Continuous Quality Improvement Program

Showcase

Nancy Dean, RN, FNP

Barbara Lloyd, RN

Joann Stroman, RN, MHA, MSN, BSN

Kristin Kastner, RN

CQI PLANS

Nancy Dean, RN, FNP

Phoenix Job Corps Center

How to Begin?

Steps

Steps for CQI• Develop an hypothesis of what the problem is• Collect data• Review the data• Does the data confirm and validate the hypothesis?• Formulate a plan of action to create change• Utilize on and off center resources• Implement a plan of change• Review the outcome for success or change• Time frame is dependent on the importance as it

relates to student and center success

CQI Examples

Recent CQI at Phoenix JCC

Pregnancy CQI

• Hypothesis: Increase in Pregnancy with Male JC Students Being the Fathers

• Data collected showed that within 1 quarter there were 6 pregnancies after entry

• Review of the data demonstrated that 4/6 were by male JC students

• The data confirmed the hypothesis

Pregnancy CQI• Plan formulated was to have on-center and

outside resources do presentations to PJC students-male and female separately

• Pregnancy Coordinator contacted Planned Parenthood to come and do a seminar with the students. This was conducted for both residential and non residential students

• Also utilized center physician and residents and the CMHC and the MH interns to assist the HWC staff

Pregnancy CQI

• Statistics were kept and reviewed data at 3 and 6 months

• Outcome measure was that there were only 2 pregnancies after the plan of action and none were by JC male students

Pittsburgh Job Corps Center

Barbara Lloyd, RN

Quality Improvement

• Definition• Planning your program• Means to obtain needed feedback• What do you do with the feedback

received• Closing the loop

Continuous Quality Improvement

• Continuous Quality Improvement is a process to ensure programs are systematically and intentionally improving services and increasing positive outcomes for the persons they serve. CQI is a cyclical, data-driven process; it is proactive, not reactive. A CQI environment is one in which data is collected and used to makes positive changes—even when things are going well—rather than waiting for something to go wrong and then fixing it. CQI is an ongoing process that involves the Plan, Do, Study, Act cycle.

Planning Your CQI Program

Planning Your Next Steps

• Wellness Staff Meetings

Planning Your Next Steps

• Good planning means students are involved in each step of the process.

Getting Feedback

• PJCC Wellness Survey• Wellness Committee meetings• Student Government Association

Acting on the Feedback

• Informational surveys and discussions

• Special events• Student incentives and recognition

Closing the Loop

• Survey Effectiveness

• Assure Recognition

• Document Results

Questions

Bamberg Job Corps Center

Joann Stroman, RN, MHA, MSN, BSN

• .Goal•Outcome

• Intervention•Problem

Area

Staff

Weaknesses

Strengths

Tools Used to Identify Areas of Improvement

• Surveys for students not utilizing Wellness

• Surveys for students utilizing Wellness

• Focus Groups• Direct Observation• Use of a Complaint Log• SGA Wellness Committee

Wellness Survey• Non/Infrequent Users• SURVEY SAYS!!!

1. How often have you visited the Wellness Center since you enter the program _____never _____1-5 _______ 5-10 _______ unable to count

2. Do you feel the Wellness staff is respectful and maintain professionalism?

3. What changes would you recommend for the Wellness Center based on your experience and observation?

Wellness Survey• Frequent Users• SURVEY SAYS!!!• Today I was seen by: Mrs. Ferguson, Ms. Stroman, Dr.

Stephens, Dr. Furtick, Ms. Perry, FNP, Dr. Jeffords, Dr. Thomas, Ms. Brooks (please circle)

1. I was treated with respect by the Wellness staff . Yes _______ No________

2. I am satisfied with the care that I received today. Yes _______ No _______

3. What do you think will make the Wellness Center better?

4. Please respond to any no answer.

Complaint Log

• Wellness Complaint LogStudent Date Complaint Resolution/Date Notification

Problem Resolution Plan

• Resolution Plan Problem Goal Interventions Staff Date of

ResolutionResolved

No Flu Vaccine

Reduce on Center Flu to < 5% of OBS

• Staff Training• Student training• Center wide

Disinfecting• Early testing for

all Flu like s/s• Early Isolation • Regional

request to replace leave time for all flu cases

HWM, LPN, MDLogistic, Finance,CDSS, SD

Ongoing until March 31, 2014 or as directed by CDC

To date 1 confirmed flu case

Denison Job Corps

Kristin Kastner, RN

How do I decide??

Brainstorming Data integrity Review reports

Areas of interest

• Student satisfaction survey results• Influenza vaccination rates• 45 day re-test results• Suspicious alcohol screenings• Identification of wellness staff• Incidence of STI rates

Results must be measurable

• Surveys• Review results• Observation • Student/ staff feedback• Annual health and wellness report

Document

• Topic• Date range• Measurement mechanism• Corrective action• Goal

= compliance

612. R15

Questions?