CQI, TQM, QA, PI….AKA “Quality

Management & Process

Improvement”

Sherri Layton, MBA, LCDC, CCS

slayton@lahacienda.comTIPSS - January 23, 2012

As providers become more accountable for processes and outcomes, measuring efficiency and effectiveness in our organizations has increased importance. We will discuss the who, what, why, where and when of quality management and process improvement, as well as ongoing monitoring and evaluation, making special note of areas unique to the addiction treatment industry.

The Responsibility of Leadership

Create and maintain a culture of safety and quality – make them a priority

Establish priority of performance improvement and outcomes

Assess and prioritize improvements needed High risk or problem prone processes High risk or vulnerable populations High volume processes

Evaluate the effectiveness of systems

Why?The Future of Healthcare

More definitive research on what is effective treatmentMove toward payment based on outcomesExpected to use objective tools to assess

processes and outcomes Recovery Oriented Care

Show that chemical dependency treatment is effective - measuring success by measuring individuals’ recovery

Patient-centered focus on care Expected to involve the patient. Not just in

their care decisions but in the processes of the care they receive.

Empower the patient

Why?Regulatory Requirements

Review and analyze incident reportsMonitor compliance with rules &

other requirementsIdentify areas where quality is not

optimalAnalyze identified issues, implement

corrections, evaluate and monitor ongoing effectiveness

Ensure appropriate client placement, adequacy of services provided and length of stay

Why?Regulatory Requirements

Mission statement drivenGoals and objectives that relate to the

program purpose or mission statementReview the progress toward the goalsDocumented process to implement

corrections or changes

What? Focuses on the ‘process’ rather than the

individual Recognizes both internal and external

‘customers’ Promotes the need for objective data to

analyze and improve processes 5 key systems that influence the

effective performance of an organization Using data Planning Communicating Changing performance Staffing – qualifications & competency among

other things

First, fix your problem areas - • Compliance issues

• Revenue/Reimbursement issues• Documentation issues• Safety concerns• Waiting lists• Patient retention

– Non-completion/Unsuccessful completion

– Level of care transitions• Timeliness• Are people getting better?

Then move to improvement -

• Quality• High risk processes (always,

sometimes)• Proactive vs reactive• Prevention vs correction• Increased efficiency• Improved effectiveness• Workflows• Streamline processes

How?

• Everything starts with asking the right questions!– What’s important to you?– Are you satisfied with the quality of

your service?– Are your customers satisfied?

• Look at everything through the customers’ perspective.– Who’s your customer?– What does your customer experience?– What do you want your customer to

experience?

How?

Empower employeesLeadership sets the stageLine staff generally has better pulse on

thingsEncourage reporting

Use statistical toolsBenchmarkingEvidence based practices –

guidelines, literatureReflect your mission statement?

Where? & When?

Data Collection• Chart audits (qualitative/quantitative)• Patient surveys• Staff surveys• Family member surveys• Alumni surveys• Referral source surveys• Continuing care provider surveys• AMA analysis• Patient outcomes• Risk management reports

Data Collection

• Sample size• Statistical analysis – charts & graphs

– Line graphs – show data change over time

– Bar charts – show how many units have particular characteristic

– Pie charts – show percentage of each contribution to the whole

• Data should lead you to answers• Beware of conclusions without data

FOCUS – PDCA Model

• F• O• C• U• S

FOCUS – PDCA Model

• F – Find an opportunity• O – Organize a team• C – Clarify the process• U – Uncover/Understand the issue

• S – Start the PDCA process

FOCUS – PDCA Model

• P – Plan the improvement• D – Do/implement the improvement

• C – Check the results & lessons

• A – Act (adopt, adjust, abandon)

Manage & Maintain• Don’t assume• Accountability

– Ongoing data collection & reporting– Visual representation – “in your face” & “on

the radar”– Take action!– Regular meetings (Can they be fun?)

• Automate all you can• Work across departments• Create, support, encourage a culture

– QI program theme– Goals and objectives

• Cooperate and collaborate• Mission – Vision – Values

Stay accountable -

If it doesn’t help our customers and we don’t have to do it for the regs, why are we doing it?

If we are not using data we are collecting why are we collecting it?

Have we asked the important questions? Will this change result in improvement? Are we building an improvement program

or are we looking to pat ourselves on the back?

• Successes tend to disappear from view.

• Building on success is the secret to sustainability.