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Quality Improvements Steps Dr Bruno Bouchet Regional Quality of Care Director

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QIP Planning Meeting Ferghana, September 17, 2002 OBJECTIVE To implement a logical sequence of activities that will lead to improved quality of care to patients, through identification of issues, understanding of their causes, and interventions to address them.

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QIP Planning Meeting Ferghana, September 17, 2002 3 Main Quality Improvement Steps 1.Express the improvement objective or quality issue to address 2.Get information 3.Implement interventions/changes

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QIP Planning Meeting Ferghana, September 17, 2002 Quality Improvement Methods (1) Many small methods promoted by various organizations Many acronyms: PI, FOCUS-PDCA, COPE, etc. Lots of confusing jargon: team-based problem solving, permanent process improvement, reengineering, quality design, rapid improvement cycle, etc.

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QIP Planning Meeting Ferghana, September 17, 2002 Quality Improvement Methods (2) The name of the method does not really matter as long as you follow a logical sequence of steps. All methods have their own little sub- steps and differences but follow the same logic/sequence of 3 main steps: express objective, get information, implement intervention

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QIP Planning Meeting Ferghana, September 17, 2002 First: Express your Improvement Objective (1) Identify an opportunity for improvement or a quality of care issue Criteria: Frequency (high volume) Seriousness (high risk) Difficulty to manage (problem-prone) Costly (high cost)

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QIP Planning Meeting Ferghana, September 17, 2002 Express your Improvement Objective (2) Criteria: 1.Frequency (high volume) 2.Seriousness (high risk) 3.Difficult to manage (problem-prone) 4.Costly (high cost) Examples: 1.25% of adult population has arterial hypertension 2.80% of women with pregnancy- induced hypertension develop eclampsia 3.60% of patients with myocardial infraction die within the first 48 hours at the hospital 4.50% of newborns are hospitalized for 2 months for neonatal infections, for an average cost of $2000.

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QIP Planning Meeting Ferghana, September 17, 2002 Express your Improvement Objective (3) Sources of information: Routine Health Information System Health Statistics Reports Performance Monitoring Systems Supervision/Visits/Inspection System Health Surveys (DHS, etc.) Burden of Diseases Surveys Providers opinions Patients opinions

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QIP Planning Meeting Ferghana, September 17, 2002 Express your Improvement Objective (4) Examples of general quality improvement objective statements: To improve the quality of care to adult patients with arterial hypertension To improve the performance of the healthcare system for women of reproductive age with anemia To improve the quality of care to children according to IMCI clinical care standards

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QIP Planning Meeting Ferghana, September 17, 2002 Express your Improvement Objective (5) Subsequent main steps: Define what is meant by system performance or quality of care in each particular situation* (health topic, level of the health system, stakeholders perspectives) Identify indicators that would reflect improved quality of care or overall system performance Setup a Quality Performance Monitoring System *When evidence-based clinical care standards are not available, use common-sense standards for the first improvement cycle

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QIP Planning Meeting Ferghana, September 17, 2002 Second: Get Needed Information (1) Identify the information you need: To know more about the topic for improvement (knowledge of the content of care) To know more about the magnitude and types of quality issues To know more about the consequences of poor performance/quality

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QIP Planning Meeting Ferghana, September 17, 2002 Get Needed Information (2) Identify the information you need: To understand the causes of poor performance and factors influencing quality To identify who is involved in the healthcare system and processes to improve To know the opinions of the stakeholders on the topic for improvement

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QIP Planning Meeting Ferghana, September 17, 2002 Get Needed Information (3) Identify the information you need: To know more about the current organization of healthcare services for the particular topic To understand the referral patterns between levels of the system To identify the components that need to be part of the healthcare system for a particular health condition/issue

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QIP Planning Meeting Ferghana, September 17, 2002 Get Needed Information (4) Get the information you need: Review of existing data (many sources) Collection of more data (direct observation, review of records, interviews, focus group discussions, inspections) Through the Quality Performance Monitoring System Transform data into meaningful information (indicators, qualitative, costs, etc.)

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QIP Planning Meeting Ferghana, September 17, 2002 Third: Implement Interventions/Changes (1) Make sense of the information you got Use the information to suggest/identify interventions Be creative Focus on interventions that change/redesign some or all components of the healthcare system involved in the particular topic

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QIP Planning Meeting Ferghana, September 17, 2002 Implement Interventions/Changes (2) Consider Interventions as ideas to test, and implement them as an operational research, following the Shewhart cycle: Plan- Do-Study-Act

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Repeated PDSA to increase compliance with standards Cycle 4: Assessment of providers performance Cycle 3: Pharmacist checks relation treatment/diagnosis AP SD A P S D AP SD D S P A Performance Indicators Cycle 2: Define job-aids for IRA Cycle 1: Remind IRA treatment standards 30% 3% 25% 15% 8%

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Chart illustrating the effect of changes on performance Change 1 Change 2 Change 3 Change 4

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QIP Planning Meeting Ferghana, September 17, 2002 The Overall Management of a Quality Improvement Project (1) Before the QI steps: Obtain consensus/agreement Discuss ideas Expose stakeholders to Quality management concepts Planning meeting Setup different teams Inform everybody

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QIP Planning Meeting Ferghana, September 17, 2002 The Overall Management of a Quality Improvement Project (2) During the QI/Steps: Reconsider the team composition and needs for new teams Maintain team cohesion Facilitate communication Sustain enthusiasm Encourage/Motivate Provide technical assistance Ensure quality of work processes

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QIP Planning Meeting Ferghana, September 17, 2002 The Overall Management of a Quality Improvement Project (3) After the QI steps: Draw lessons and conclusions Celebrate/reward Document Present/Communicate Replicate, expand changes/results Institutionalize an improvement dynamic

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QIP Planning Meeting Ferghana, September 17, 2002 Conclusion Pilot Quality Improvement Projects in Ferghana have the potential to significantly influence the design of the health sector reform through increasing our knowledge of more effective clinical practices and better organization of healthcare services