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8/14/2019 CQI in Healthcare Organizations
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Continuous QualityImprovement
in
Health Care Organizations
Prepared by: Dr. Alber Paules
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Definition
Quality Improvement (QI): the sum of all activities
which create desired change in the quality.
An effective QI system results in a stepwise increase
in quality of care. QI approach emphasizes reducingthe variability in the entire process and shifting the
process in the desired direction; rather than just
taking actions whenever thresholds are exceeded.
Continuous Quality Improvement (CQI): implies the
continuity of the improvement efforts(i.e.)whenever
an improvement is achieved, we might seek another
opportunity to achieve further improvement.
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Why Healthcare Organizations
Adopt CQI Strategies/Initiatives?1. To maximize their quality of care as defined in both
technical and customer preference terms.
2. To gain more competitive advantages and increasetheir share in the local health care market through
excelling in the service they provide.
3. To gain or maintain an accreditation status with
bodies such as the JCAHO (JCI), NCQA, and others.
4. To respond to the pressures imposed on them by the
patient advocacy groups, employers, payers, and
regulatory bodies.
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Why Should Health Care
Organizations adopt CQI?1. To maximize their quality of care as defined in both
technical and customer preference terms.
2. To gain more competitive advantages and increase
their share in the local health care market throughexcelling in the service they provide.
3. To respond to customer requirements/expectations
which change over time because of changes in
education, economics, technology, and culture; in
addition to changes in thecompetitorsperformances.
Such changes require continuous improvements in the
administrative and the clinical methods that affect the
quality of care.
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Elements of CQI
1. Philosophical elements
2. Structural elements
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1. Strategic Focus--Emphasis on having a mission, vision,
values, and goals that performance improvement processes
are designed, prioritized, and implemented to support.
2. Customer Focus--Emphasis on both customer satisfaction
(whether external or internal ones) and health outcomes as
performance measures.
3. Processes ViewEmphasis on analysis of the system
processes.
4. Continuing Improvementemphasis on continuing the
process analysis even when a satisfactory solution to the
presenting problem is obtained.
Philosophical Elements
of CQI
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4. Top Management Commitment.
5. Emphasis on avoiding personal blame. The initial assumption
is that the process needs to be changed and that the personsalready involved in that process are needed to help identify
how to approach a given problem.
6. Encouraging participative management (through encouraging
the involvement of all personnel associated with a particularwork process to provide a contribution and share in solving
the problem) and decentralization (through placing
responsibility for ownership of each process in the hands of its
implementers).
Philosophical Elements
of CQI
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7. Increasing the pride and the morale of the employees by
recognizing their important role when they become
members in a process improvement team and become
involved in the re-design of a relevant process.8. Data-driven AnalysisEmphasis on gathering and use of
objective data on process performance with subsequent
fact-based decision making.
Philosophical Elements
of CQI
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1. Process Improvement TeamsEmphasis on forming and
empowering team of employees to deal with existing
problems and opportunities.2. Seven Toolsuse of one or more of these seven quality
tools: flow charts, cause-and-effect diagrams, histograms,
Pareto chars, run charts, control charts, and correlational
analysis (e.g.) scatter diagram.3. Quality Councildevelopment of the quality council,
which is an organizational structure formed from the top
institutional leaders, to set priorities for and monitor CQI
strategy and implementation.
Structural Elements of CQI(elements which structure, organize, and support the CQI
process)
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4. Development of a comprehensive set of indicators to
monitor our performance.5. Benchmarkinguse of benchmarking to identify best
practices in similar settings to use as performance targets.
Structural Elements of CQI
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The Iceberg Model of QI
Tools (what we can see and do)
Systems, Frameworks, and Models
(shaped by theories and assumptions;
unseen)
Theories and Assumptions
(deep under the surface;
we are largely unaware of)
Tip
Base
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These include the contributions of the quality leaders,
like:
1. Walter Shewhart
2. Edwards Deming
3. Joseph Juran
4. Philip Crosby, and others.
Foundation of the Iceberg Model:
Theories and Assumptions
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They are derived from the ideas and theories developed by thethought leaders; they include:
1. FOCUS-PDCA:
o Designed by a healthcare QI consulting group in the 1980s .
o Uses theDemingsCycle (PDCA cycle).
o FOCUS-PDCA is an acronym for the following:
Find an opportunity for improvement
Organize a team that knows the process
Clarify current understanding of how the process works
Understand the process variation
Select a strategy for improvement
The PDCA cycle tests the strategy to determine its
effectiveness (i.e., if it results in improvement)
Middle of the Iceberg Model:
Systems, Frameworks, and Models
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Find a process to improve This is relatively easy when the organization first begins
performance improvement activities.
A comparison has been made to a fruit tree. When you firstbegin to harvest the fruit, it is very easy since it probably is
lying about the ground; however, the more harvested the
more difficult it becomes to obtain.
Selected improvement opportunities should be approved by
the quality council.
FOCUS-PDCA
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Find a process to improveBecause of this increasing difficulty in identifying
opportunities, there are many ways for finding opportunities
than simply picking one up from the ground.The following references may suggest opportunities for
improving performance:
Standards of Care
Customer Satisfaction Surveys
Incident Reports
Action/Recommendation Sections of Committee Minutes
Employee Suggestions
Accreditation Surveys
FOCUS-PDCA
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Find a process to improveMistakes to avoid while searching for improvement
opportunities:
Selecting a System to study instead of a Process:(e.g., selecting a phase on the medication management
system rather than addressing the whole system)
Selecting a desired Solution instead of a Process:
Frequently managers will already have a desired solution
to the problem in mind and will convene this solution to
the team to study. Teams must be free to select whatever
interventions they think are best. Sure, the suggested
solution may be the best, but this is determined only after
thorough analysis of the process.
FOCUS-PDCA
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Organize a team that knows the process The Facilitator:
o Assigned by the quality council to assist the team.
o
Attends the meetings.o Not a team member.
o He/she facilitates not dictates.
o He/she is more concerned with how decisions are made
rather than with what the decisions actually are.
o Responsibilities include: assist team in using PI tools, assist
team in preparation of presentations to management,
assist team in measurement and understanding of
statistics, assist team leader in dealing with divisive
members..etc.
FOCUS-PDCA
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Organize a team that knows the process The Recorder:
o A team member.
o
Assigned by the team leader.o Responsible for keeping the minutes of the team and for
documentation of the progress of the team.
o A single team member may serve for the duration or this
responsibility may rotate among all team members.
o If one team member is asecretary,he/she should not be
automatically chosen to serve as the recorder.
FOCUS-PDCA
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Organize a team that knows the process The Time Keeper:
o A team member.
o
Assigned by the team leader.o Responsible for periodically reminding the team of the
assigned time remaining for agenda items and the meeting
as a whole, aiming at keeping the team on track and
focused.
FOCUS-PDCA
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Organize a team that knows the process Team Members:
o They are usually the process experts (i.e., those who best
understand the process to be improved). Sometimes, the
team member may be a supervisor of the expert (i.e., does
not have direct knowledge of or experience with the
process).
o Chosen by the leader and approved by the quality council.
o Responsibilities include: attending team meetings on aregular basis, full participation in team activities, and
conducting the in-between meeting assignments in a
timely manner.
FOCUS-PDCA
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Clarify current understanding of how the processworks Ensure that all members understand the whole scope of the
process to be improved. Frequently, members are familiar
with only a few steps of the process and are not aware of
what might be occurring on either side of their activity
segment.
A frequent problem that occurs at this stage is the temptation
to prematurely think about suggestions for process
improvement. Interjecting fragmented solution suggestions atthis point only makes it more difficult for the team to arrive at
a complete process analysis.
FOCUS-PDCA
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Clarify current understanding of how the processworks Another barrier to good process analysis is the failure to
drive out fear. For example, a team member may be
afraid to tell that a process does not follow an existing
policy. Clearly, if this information is not available to the
team, the process improvement efforts will fail. The team
leaders political-sensitive approach towards encouraging
the team member to share his/her opinion is crucial.
Several tools are available to assist the team in driving outfear and facilitating the free and open communications
necessary to the project. One of the most important tools
used during the clarification (C) phase isflowcharting.
FOCUS-PDCA
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Understand causes of process variation In this stage, the team strives to understand why the
existing process is not working well, i.e., what are the
reasons for process variation.
Cause-and-effect diagram, also known as "fishbone"
diagram, is an excellent aid in the (U) understanding phase
of the FOCUS-PDCA cycle. A cause-and-effect diagram is
actually only a graphic presentation of a list.
FOCUS-PDCA
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Understand causes of process variation Whilebrainstormingmay be used anywhere in the FOCUS-
PDCA cycle, the first need for it will likely be encountered
in the (U) understanding phase. Brainstorming is effective
because it is free form and does not restrict people in
offering ideas. It encourages responses from team
members who may for a variety of reasons be reluctant to
participate.
Brainstorming can be followed by amultivoting technique. At this point, it may become necessary to use thePareto
analysis to determine what is causing most of the
problems.
FOCUS-PDCA
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Select the strategy for improvement At this point in the cycle the team should be ready to
select the improvement or improvements that will be
made in the process. It may be necessary to use a structured approach that
results in a precise statement of the planned
improvements that was reduced down from a
thorough study of the alternatives (e.g., prioritizationmatrix).
FOCUS-PDCA
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Plan the improvement Here, the team should outline how the improvements
will be accomplished, i.e., the who, what, where, and
when. Consideration should be given to developing a pilot
projectfor the selected changes.
Considering what resources, training, etc., shall be
needed is crucial.
FOCUS-PDCA
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Do the improvement Implement the planned improvement.
Usually, the implementation is the responsibility of
the team.
FOCUS-PDCA
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Check the results After the implementation of the improvements, it will be
necessary to continue data collection to determine if the
improvements have proven successful in bringing the processto the desired direction.
If continued checks indicate that the desired outcome has
not occurred, it may be necessary to return to theselection
stageand take another look at the alternative improvements.
If all is going well, the team should perform a self analysis oftheir performance with emphasis on how the team process
could have been improved. This team self-analysis can be
reported to the quality council to benefit future teams.
FOCUS-PDCA
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Act to maintain the gains There is often a tendency for things to reverse to their
previous state if well-planned controls are is not in place.
It is very important to ensure that initial gains are not lostdue to subsequent satisfaction, failure to stick to on
implemented changes, etc.
Now after the new improvements have proven success, the
team should consider revising and modifying the relevant
policies and procedures, etc. Additionally, performingregular internal audits is crucial to ensure the compliance
to such new or modified policies and procedures.
Control charts are usually used to monitor the maintenace
of such gains.
FOCUS-PDCA
Middl f h I b M d l
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2. ISO 9000:o The ISO 9000 Quality Management System was created
in 1987
o In 1994, ISO 9001 standards were released.
o The most recent version of ISO 9000 is ISO 9001:2008
o Applicable to both manufacturing and service sectors.
o Emphasizes:
documentation and recording.
conduction of internal audits on a regular basis.
taking corrective and/or preventive actions,
whenever needed.
listening to customers.
continuous improvement.
Middle of the Iceberg Model:
Systems, Frameworks, and Models
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Middl f th I b M d l
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4. Six Sigma:o A system for improvement that was
developed over time by GE and Motorola in
the 1980s.
o The aim of Six Sigma is the to reducevariation/eliminate defects in key business
processes.
o Methodology follows the following five
steps: Define, Measure, Analyze, Improve,and Control (DMAIC).
Middle of the Iceberg Model:
Systems, Frameworks, and Models
Middl f th I b M d l
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o All of the pre-mentioned are systems or frameworksfor performance improvement, and each has a
slightly different focus, tools, and techniques
associated with it.
o However, all these programs emphasize customer-focus, process analysis, and teamwork.
o The compatibility of any of them within any
organization depends on the organizational culture
and infrastructure, the top management support
(both ideologically and financially), and the
employees buy-in and support (which is again
dependant on the top management commitment).
Middle of the Iceberg Model:
Systems, Frameworks, and Models
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Tools, methods, and procedures are analogous
to the tip of the iceberg.
We can observe people using tools and
methods for improvement. We can see them
making a flowchart, plotting a control chart, or
using a checklist.
Tip of the Iceberg Model:
Methods, Procedures, and PI Tools