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NAHQ: Foundation

Q solutions module one and 5, 80% test of Foundations, tools and techniques
Quality Management Philosophy: Healthcare quality is the extent to which health services provided to individuals and patient populations improve desired health outcomes (Institute of Medicine). How do you if you have achieved quality? How do you measure? Difference between quality assurance and quality improvement is quality assurance gets rid of the bad apple; quality improvement makes a system better. Total quality is an attitude, an orientation that permeates an entire organization and the way the organization performs its internal and external business. Total quality management is how we do things, the way we do things; it is the culture of quality. Total quality management says if we are going to define quality, these are the things that are important. Total quality permeates the entire organization. Performance assessment: Quality improvement (QI), early 1990s; total quality management (TQO)/QI; a collaborative culture that focus on processes, quality defined by customer, reduction in variation and focus shifted to systems and processes. Quality is what the customer says it is Quality reduces variation by making sure it all fits Quality reduce the steps to get it right Quality starts at the top Demings 14 points : why we do the things we do involve workers Current and evolving approaches: Six Sigma which uses statistical analysis to measure and improve performance with elimination of errors in processes, normal distribution (Bell-shaped curve) of errors and six standard deviations from the mean (only 3.4 defects per million opportunities). Six sigma requires a lot of measuring; some things are hard to measure in health cares because people are involved. Current and evolving approaches: Lean enterprise which emphasizes reducing waste and focusing on activities that add value for the customer as applies value stream analysis, eliminates waste, makes changes in a short period of time and uses crossfunctional team. It uses macro flow charts and does it fast, has a lot of pre work, than applys six sigma to it to see if it worked.

Current and evolving approaches: Rapid cycle improvement which identifies and prioritizes aim for improvement and gains access to methods, tools and materials for evidence-based QI. Everyone shares in resources.

Focus on Patient Safety Elimination of medical errors with creating a safe environment, improving clinical patient safety, analyzing where and how patients are at risk and intergrading risk management. Blame free culture on reporting errors, however, now has shifted to a fair and just culture: know that good people make mistakes and good people do work a rounds to get things done faster,,, worst thing not to do in a fair and just culture is not report. It is a must to find out what is putting people at risk.

IOM Priorities for patient Safety: Patient safety and harm To Err Is Human: building a safer health system (2000). There is a direct relationship between quality of care and patient outcomes. There are three types of quality issues: Underuse of care, overuse of care and misuse of care (errors). Establish Safety Goals with establish patient safety as a visible commitment to the philosophy of putting patients first, move from blaming people to improving processes, improve use of technology to prevent and detect error and use data to identify and measure improvements. This is why it is important for people to report near misses or mistakes so processes can be looked at. Performance problems as safety issues; focus on the issue or error, not the outcome, interpret the error (intentional or unintentional?) and identify contributing factors. As example for medication error, look at the entire case, not just the outcome. What were the mitigating factors; MD order, order carried and patient circumstance. Approaches to improving safety: improve medication practices, improve emergency services, improve workplace safety and prevent nosocomial infection. Focus on Patient Safety with Structure: facility design, supplies and policies and procedures. Environment assessment as with lighting, surfaces, temperature, noise levels, storage and ergonomics. In regards to equipment and technologies with examination of labels, instructions and safety features. Processes, evaluation of whether or not redesign would improve safety as with complexity, inconsistencies, time constraints and amount of human intervention (lack of automation). People as with complexity, attitudes and motivation, health, education and training and cognitive functioning (is everybody functioning at the level they should be). Leadership and culture as with the willingness to allocate resources, analyze processes, implement changes, support non punitive error reporting and promote evidence-based practice. Leadership must support safety just as they need to support quality.

Steps to creating a safety culture: recognize that leadership owns the culture whether the leader wants to or not, have a clear vision of the culture required (everyone is on the same page), compare where the organization is to its stated values and goals, create tools to reinforce the behavior and culture desired and link culture and performance review every year. Patient safety program consist of patient safety officer, program development and coordination, link with strategic planning, link with quality management, risk management, information management and infection control, structure and mechanism for program coordination (across the organization as with hand hygiene program). Patient safety program continued with communicating with patients about safety, safety education, program goals (consistent with organizations mission), scope of the program, safety improvement activities, definition of terms (for comparison, no apples to oranges, everyone knows the same definition) and prioritization of improvement activities. Patient safety program continued: routine safety data collection and analysis that includes; incident reporting, medication error reporting, infection surveillance, facility safety surveillance, staff perceptions of patient safety and suggestions for improvement, staff willingness to report errors and patient and family perceptions of patient safety and suggestions for improvement. Patient safety program continues with identification, reporting and management of sentinel events with proactive risk reduction, identification of high-risk processes and failure mode, effects and criticality analysis. Reporting of results goes to the safety program, organization staff and to executive leadership and the governing body. Sample of events to report: suicide, infant abduction or wrong discharge, rape, hemolytic transfusion reaction, wrong site surgery, falls, medication error, adverse drug events, missing patients, major loss of function and death. Role of external reporting: allows lessons to be shared so others can avoid the same mishaps, can lead to improved safety, sends alerts about new hazards generated, allows sharing of information about experience of individual institutions in using new methods to prevent errors and reveals trends and hazards that require attention and leads to recommended best practices. Principles for safer health care: Human factors. Process includes simplify work processes and standardize procedures, reduce reliance on memory and vigilance, use checklists and trigger tools, use constraints and forcing functions (will not dispense med to give med to pt. due to allergy), eliminate look- alike/sound alike names, provide education and training, eliminate design failures and use technology appropriately.

Principles for safe health care: Human factors continued. Organization includes increased feedback and direct communication, make rounds, emphasize teamwork and crew resource management, drive out fear of reporting, solidify leadership commitment and safety culture, provide training to staff, make environmental adjustments and adjust work schedules. Confidentiality principles (think in general, HIPAA will not be on exam) Confidentiality: organizations are required by state and federal statutes to maintain the security, integrity and confidentiality of patients personal data and other information and, organizations, must protect records against loss, defacement, tampering and unauthorized use. Effective confidentiality policies include: identify individuals with access (who needs it), delineate accessible information, keep information confidential, specify conditions for release of information, specify conditions for removal of medical records, protect personal health information (PHI is a HIPAA thing, not on test), establish a policy for handling root cause analysis (RCA) and establish mechanism for securing information. Medical records confidentiality: Health care facilities must maintain adequate medical records as the basis for planning care and communicating, have clear policies regarding access to records and preserve confidentiality (in US only accordance with physicianpatient privilege and the Patients Bill of Rights). Information security Methods include: separate storage of some portions of medical records, restricted access to computer files, adequate backup plan and firewalls for computer applications and requirement of signed forms for release of information. Release of Information: release without written authorization (as regulated by national and state statue) may include; governing body representatives (governing body is responsible for everyone and everything), the organization director, healthcare personnel (taking care of the pt.), quality improvement staff and health information management staff.

Credentialing Process. Two part process used for; one, appointments and reappointments (yes, you can work here and we will see at a later date if you can still work here) and two, granting, renewing and revising clinical privileges (while you are working here, you can do only this type of work). Organization credentials applicants using clearly defined process. Credentialing process based on recommendations by organized medical staff. Credentialing process approved by governing body. Credentialing process outlined in the medical staff bylaws. Clinical Privileges may by defined several ways and categorized by practitioner specialty, level of training and experience, patient risk categories, list of procedure or treatment and any combination. Reappraisal: conducted at time of reappointment to medical staff or renewal or revision of clinical privileges and it is based on ongoing monitoring of information. Includes

confirmation of adherence to medical staff membership requirements, rules and regulations and policies, considers relevant practitioner-specific information (often collected by quality department) and considers results of peer review and other performance evaluation. Credentials files. Credentials files contain clear evidence that the full range of privileges has been included in reappraisal, particularly privileges for performing high-risk procedure and treating high-risk conditions and the information needs to be substantive and practitioner specific. Credentials files continued. The effectiveness of the reappraisal process may be measured by objective documentation that the individuals privileges were increased, reduced or terminated because of assessments of documented performance (often quality job), nonuse of privileges for high-risk procedure or treatment and emergence of new technologies.

Medical Peer Review; Definition: medical staff involvement in measuring, assessing and improving performance of licensed practitioners. Method for selecting peer review panels for specific circumstances: setting time frames, establishing circumstances requiring external peer review and providing for participation by individual whose performance is being reviewed. Peer reviewed continued: Medical staff must be involved, outcomes and processes should be measured (performance is being measured), performance in relation to design of processes and expected or intended outcomes should be assessed and individuals with clinical privileges whose performance in questioned as result of QI activities should be evaluated. Peer review process should: have consistency and conducted according to defined procedure, defensibility as conclusions reached through the process are supported by a rationale and balanced as minority opinions and views of the person being reviewed are considered and recorded. Effective peer review process included: activities are conserved in reappointment process, tracking of conclusions from peer review is done over time and actions based on conclusions are monitored for effectiveness. Findings, conclusions, recommendations and actions are communicated to the appropriate entities, recommendations to improve performance are implemented and physician leaders have a role in improving clinical processes used for clinical privileging. Documenting Peer review: medical records are highly confidential, policies and procedures define access and circumstances, legal representative is consulted, state laws govern peer review, peer review files are marked confidential and minutes are usually protected.

Practitioner Profiles (quality most involved with): profiles are based on performance, profiles are provided to each physician or provider on a regular basis, organizations may use risk-adjusted software, evidence-based medicine determines metrics used and data are timely and accurate. Physician Profiles; profiles are process focused, physician data are grouped by specialty type or specific diagnoses, data are reported regularly and physician champions talk directly with medical staff bout numbers. Physician data: data are meaningful to physicians, data represent major service lines and patient safety issues and include outpatient data, national targets and benchmarks are used, data are easily accessed and used and profiles vary according to physicians specialty or area of practice. Examples of physician profiles: patient volume, length of stay, average length of stay, diagnosis-related groups, average cost per case, conformity with system wide initiatives, legibility of records, use of unapproved abbreviations, death or loss of function and unexpected ICU transfers. Profiles will be on test. Profile confidentiality: develop a mechanism to track activity, use a log or sign out sheet (date of request, reason, and name of person reviewing, pertinent notes), establish circumstances for copies in policies and procedures and develop a mechanism for release of information.

Utilization review. Internal review includes policies and procedures to ensure confidentiality during medical record review process and patients to be informed of policies and procedures related to utilization management. External review is by telephone review or on site reviews by external agencies. Quality management is not research. QI includes: identify process improvement, survey, literature and construct flow charge of process, define customers and problem then formulate a plan, draw conclusion, act upon recommendations deduced from conclusion, continue to monitor, evaluation and communicate conclusion, hold the improvement. The difference is how rigorously you collect data. QM and Research Continuum. Underlying assumptions of design, measurement, and interpretation are the same. The level of research rigor that best answers the questions is used, balancing rigor and practicality. Research requires more in depth study.

Information Management. Quality information system consists of identify who needs to know, determine what information they need and develop a system whereby right people receive right information at right time in the right way. QM information: healthcare data must be carefully defined and systematically collected and analyzed, tremendous amounts of healthcare data and information are available and mature QI information revolves around clearly established patterns of care. Most quality indicators are useful only as indicators of potential problems, not as definitive measures of quality. Multiple measures of quality need to be integrated, using outcomes information without monitoring the process of care is inefficient and cost and quality are inseparable. Decision support: helps in making comparison with competitors, identifies practitioners and providers who meet acceptable levels of quality, allows providers to respond rapidly to market changes, justifies pay for exceptional performance and used to develop outcomes information management plan. Decision support continued; analyzes and interprets outcomes data, chart-based system as with medical records reviewed by analyst and severity and risk-adjusted information identified (NSQIP). OR by code based system which is based on retrospective administrative data, uses clinical information spanning entire stay, and has lower cost and larger sample size and submission of payer data deemed public information required by states. Code based cheaper but not as detailed as chart based. Decision support continued: Identified positive and negative outcomes, includes risk/severity adjustment data, facilitates cross-functional analyses and integrates clinical and financial data.

Risk adjustment: takes into account the fact that different patients with the same diagnosis might have additional characteristics or conditions that could affect outcomes. Some systems define differences between risk adjustment and severity Risk adjustment methodologies apply to binary (yes/no) data (count data) whereas severity adjustment methodologies are applied to cost or length of stay data (continuous data). Exam uses Risk adjustment and severity interchangeably. Both raw and risk adjusted data can be available for outcomes. Handling of outliers requires a consistent approach (stick with the same decision, do you throw it out or keep it, do you want to leave it in your data) and the best system includes every patient, practitioner and payer. Benchmarking vs. Comparison. Benchmarking identified processes and results that represent best practices for similar activities inside or outside the healthcare industry and uses an ideal reference point. Comparison measures processes and results against a reference point either internally or externally with competitors and other organizations providing similar services. Both Comparison and benchmarking results should be interpreted.

Benchmarking involves asking the right questions: what is the best practice, what are we doing, how are we doing it, how well are we doing it, what are the measurement results and why are we looking for improvement. Benchmarking is an essential part of clinical pathway development. Benchmarking enables organization to set target or goal for process improvement (PI) activities and uses various data sources as in the government, large healthcare alliances, peer review organization and for-profit data base companies.

Evidence Based Practice medicine is the conscientious, explicit and judicious use of current best evidence in making patient care decision. Evidence-based practice promotes patient safety through the provision of effective and efficient healthcare. Third party payer states why should I pay for it if it is not based on evidence based practice.

Interpret and utilize information: Step 1. Planning and organizing: anticipate barriers, identify responsibilities, lay ground work for multidisciplinary collaboration. Develop data dictionary, everyone needs to know what they are collecting and for what. Step 2. Verifying and correcting; identify data limitations, you can only get the data you can get. Step 3. Identifying and presenting findings: how does data compare with data from other organizations, what is the trend over time, how are data likely to be interpreted, is there an opportunity for improvement, who should receive the data and for what purpose. Step 4. Studying and developing recommendations; perform variation analysis, look at data and ask what are we going to do with this data, what does it say, review additional data , do you need more data to see a picture, conduct retrospective medical reviews and perform process analysis. Step 5. Taking action. Empower teams to make decisions and implement changes based on information discovered by the data analysis, educate and train staff, report findings, make necessary changes in policies and processes and implement changes in practice patterns. Does the action match the problem? Step 6. Monitoring performance. Have proposed changes actually been implemented? How could compliance with changes be enhanced, what effect are changes having on patient outcomes and should changes be modified and then tested further, tested longer or ended? Step 7. Communicating results. Barriers to interpretation and utilization of information: human, statistical and organizational.

Specific Quality Improvement reviews which are: Medication usage review, medical record review, peer review, Patient advocacy (e.g. Patient rights, ethics) and service-specific review (e.g. Pathology, nursing, pharm). Organizing information (committee meetings) which are: lay foundation with good background, prepare productive agenda, construct pre -meeting checklist, run meeting correctly as make sure items are consistent with strategic plan, focus on helping day-to-day business, consider resources, consider ethical implications and allow time for follow up and evaluation. Data helps leaders assess progress toward mission and values, understand changes, develop a vision and evaluate program achievement, prioritize strategic goals, judge progress toward strategic goals, weight long -term and short-term financial viability, assess the impact of budgetary decisions, monitor aspects of organizational performance and take corrective action, understand mechanism for physician appointment and credentialing, make individual credentialing recommendations, determine goals regarding community, evaluate effectiveness of programs, defend organizations resources, efficiency and effectiveness and help governing body evaluate and improve its performance. The governing body is responsible for everything. Information systems, clinical information systems support direct care processes (e.g. Pt. monitors), administrative support systems aid day-to-day operations in healthcare organization (e.g. Budget) and decision support systems deal with strategic planning functions. Implementation. Evaluating systems: allow capture, storage and retrieval of clinical and financial information from variety of sources, interface with existing systems, allow triggers or thresholds, send critical alerts (e.g. Abnormal labs), allow rules-based processing and are flexible, support accreditation requirement, aid data mining reporting (getting data out that has already been collected), statistical analysis, allow multiple users access, have an open operating system (anything will go into it), have networking capabilities, display data graphically, provide for drill-down analysis and allow accessing of report via website. Buy or build? Factors to evaluate: In-house expertise, data processing/QM staff, staff provision of documentation, training, support and ongoing maintenance and plan to be implemented if staff member leaves, expertise to build with broad picture in mind, resources available to keep updated, dedicated time of programmer or coordinator, benefits to joining vendor network and cost benefit analysis. Data and data management. There are two types of data; measurement or continuous and count or categorical. There are different sampling method, data collection and analysis for each type.

Are you using the right tool for evaluating the right data? Count or categorical data : Things that are counted which is used a lot in Quality like number of admissions, deaths and births. Nominal, which is counted, discrete, qualitative and attributes. Binary (which is nominal), which is a specific kind of count data, has only 2 possibilities (e.g. male or female). Ordinal, are categories in ranked order. Examples of Nominal Data: counting things where order does not matter Normal Value Surgical Patients Values Pre-operative Post -operative Patient education Attended video Did not attend video

Ordinal data: counting things but order makes a difference Ordinal data Values Nursing staff rank Nurse level 1 RN Nurse level 2 LVN Nurse level 3 NA Education PhD MA BS

For the exam think of nominal data and continuous data. Continuous data: measured on scales that theoretically have no gaps, variables data. There are 2 types of continuous data, Interval data: like the distance between each point is equal (e.g. height, weight, temp) and Ratio data: like the distance between each point is equal, but there is a true zero (like money, it is a true zero, dont have any, you dont have any). Continuous data continued: Measurement or continuous data could be converted to count or categorical data. Critical issue is whether right data are measured or counted. Most QI data readily available are analyzed because they are easy to retrieve. Measure data is better data. Statistical Power: Categorical (count) data have the least statistical power. Continuous (measured) data have the most power and need fewer data points.

Data Collection: constructing a data collection plan determine who, what, when, where, how and why. structure design-choose and develop sampling method. determine and conduct training. delegate responsibilities. facilitate coordination. forecast budget. conduct pilots. Basic Sampling Designs. Population (N)- total aggregate or group. Sample (n) - a portion of the population. Sampling provides a logical way of making statements about a larger group and allows quality professionals to make statements or generalize from the sample to the population. Two types of sampling designs: Probability sampling -every element in the population has an equal or random chance of being selected. Most common way is simple random sampling. Simple random sampling - each individual in the sampling frame (population) has an equal chance of being chosen (e.g. Put all names in a hat and pick from hat) Systematic sampling- after random selection of first case, every nth element from a population is drawn (e.g. from a list, pick every fourth name, there is a system to this) Stratified random sampling - population is divided into strata, each member of the strata has equal probability of being selected (e.g. list of people, divide list in to male and female (the strata), than do random selection). Cluster sampling - population is divided into groups or clusters to drive random sample (e.g. List of people, divide in groups, than do random selection). Nonprobability sampling: it is not possible to estimate the probability that every element has been included. Nonprobability sampling- convenience sampling, pick anyone you want. Any available group of subjects is used (this lacks randomization). Snowball sampling- subjects suggest other subjects (subtype of convenience sampling). Purposive or judgment sampling- particular group is subjectively selected based on criteria. Expert sampling- experts in a given area are selected because of their access to relevant information (same specialty). Quota sampling a judgment is made about the most representative sample. All nonprobability samples are examples of not given everyone a chance of being chosen. There is no randomization.

Sample size. A larger sample yields a more valid and accurate study and a larger sample yields a smaller standard error of the mean. Regardless of shape of original population distribution, as sample size increases, shape of sampling distribution becomes normal. With a sample size of at least 30, sampling distribution appears almost normal; no perfect minimum sample size exists, power analysis determines appropriate sample size. In general, need to have 30 data points to get to where you will see an outlier. Data analysis reporting: report and analyze data regularly validate accurate data collection display data in easily understood format provide a brief summary of data and analyze variances identify unexpected patterns. Data analysis context: provide background supply graphs and tables report summarizing values identify removed outliers include time order. Data analysis variation in process performance: use SPC chart (Strategic Process Control chart, there are software programs for this) analyze random and common-cause variation look for special cause variation identify trends and initiate investigation to determine the cause of a trend. Statistical Analysis and interpretation: Measurement tools (what to use to measure, try to use a tool that has already been established). Measuring tools must be reliable. Reliability is the extent to which an instrument yields the same result on repeated trials. Reliability coefficient is the stability of an instrument (should be >70 or otherwise stated as .7) test/retest, split-half (even number questions are compared with odd number questions) and reliability by equivalence. Interrater reliability is the likelihood that two raters will assign the same rating. You have to start with reliability, if the tool is not valid, it does not matter if it is valid.

Statistical analysis and interpretation continued: Validity. Content (face) validity (know this for test) is the degree to which the instrument adequately represents universe of content. (e.g. An expert looks at the test and says its ok, its valid). Construct validity is the degree to which the instrument measures the theoretical construct or trait it is designed to measure. Criterion-related validity is the degree to which the score on instrument is related to a criterion. Concurrent validity is assessed when the criterion variable is obtained at the same time as the measurement Predictive validity is assessed when the criterion measure is obtained at some future time. Statistical Techniques. Measures of central tendency describes the clustering of a set of scores or values of a distribution; central refers to the middle, tendency refers to the trend, how alike the scores are. Mean: average. Most commonly used measurement, most sensitive to extreme scores and used with interval, ratio, ordinal (continuous measurement) data with normal distribution. (e.g. Add up the items, zero counts as a number in this, divide the answer by the number of items. Median. The measure that corresponds to the middle score, does not take into account quantitative value of individual scores. (e.g. to determine the median, arrange values in rank order, if number of values is odd, count up to and down over to the middle value, if the number of values is even, compute mean of two middle values.) Mode. The score of the value that occurs most frequently and is the easiest to determine. (e.g. calculated quickly and easily as it is the values that comes up the most in the series of values, it tends to be unstable and describes typical values in nominal data). Measures of variability. Measuring of variability that is measuring how things are dispersed. Range; the difference between the highest and the lowest score. Reported as values, not distance (e.g. if the test scores range from 60-98, you would report the range as 6098, NOT 38) and provides quick estimate of variability, it is unstable. Standard deviation (SD). Most frequently used statistic for measuring degree of variability. Standard is the average spread of scores around the mean and the deviation is how much each score is scattered from the mean. SD continued the greater the spread of distribution, the greater the dispersion or variability from the mean. the more values cluster around the mean, the smaller the variability or deviation. all scores are taken into consideration.

SD is used with normally distributed interval or ratio data and a normal distribution is a standard bell curve.

Standard Bell Curve SD -1 = 68.3% -2 = 95.4% -3 = 99.8% Not likely on test Interpercentile measure: Interquartile is a range extreme scores are excluded only middle cases are used measures line up in order of size and divided into quarters (e.g. Growth charts 25-75%)

Comparing one set of counting data with another, use Chi square Comparing one set (comparing difference of to means) of continuous or measured data, use T test Chi Square compares observed frequencies to expected frequencies ex: Is the distribution of sex and voting behavior due to chance or is there a difference between the sexes on voting behavior? t-Test looks at differences between two groups on some variable of interest the t-test must have only two groups (male/female, undergrad/grad) ex: Do males and females differ in the amount of hours they spend shopping in a given month? Parametric tests. T test is used to analyze the difference between two means (scores) when determining whether difference between two group means is significant, e.g. Compare group who had education on a subject to those who did not have education on same subject or, comparing a pretest to a post test. Regression analysis is based on statistical correlations, associations among variables. Simple linear regression, one variable (x) used to predict second variable (y). e.g. Weight to predict height. Multiple regression analysis estimates effects of 2 or more independent variable (x) on dependent measure (y). Always measuring dependent variables.

Chi square, most seen in quality, measures statistical significant of a difference in proportions. In quality, we count things, dont measure, it is the easiest statistical test to calculate manually. Chi square example: 15 of 30 males (50%) and 10 of 40 women (25%) missed appointments. Referent rate (RR devide total number of males or females by the number of those that showed will give you the precent) 0.5 divided by 0.25 = 2. Men are twice as likely to miss appointments; could this have happened by chance? Null hypothesis is that men and women fail to show up for appointments at the same rate (RR = 1). Chi square indicates likelihood of noting a twofold difference in missed appointments. Chi square value = 5.84, corresponds to significance (p) value of <.02 (fewer than 2 out of 100); 2% probability difference is due to chance. SO, take 50% of men who missed appointments and divide by the 25% of women who missed appointments, you come out of a reference rate of 2. Look up Chi square with the data you have which will give you the P value. P is less than .05 results are significant. Confidence intervals (CI) provides a range of possible values around a sample estimate (best guess about true value). It has been observed that men are twice as likely as women to miss appointments. 95% CI around RR (referent rate) of 2 is 1.27 3.13; there is 95% certainty that men are between 1.27 and 3.13 times more likely to miss an appointment; 90% CL is 1.44-2.77. The larger number of your sample, the large the spread for CL. Level of significance (p value) gives the probability of observing a difference as large as the one found in the study when there is no true difference (when the null hypothesis is true). Historically, when p values < .05, results are statistically significant. P value for missed appointments = .02. Process improvement tools (PI tools) Decision making tools: Stratification chart show differences with data How to construct examine process to identify biases, enter data on collection forms and look for patterns, Alternate tool: IS/is not matrix. PI tools continued: Histogram or bar chart frequency distribution tool for one value; plotting points shows center and spread of data; measurement on x axis; frequency n y axis. 25 data points, rank smallest to largest, subtract smallest from largest. Estimate number of bars (square root of data points). Divide range by number of bars for width. In a histogram, the bars have to touch.

Pareto diagram displays series of bars with tallest bar representing the most frequently occurring issue. Identify independent categories and way to compare them. Rank the order in descending categories. Calculate percentage of total each category depicts. In the Pareto diagram, the bars have to touch. Scatter diagram or scatter plot- used to determine extent to which two variables relate to one another (correlation), collect 25 pairs of data for two variables, plot paired sets of data.

PI tools continued, Analysis: Root cause analysis (RCA) is a systematic process aimed at finding the basic problem (root cause) and taking action to correct the problem. RCA ask why 5 times RCA- must be identified when variation is inherent in process Identify potential causes, verify potential causes by collecting data, analyze data utilizing tools to determine actual causes or most probable causes and develop and implement action plan. RCA factors to address in analysis. Human factors as communication and information management systems, human factors as in training, human factors as in fatigue and scheduling, environment factors, equipment factors, rules, polices, procedure and leadership systems and culture.

Failure mode and effects analysis (FMEA) is a systematic method for reducing risk before an event happens.

RCA is when the plane has already crashed, FMEA is when you look at the plane before it crashes to prevent it from crashing.

Decision making tools: Cause and effect tool: Ishikawa or fishbone diagram which is used to analyze and display potential causes of a problem (after the fact) used to identify potential causes to make something occur (before the fact) and it uses common categories. Cause and effect, Ishikawa diagram: Determine effect or label and place on far right, draw horizontal line to the left, determine categories (Method, Manpower, Material and Machinery or use 5 Ps), draw diagonal line for half of categories above and half below the line, organize each of causes on each bone and draw branch lines for relationships. Good tool to use with brain storming.

Prioritization Matrix selects the appropriate format, determines relationship symbols and creates matrix and indicates relationships. What you want to do on the left then the what needs to be taken into account (like cost, priority, concerns) goes on the top. Flow Chart or process flow chart: can help figure out what your process is - select the process, determine beginning and end, place first steps in an oval, place each of the next steps in a rectangle, if a decision is made describe it in a diamond, decision loop reenters process and place last step in an oval. Statistical process control control charts and types of variation which are common cause variation which are the points between control limits in no particular patter and special cause variation which are points outside limits that exhibit special patterns. Run or trend chart; line graphs that display data points plotted over time. Use run charts with categorical data that are being examined over time. Data are kept in time order and charts make it possible to see flow of data from one point to the next. Run chart analyze run charts using rules for determining statistically important events: Rule 1 six or more consecutive points either all above or all below the median, Rule 2 five points all going up or all going down, rule 3 number of runs above and below the median and rule 4 data that are obviously different values. Balance Scorecard views organization from multiple perspectives and there are four perspective of measurement: Financial, customer, internal business processes (are we meeting goals) and learning and growth. Pick out several strategic objectives for each of the four perspectives, each objective should have at least one objective measure, then define as structure, process and outcome (indicator). Indicators are on the exam; is it structure, process or outcome. Balance scorecard findings are presented to governing body. Balance scorecard example: Strategic Goals Be recognized as A number one facility Establish a program for Chronic illness Strategic Objective for Goals Hire skilled staff Obtain community technology

QUESTION and ANSWER


1. What part of a job description should be used in a criteria-based performance evaluation? Question is asking about of job description, need to know what the parts of a job description are. Also need to know what a criteria based performance evaluation is. The evaluation is going to be based on what the person does. Need to look at the job description to know what the person does. Answer options are: salary grade, duties and responsibilities, working conditons or qualifications. Answer would be duties and responsibilities as those are the criteria on the job description. Qualifications might help you obtain a job but has nothing to do about how you do the job. 2. Which of the following monitors provides patient outcome information? Looking for what the monitors are and what are patient outcomes. Answer options, nosocomial infection rate, degree of compliance with nursing documentation, degree of compliance with renewal of antibiotic therapy or equipment malfunction rate. Answer is nosocomial infection rate as the monitor of nosocomial infections provides outcome patient data. The degree of compliance with nursing care documentation is not a patient outcome (this is really a process), degree of compliance with antibiotics renewal is again not a patient outcome and equipment malfunction rate is an outcome but not a patient outcome. 3. The following represents two samples of 5 hospitals hysterectomy rates per 1,000 women 40-6- years of age. Rates Mean Standard deviation Sample A 3,5,7,8,5 5.6 1.8 Sample B 4,5,6,7,5 5.4 1.1 Answer options; sample A has more variability than sample B, Sample As performance is superior to sample B, there are more cases in sample B and there is a data collection error in sample B. In analyzing this information, it can be concluded that sample A has more variability than sample B as the larger the SD the more variability. There is no performance outcome data. With the numbers provided, there is no indication of how many cases was done for each sample, you have rates, but no case numbers. There is no information of data collection in either sample, you do not know how the data was collected. 4. The primary benefit of adopting a countrywide or global uniform set of discharge data is to Answer options: facilitate computerization of data, validate data being collected from other sources, facilitate collection of comparable health information and assist medical records personnel in collecting internal data. Facilitating computerization would help but, validating data has nothing to do with set of discharge data, correct answer is facilitate collection of comparable health information as if everyone is discharging with the same data codes, the information can be compared.

5. A surgeons wound infection rate is 32%, further examination of which of the following data will provide the most useful information in determining the cause of this surgeons infection rate? Question asked why this surgeon rate 32kind of high is. Answer options: Mortality rate, facility infection rate, use of prophylactic antibiotics and type of anesthesia used. No mortality as you dont know whos mortality it is, is it the surgeon or the hospital, not defined, facility infection rate does not tell you anything about the surgeon, no connection between anesthesia and infection rate,, answer is prophylactic antibiotics.

Strategy and leadership Objective, to identify key concepts in strategic planning, frameworks for healthcare systems, alignment of culture to support quality, PI teams, risk management, utilization management and case management and education and training. Systems thinking: interacting units to perform a whole. A way of seeing interrelationships in patterns rather than things. Hospital organizations have 3 entities of influence: Administration providers (as they are not employees of the organization) all regulatory and accrediting bodies.

Total quality management is a top down system that looks at the value of every associate, that focuses on customers and that looks at continuous improvement. Frameworks: Avedis Donabedian, the founder of quality assurance, states a theoretical framework for evaluation of patient care). This is a model for looking at healthcare: structures (foundation, things, people and policy) processes (what is does) outcomes (how is the patient now after doing what we did.

Excellence and quality models; evaluate quality models, provide education to staff regarding quality model components and criteria, assess applicability of model and determine whether to change quality model based on assessment. Frameworks continued: Baldrige National Healthcare Criteria, Department of Commerce initiative to improve organizational excellence of nations businesses and organization, Baldrige Award honors organization demonstrating a commitment to quality excellence. External quality awards, should organization go for it, look at: evaluate applicability of external quality award (does it apply to your organization) review quality award components and criteria assign teams to conduct assessments assess organizations processes according to quality award criteria determine whether to apply for quality award based on assessment.

Strategic Planning. Strategy - the plans and activities developed by the organization in pursuit of the goals and objectives. Without a strategy the organization is like a ship without a rudder, it just goes around in circles.

Goals of strategic management are: create a framework for operations create fit with external environment establish process for coping with change and renewal foster anticipation innovation and excellence facilitate consistent decision making create organizational focus.

On the test there will be questions on goals and objectives, classic management theory. Mission (purpose): why, whom, what- who you are Vision; the future of the organization, where the organizations direction which is built on the mission that is guided by vision. Where to you want to be. Guiding principles help direct vision Core value is the customer; key is knowing and understanding customer needs and expectations. Strategic management process: assessment of what the organization wants to do. Goals and objectives guide actions and serve as a yardstick for measuring process. Goals, are broad things and must be: observable measurable challenging but attainable controllable visible time limited

Objectives, what are you going to do to meet the goals, should: be action-oriented statements written precisely be short and simple state specific activity result or outcome

specify actions to be taken conditions and criteria for completion be prioritized

Assessment of the external environment (what the organization should do in comparison of what others are doing): need to look at the overall environment and immediate environment. Look at the surrounding community, what services are needed.

Assessment of the internal environment (what the organization can do); need to look at the tangible items, human, financial and physical than the intangible item which is reputation.

Strategy formulation. Gap analysis; what is the organization doing and where does it want to go. Strategy implementation: integration for TQM/QI with strategic planning. Hoshin planning: one approach. Hoshin Planning. Component of TQM system used to ensure that vision leads to objectives and actions that accomplish long term strategic goals. This applies to all levels of those who are employed. There are three levels: general (senior management), Intermediate (middle management) and detailed (implementation teams). Look at all in the organization and design. Strategic management process continued. Measure and control: Management evaluates accomplishment of goals. Actual performance is evaluated and compared to performance goals and objective. Gaps require action. Leadership: Translating strategic goals into quality outcomes. The board (governing body) bears the ultimate responsibility for TQM and QI: Organization, public policy and external relationships, strategic planning, resource management, human resource development, education and research and quality. Distinction between leadership and management: Leaders develop vision and align subsystems, the pinciples of excellent leaders are able to inspire shared vision challenge the system (there are a lot of rules) enable others to act model the way (walks the walk)

encourage the heart - keep reminding that you have to meet the measures but, keep also in mind what you are ultimately doing is providing the rationale for proper care and maintaining the proper and standard of care for patient.

Managers perform functions to keep organization on path. Both strong leadership and strong management are necessary and selling the vision to the organization.

Culture supports quality. Culture is shared values and behavioral norms. A strong culture: provides sense of identity enhances cooperation creates system of informal rules creates distinctions between organizations that allow for a competitive edge.

Elements of culture are: values and norms symbols language rituals and ceremonies stories legends, myths and heroes.

Assessing culture related to quality: involvement of leader allocation of resources reward of QI behaviors active involvement in QI activities time spent on QI activities discussion prevailing QI attitude

Strengthening culture for QI. Leaders should: make QI everyones responsibility have an annual budget for QI make QI part of strategic planning reward QI behaviors.

If you pay attention to visible culture elements, the old negative stories are replaced, symbols and rituals supporting QI created, QI successes celebrated and persistent leadership is shown. Structure supports quality. Organizational structure helps identifies parts and links together. Basic structural elements are: focus on processes recognition of internal customers (in healthcare we are good at recognizing the external customer, lets look at the internal customer) reduction of hierarchy (empower people, let them do things) creation of a team-based organization use of steering committees development of an agile organization.

Process: Risk Management.


Risk management (RM) is an organized effort to identify, assess and reduce risks to patients, visitors, staff and organizational assets. Initially was organizational reaction to increasing litigation and now has a more proactive role. Clinical risk management is the regulatory compliance, safety management, credentialing (hospital must make sure the provider is appropriate for the job), client-provider relations, publicity and media coverage, patient care. RM and QM/QI are closely related.

Risk Management process. Basic risk management functions are: maintenance and monitoring claims management clinical and administrative responsibilities collaboration with safety officer collaboration with finance staff regulatory compliance.

RM identifies exposures (what could make us at risk), examines techniques to reduce exposure, selects best techniques, implements techniques and monitors effectiveness. Sounds like PDCA!. RMs written plan includes what they need to do and best for background in education and skills for clinical, legal and insurance issues.

Utilization Management is the organized, comprehensive approach to analyzing, direction, and conserving organizational resources, also response to changing needs of consumer. The UM goal is to facilitate delivery of high-quality, low-cost, efficient, and effective care to all patients. For the exam, do not get caught up on specifics, just think general. Is the admission, surgery or procedure the right one for the patient. Discharge planning is general as well; think general Overutilization and underutilization; you do not want to provide services that you do not need too. Are people getting the services that they really need? Quality of care and liability: staff and provider education as to what they can and cannot do Governing body needs to know how the organization is doing from utilization prospective, are resources being used appropriately, is it evidenced based? Internal review issues in regards to utilization, confidentiality due medical records review process is utmost importance, if there is an external or outside reviewer for review, must insure confidentiality and that they are who they say they are.

Case Management models: reimbursement-based model institution-based model social services private management-based model insurer-based model life-care planners.

The importance of case management is critical to the continuum of care, patient satisfaction and efficient use of resources.

Case management takes utilization to a higher level. Utilization looks at one level like a hospital or SNF. Case management looks at the total spectrum. CM moves the patient thought the entire continuum of care. Case management process: intake and assessment development of comprehensive plan discharge planning monitoring of outcomes for effectiveness of care.

CM Discharge planning: care coordination among various case managers involvement of ancillary services expected discharge date goals to be meet before discharge specific instructions specifics regarding follow up plans.

TQM/QI Structural elements involves recognition of internal customers. Every process has internal and external customers and an employee is customer when he received material, information or services from others in the organization and internal customers may also be suppliers of goods to external customers. Internal customer approach: remind departments without direct external customer contact of critical link to customer satisfaction improve relationships make work processes flow smoothly avert potential bottlenecks.

TQM/QI structural elements continued, Reduction in hierarchy(flattening of organizations); requires decentralized decision making, shared governance and it is affected by leadership style, The leadership styles are: Autocratic (authoritarian, leader directs) Participative (listens to staff but leader still makes discussions) Empowering (listens to staff and lets staff make discussions).

Deming: Improvements in quality are more likely to be realized when workers are empowered, give people the chance to make things better. Empowerment allows employees to: take ownership of jobs make decision concerning their area take responsibility for decision add value to jobs.

Creating a team-based organization. A team is a group of people who are interdependent with respect to information, resources and skills and who seek to combine their efforts to achieve a common goal. Types of QI teams are Steering committee or council (one group that has overall responsibility for quality in the organization) and Process (or performance) improvement. Quality Improvment council (team) responsibilities: set priorities lend legitimacy to the QI effort maintain focus on identified goals foster teamwork provider resources formulate QI policies.

The Council has overall knowledge of what the organization is going through.

Teams.
Process Improvement teams are natural work teams a (work place team that works on a project than, when completed, moves on to the next), a cross-functional or intact and are temporary or permanent. Use of teams depends on the task complexity, task interdependence and task objective. The Team Charter (which is the information for all the team participants that clarifies its purpose) provides: description of process of why and who development of criteria timeline for meetings resources available structure of leadership expected communication of progress and results.

Teams continued; how do teams develop? Stage I Forming (team just gets together) Stage 2 Storming (everyone gets mad and stomps off) Stage 3 Norming (gets back together, do the work as a team) Stage 4 Performing (performed effectively). These Stages are not liner; they can go forward in a stage than regress back. Characteristics of effective teams are: competent members with skills commitment to clear common goals standards of excellence contribution from all collaborative environment leadership support.

How should teams be evaluated? Productivity; progress or success in meeting team and organizational goals, satisfaction of team members and individual growth.

Staff supports Quality. Methods for determining education and training needs include (how do you know what people need to know): evaluating knowledge and skills in job description asking participants asking participants supervisors asking others knowledgeable about job testing participants analyzing past performance appraisals.

Fundamentals of TQM/QI curriculum: explanation of need for organizational improvement (why we want to make things better) development of quality language (what are you all going to use PCDA?) discussion of quality goals definition of structured for TQM/QI articulation of TQM/QI philosophy description of process for TQM/QI description of responsibilities tools and techniques for teams description of change of process.

Roles of team of team members: team leader (person involved of every aspect of the team and to see the process through) facilitator (someone who does not have a vested interest in the outcome, role is the quality expert who provides to tools for the group process person and to keep the group together and focused) team member (every member has a job and to actively participate with that job).

Mature teams do not need a facilitator because the leader can take over the facilitator role and the team members are used to it.

Education and training issues.


Top management needs to understand: quality as strategic advantage role of leadership in sustaining quality vision integration of quality values indicators for measuring and evaluating components of QM implementation process basic QI tools role as team leaders awareness of accreditation standards.

Middle management (operational people) needs to understand; quality management customer service management of process performance measurement of quality outcomes

management practices.

Staff needs to understand: quality awareness quality participation organizations mission and vision QI plan concepts of QM promotion of cooperation communication skills customer service relevant standards.

Reasons for evaluating results of training are; to improve future training, to determine whether participants and organizations needs were met and to determine whether current training should be continued. The levels of evaluation are; reaction (yes I liked the class give me my ceu or it sucked index), learning (survey after class to inquire what one has learned), behavior changes (survey asked if you changed your ways) and results (retro review for results) Consultants. The Quality person states whether or not a consult will be used. Advantages of using consultants, bring in expertise you do not have and they reinforce message. Disadvantages of using consultants are costly and may not deliver the message as you want it delivered. Monitoring of the consultant activities is indicated by; are they doing what you want them to do? Consultant contracts, Quality must look it over! The Consultant evaluation will be done by Quality. Exam question in regards to contracts, Quality management has oversight of contracts. Elements of contracts are; identify all contracted service evaluate the accreditation requirements, data submission and evaluation (consultant must use the same as you).

Process Improvement in Performance Appraisal. Process Imporvement must be a part of the quality culture, if not incorporated, it turns out not to be important to people. Work motivation- psychological forces that determine the direction of a persons behavior, level of effort and level of persistence. Skills to aide in performance - coach employees. Guide employees in the outcomes and policies about performances to be rewarded. Having the staff know motivation and culture will be part of their evaluation. Process improvement in performance appraisal continued: setting up a reward system: determine priorities, values and behaviors identify criteria for recognition establish a budget (money is good but recognition is also good) determine accountability for recognition develop procedures obtain feedback modify program based on feedback give rewards based on the program.

Rewards need to be built in to the quality program.

Financial Systems Support Quality.


Capital budgeting, large initial cash outflows (big ticket items like replacing all mattresses), annual activity and trigger: capital request presented to senior management and expenditures committee and prioritized. Operational budget goes for salaries, supplies and needed items like x ray film. Cost-benefit analysis is performed for capital expenditures (large ticket items) requests to determine viability and benefit, helps utilize financial and human resources. Quality Improvement should be carried out only if benefits exceed costs over life of project and include time frame demonstrating costs and benefits over time. E.g. Sleep lab of two beds, want to increase to four beds. With the extra two beds, construction and staff that have to be purchased, what will the benefits over time show if other facilities referring patients for sleep studies, will the costs will go down and benefit will raise in time. Cost benefit analysis will reveal this information. Will the benefit exceed the cost?

Financial systems support quality continued. Establishing a business case for quality related expenditures; returns on investment, reduced expenditures or cost avoidance and costs. Difficulty to show but mostly quality avoids extra costs as it reduces errors. Organizational renewal. Learning organizations are adept at: experimenting with new approaches learning from own experience learning from past experiences best practices of others transferring knowledge quickly solving problems systematically.

Question and Answer:


1. Which of the following processes is most cost-effective in preventing unnecessary resource consumption in the hospital? Looking for a process, things that we do, what is the best at saving us money by not using resources in the hospital Answer options: effective preadmission screening, accurate DRG assignment at admission, second opinions for all surgeries and preadmission insurance benefits denials. This is one of those questions where there is no good answer. Effective preadmission screening is the correct answer. It really has little to do with preventing unnecessary resource use while the mbr. Is in the hospital however, the other answers are worse as they have nothing to do with cost except the second opinon which will cost more. There is no right answer,, look for the BEST answer 2. A social service department regularly monitors the number of inappropriate referrals, the timeliness of discharge planning and the number or days of discharge delays. What additional monitor should be added to evaluate the appropriateness of social service interventions? Need to know if social service is doing what they should be doing as it is monitoring appropriate intervention. Answer options: inadequacy of documentation in progress notes, attainment of social service goals, timeliness of referrals to social service or number of social service referral from nursing.

Continuous Readiness: Objectives is to identify key concepts in accreditation processes and survey preparation training. Context of continuous readiness; past survey experiences as to ramp-up activities meetings new work copy and production costs relief after survey difficulty getting leadership attention unplanned surveys crisis-management mode

Context of continuous readiness continued: Now, culture of continuous readiness (company or corporate attitude and values demonstrated throughout the organization)- unknown survey dates, immediate readiness to demonstrate compliance required and mental preparedness. Be ready for survey at all times. Surveys require continuous readiness; corporate surveys, payer surveys, surveys by regulatory agencies and accreditation surveys. Accreditation cycle: application submitted application reviewed inspection team assigned date determined documents possibly requested in advance on-site review conducted length of site visit determined by organizations size and complexity.

Accreditation cycle following visit: summation conference and report of findings deficiencies or requirements for improvement action plan submitted notification of accreditation status periodic self-assessment or performance review fees

Changing organizational culture to one of readiness of culture: system of beliefs and actions norms of behavior and shared values people often unaware of organization culture modifying organizational culture key to success cultural change tied to individual change (you really have to change the individual, the individuals together make the culture) slow, hard work.

Leading readiness change, leadership defines vision; successful transformation depends on successful leadership. Successful leaders; enable others to lead foster a sense of community create consistent system of rewards

Significant change in culture is seen in about 18-24 months, it takes 10 years to anchor a cultural change. Top-managements commitment to the hard work of altering corporate culture. Common errors include: allowing too much complacency failing to create sufficiently powerful guiding coalition underestimating the power of vision under communicating vision (everyone must know what the vision is and understand the vision and, the leaders must live the vision) permitting obstacles to block new vision failing to create short-term win declaring victory too soon neglecting to anchor changes firmly in corporate culture.

Continuous readiness programs: previous survey preparation used in just- in- time model requiring ramp- up activities and goal of continuous readiness is to break crisis-management cycles and just-in-time cultures. Goal is to break the just-in-time culture and have continuous readiness.

Leadership components. Leadership commitment includes; must be in place must be willing to change culture and commit to personal change must understand business case for compliance must include continuous readiness within strategic priorities.

Manager accountability includes evaluation of compliance evaluated, operational oversight and education of new managers. Managers must also understand their role in continuous readiness. Continuous readiness program continued. A critical step is routing self-assessment. An Annual assessment is resource dedicated and corrective action plans implemented to developed and monitored. Ongoing assessment (if not done annually) which is thorough assessment made over calendar year (you can take some of the standards that are being observed and divided them up each month however, this way is more difficult to track, if you do an annual assessment annually, say at the beginning of the year, you know what all the issues are and you can follow them throughout the year), responsibilities assigned, assessment components presented to leadership, monitoring schedules developed and focused project management required. Corrective action plans: organize improvements needed, provide written response to survey or gap analysis and require oversight during implementation, evaluation and revision. New standard oversight (someone has to be the one to look out for new standards) includes: define the process, understand the frequency with which changes are made and the feedback and notification process, begin to implement the changes as soon as possible as do not wait to begin the implementation until the date that the new or revised standard becomes effective and be ready to be surveyed soon after the effective date of the standard. Understand the frequency that the accreditation makes changes, how are they going to get the information to you (how are you going to know about it) than you have to implement the changes as soon as possible. Continuous Readiness program continued. Staff education includes; solid programs with participation from all levels, effective, creative, targeted education plan and cohesive program designed around survey cycles and actual survey process. Education needs to be designed around the survey process. Survey preparation includes staff recognition and rewards in regards to; contribute to success, are seen as important in culture of readiness, encourage participation, can be simple and still effective and can involve leadership acknowledgement.

Survey preparation. Processes: is the role of the QI professional survey initiation with application and submission requirements survey coordination with formation of multidisciplinary team frequency of meetings depends on ongoing self-assessment available resources command center which is a central point of contact for surveyors education includes review of standards and conducts orientation and practice sessions space planning for surveyors as in reserving rooms and consider hosting needs after the survey, provide for debrief and evaluate survey process post survey activities make plans for unannounced visits or surveys.

Questions and Answers:


1. In order to perform a task for which one is held accountable, there must be an equal balance between responsibilities and Answer options: authority, education, delegation and specialization. Answer authority. In order to get something done, you need both responsibility and authority. Education does not make a difference and delegation and specialization does not help.

The primary purpose of an emergency preparedness program is to answer options; conduct evaluation of emergency training, provide evaluations of semiannual evacuations drills, prevent internal disasters that disrupt the facilities ability to provide care and treatment, manage the consequences of disasters that disrupt the facilities ability to provider care.. (this is the answer). Conducting evaluations of training is part of it but the totally it, evaluation evacuation is also part of it but not most important thing in the answers given and prevent internal disaster is ok but not the most important is the management of the preparedness. 2. The separate services of Pharmacy and Nursing are having difficulty developing an action plan for medication errors. Pharmacy services states that nursing services causes the majority of the problems related to the errors while nursing services states the opposite. The quality professional role in resolving this problem is to do what? This is a dispute between two parties. Answer options are; Provide them with directives on how to solve the problem, facilitate discussion between the groups to enable them to assume ownership of their portions of the problems, assign the task to un uninvolved manager or refer the problem to the facility-wide quality council. Answer is to facilitate discussion. All the other answers you could do as the quality professional however, the best answer is to facilitate discussion.

Change Management and Innovation. To identify key concepts in: priorities for change forces for change models for creating change techniques for facilitating change models for performance improvement failure mode and effects analysis.

Darwin states, It is not the strongest of the species that service, nor the most intelligent, but the ones most responsive to change. 21st Century Healthcare System. Healthcare at a minimum should be safe, effective, patient-centered, timely efficient and equitable. The exam will not ask about specific models of change, they will give you a scenario and will ask what is the best way to get there. Need to look at change as to how to implement change. IOM Priorities for Change. To Err is Human and Crossing the Quality Chasm. Healthcare frequently harms and routinely fails to deliver potential benefits and care is not provided using best scientific knowledge. The Agenda for changing healthcare delivery system; commit to national statement of purpose for healthcare system adopt new set of principles identify priorities implement more effective support processes create supportive environment.

Transparency: Public Reporting. CMS and private groups are to compare healthcare providers to national benchmarks and provide rating. The National Quality Forum endorses consensus-based standards. Rewarding for Quality. Rewarding organizations and provider through pay-for-performance. Leapfrog (group of consumers who want to harness healthcare providers for best value). Leapfrog rewards are based on 4 elements; proven methods to ensure patient safety improved clinical information system routine use of model Quality Improvement methods routine participation of consumers.

Change Management. Change is inevitable and essential for growth. Different strategies
required for each level of change, depending on type of change, people involved magnitude of behavior to be modified, managing change is a key skill and an organizations ability to change is dependent upon individuals, including leaders. The organization must have leaders that have the knowledge of change management and are willing to do it. Healthcare is a complex system. There is intense competition for limited resources; some critical factors to change are limits to human performance in their ability to respond to change and systems actual capacity to handle change. Change: moving people from existing state through transition to future state. Resiliency of individuals is a critical element. Resilience: the process of adapting well in the face of adversity or significant stress and the role of leaders: to establish the culture of change, role model flexibility and behaviors needed to adapt to change. First-order change: small, requires minimal effort. Second-order change; complex, requires significant change in behavior. Changed linked with how people view work Change is a significant possible cause of distress. Change seen positively is valued.

All changes do not necessarily lead to improvement, but all improvement requires change) the IHI, also, if the change does not work, not all change will work, go back and start anew. change is likely to cause disruption. there is no single model or tool that will fit every situation. building and sustaining resilience: make connections avoid seeing crises as insurmountable problems accept that change is part of living move towards goals take decisive actions look for opportunities for self-discovery nurture a positive self-view keep things in perspective maintain a helpful outlook take care of self.

KEEP FOCUS ON THE CUSTOMER (internal and external).

Lewins Change Model: Motivation and readiness must come before change is accepted (sometimes there is no time to wait for all to become motivated). For change to occur driving forces must be stronger than restraining forces and more impact may be achieved by removing restraining forces than by adding more driving forces. Change management continued: there are 3 groups of people people that support the change people that sit on the fence those 20% who are not going to support any change

Focus on the people who already support the change, they will hopefully bring those last 20% along with them. Always, assess readiness for change as the change concepts must be understood. Items of improvements that require change. Change Concepts include; eliminate waste improve work flow optimize inventory change the work environment enhance producer-customer interface manage time manage variation design error-proof systems focus on product or service.

Models of Change; Traditional Plan-Do-Check-Act (PDCA) Shewhart model and Plan-DoStudy-Act (PDSA) Deming modified Cycles of Change. Shewhart PDSA: setting aims establishing measures selecting changes testing changes.

Deming Cyles of change: plan for multiple cycles of improvement scale scope and size of test choose people who want to work capitalize on existing resources select easy and visible wins (most of the easy stuff is done so you need to do whats left) dont delay for technology (move on) collect useful and meaningful measures (is what you are collecting to the point) test change under different conditions be prepared to stop if no improvement is seen.

QI study design and analysis. Getting started on quality improvement projects needs; ensure leadership support and commitment first assess priority and feasibility of initiatives identify aim of initiative convene interdisciplinary teams utilized tools and techniques to analyze.

Develop change to be implemented; identify measure to identify improvement educate staff on desired change implement test change collect, analyze and evaluate data make additional changes based on the findings of data disseminate to all areas report and display results to reward staff continue to monitor performance, compare performance internally and externally celebrate successes.

THESE ARE THE STEPS TO THE PERFORMANCE IMPROVEMENT PROCESS!! Failure Mode and Effects Analysis (FMEA). A traditional technique adapted from industry, creation of healthcare FMEA by Veterans Affairs, reduces risk before an event happens and there are steps. IHI web page has good info and forms and so does www.patientsafety.gov. FMEA continued: Nothing has happened yet. This is a systematic method used when a new system or redesign of a system is in early stages, also good for existing systems and, analysis completed for each failure identified (known or potential).

Steps: define topic and process to be studied (describe continuous readiness program and FMEA boundaries) ,what is the issue? define individual and team responsibilities convene interdisciplinary team (assign team leader, encourage adequate team composition, who and at what level of personal are you going to need?) complete FMEA team start up worksheet (see web pg, for form) develop flow diagram of process and sub processes (review the process and flowchart for continuous readiness program the processes and sub process steps) list all possible failure modes of each sub process (team brainstorms each process and sub process for potential failures, how could each process fail?) analyze each failure mode (this is time for what if, this answer will provide insight into probability) for each failure mode, list the potential effects on the patient. assign a risk codes from the risk matrix to each potential failure mode effect combination then, develop actions or counter measure to reduce risks and identify feasible actions or controls, to reduce or eliminate risk associated with the failure mode. reassign risk codes (determine residual risk and code assists in prioritizing actions and monitoring to determine effectiveness in reducing risk). assign responsibility for actions (assign responsibility for implementing corrective actions and determine project completion date). monitor the action results and risk reduction (Monitor to evaluate whether the risk reduction strategies have reduced risk and take additional action if necessary to further reduce risk).

FMEA Resources: www.ahrq.gov , www.ihi.org, www.npsf.org

Creating Major Change.


Establish a sense of urgency create guiding coalition develop vision and strategy communicate the change vision empower broad-based action generate short-term gains consolidate gains anchor new approaches in the culture

Factors that support successful change are: leadership systems are designed for results strategy is simple aligned and deployed design of organizational culture is intentional mission and vision are clearly understood rapid response is employed desired results are defined, measured and aligned decisions are based on sound data customer focus is foundation measurement is deployed at all levels. Innovation is valued partnerships are created (get away from silos) continuous improvement is integrated into daily work organizational learning is valued human resources practices support culture employees are involved focus is on improving employee knowledge social responsibility in integral systems perspective is valued.

Reducing resistance, this is a performance issue and a behavior issue and must be handled at a management level. For people who are not willing to make the change: set goals measure performance provide coaching feedback reward and recognize positive efforts.

For people not able to perform change: provide education and training.

For people who lack necessary knowledge: Communicate present positive outlook have clear focus be flexible

use structured approach plan and coordinate change use proactive approach.

Questions and Answers:


A quality manager needs to assign a staff member to assist a medical director in the development of a quality program for a newly established service. Which of the following staff members is most appropriate for this project? Answer options: a newly hired staff member who has demonstrated competence and has time to complete the task, a knowledgeable staff member who works best on defined tasks, a motivated staff member who is actively seeking promotion or a competent staff member who had good interpersonal skills (this is the answer as the key word is interpersonal skills).