the
  program
• To evaluate the quality and appropriateness of
  diagnosis and treatment, and treatment outcomes
• To identify and resolve patient care, health
  and/or safety problems

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Purpose Statements

• To proactively identify and resolve patient care
  and/or safety problems or concerns
• To improve patient, family and community
  satisfaction with XXXs services
• To improve effective resource utilization
• To ensure appropriate remedial action is taken
  to address deficiencies

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Procedure or Approach

• Describes in detail how the program works
• The level of detail is sufficient so that someone
  who is unfamiliar with the program could do it
• Often begins with describing program scope
• Who some staff? all staff? medical staff?
• What some services? all services?

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Procedure or Approach

• Describes specific roles and responsibilities
• Individuals ultimately responsible for the
  quality of care provided (Board)
• Who implements the program on behalf of the Board
  (CEO or Administrator)
• Who is responsible for directing and improving
  medical care (Medical staff)

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Procedure or Approach

• Describes specific roles and responsibilities
• What the PI Director/Coordinator does
• What the Quality Management Team does
• What Department/Service Directors do
• What all staff do

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Procedure or Approach

• Describes the data to be collected
• Regulatory requirements
• All patient cares services and services
  affecting patient health and safety
• PI team work
• Strategic and operational work plan objectives

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Procedure or Approach

• Describes the method of improvement the
  organization will use
• Plan, Do, Study, Act or Plan, Do, Check, Act
• Six-Sigma
• Rapid Cycle Improvement
• Quick fixes
• Heads up surveyors frequently ask staff about
  this to see if they are familiar with it, have
  been trained in using it

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Procedure or Approach

• Describes how data is collected, aggregated,
  assessed and performance is reported
• Describes how priorities for improvement are
  selected
• Describes how multi-disciplinary PI teams are
  requested, authorized and monitored

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Procedure or Approach

• Describes how the organization responds to
  sentinel events- who does what and when
• Describes how the effectiveness of the PI Program
  will be evaluated and improved
• Describes how an annual evaluation of the CAH
  Program will be conducted
• SOM 485.641 C-0330 through C-0335

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Key Points

• Performance Improvement is a strategic approach
  to organization management
• It exists to support the fulfillment of the
  organizations mission by linking strategic goals
  to operational plans and continuous cycles of
  performance improvement
• It must be adopted and supported by the
  organizations leadership to be successful

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Key Points

• Its scope covers all aspects of the
  organizations services, departments, functions,
  people, planning
• Decisions about how to improve are primarily
  based in team members coming to consensus
• based on hard, objective data that is analyzed
  using valid statistical methods

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Key Points

• All members of the organization, from the Board
  to the line, are held responsible for
  continuously improving performance
• It has the capacity to permeate the organization
  with a culture of continuous learning,
  cooperation, collaboration, celebration and
  substantive improvement

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Session One References

• Health Care Quality Outcomes Management
  Gulledge,J Haught, L. Aspen Publishers, Inc.
  Gaithersburg, MD. 1999.
• State Operations Manual, rev. May 2004.
• Total Quality Management in a Hospital. McCabe,
  WJ. Quality Review Bulletin April 1992 pg
  134-140. JCAHO.

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Questions?

• Sponsored by MT Rural Healthcare PI Network
• Co-Sponsored by Mountain Pacific Quality Health