Quality Assurance & Accountability and Collaborative Decision-Making
May 2009
Objective By participating in this session, you will understand specific examples of QA&A programs AND collaborative decision making and problem solving.
Agenda • Concepts of Quality • Quality Challenges • Culture • QA&A • Shared Governance and Accountability • Collaborative: • Decision Making • Problem Solving
Who Started The March Towards Quality?
“Santa Filomena" Henry Wadsworth Longfellow, 1857 Lo! in that hour of misery; A lady with a lamp I see; Pass through the glimmering gloom, And flit from room to room.
Florence Nightingale
Quality Evaluation in Health Care
Agenda • Concepts of Quality • Quality Challenges • Culture • QA&A • Shared Governance and Accountability • Collaborative: • Decision Making • Problem Solving
Concepts of Quality Why the discussion of AL standards of care and quality indicators? – Serving an increasingly vulnerable population (greater functional limitations and higher acuities)
– Perceived lack of internally-developed or professionallymandated standards of quality and care – Distrust of the free market to provide quality – Accepting more public funds in payment
Defining Quality in Assisted Living: Comparing Apples, Oranges, and Broccoli: Hawes, Catherine, Phillips, Charles D.; Gerontologist 2007 47: 40-50
Concepts of Quality • Lack of consensus: – Definition of quality measures – The role of AL
• Significantly confounds the task of comparing quality: – Among AL settings – Between AL and other LTC settings
• Quality must embrace: – – – –
Quality of care Quality of life Physical environment Resident rights Defining Quality in Assisted Living: Comparing Apples, Oranges, and Broccoli: Hawes, Catherine, Phillips, Charles D.; Gerontologist 2007 47: 40-50
Concepts of Quality One Philosophy of Assisted Living: • Principle 1: Provide resident autonomy in the environment • Principle 2: Meet scheduled and unscheduled needs • Principle 3: Facilitate aging in place • Principle 4: Promote resident independence and autonomy
Defining Quality in Assisted Living: Comparing Apples, Oranges, and Broccoli: Hawes, Catherine, Phillips, Charles D.; Gerontologist 2007 47: 40-50
Concepts of Quality One Definition: A congregate, residential setting providing and coordinating: •
Personal services
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24-hour supervision and assistance (scheduled and unscheduled)
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Activities and health related services.
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And designed to:
Defining Quality in Assisted Living: Comparing Apples, Oranges, and Broccoli: Hawes, Catherine, Phillips, Charles D.; Gerontologist 2007 47: 40-50
Concepts of Quality One Definition: A congregate, residential setting providing and coordinating: •
Personal services
•
24-hour supervision and assistance (scheduled and unscheduled)
•
Activities and health related services.
•
And designed to: – Accommodate changing needs and preferences –
Maximize dignity, autonomy, privacy, independence, safety
– Encourage family and community involvement – Minimize the need to move Defining Quality in Assisted Living: Comparing Apples, Oranges, and Broccoli: Hawes, Catherine, Phillips, Charles D.; Gerontologist 2007 47: 40-50
Concepts of Quality * Some suggest that quality indicators should include the residents’ assessments of : – Choices and control they have – How they are treated by staff – Level of social interaction and community involvement – Whether activities meet their preferences – Degree to which changing needs and preferences are met – Policies and service availability
Defining Quality in Assisted Living: Comparing Apples, Oranges, and Broccoli: Hawes, Catherine, Phillips, Charles D.; Gerontologist 2007 47: 40-50
Agenda • Concepts of Quality • Quality Challenges • Culture • QA&A • Shared Governance and Accountability • Collaborative: • Decision Making • Problem Solving
Quality Challenges Behavior Environmental Conditions Falls Pain Restorative Wounds
Elopements Events/Accidents/Incidents Nutrition Restraints Resident-to-Resident Incidents ??
“More than 50 percent of residents in assisted living and nursing homes have some form of dementia or cognitive impairment … and that number is increasing every day.”
Quality Challenges Behavior Environmental Conditions Falls Pain Restorative Wounds
Elopements Events/Accidents/Incidents Nutrition Restraints Resident-to-Resident Incidents Dementia
How do you solve them? How do you achieve “resident safety”?
Agenda • Concepts of Quality • Quality Challenges • Culture • QA&A • Shared Governance and Accountability • Collaborative: • Decision Making • Problem Solving
Culture of Safety and Quality • The utopian environment where medical errors do not occur because everyone is safety-conscious enough to avoid all mistakes. www.idph.state.ia.us/patient_safety/glossary.asp
A facility with a commitment to safety: 1. Acknowledges high-risk nature of population and setting 2. Develops reporting system that does not place blame 3. Involves all staff in identifying solutions (interventions) 4. Directs resources to address safety concerns and 5. Demonstrates commitment to safety at all levels of the organization
Culture of Safety and Quality • The utopian environment where medical errors do not occur because everyone is safety-conscious enough to avoid all mistakes. www.idph.state.ia.us/patient_safety/glossary.asp
Creating a culture of resident safety: 1. Acknowledges high-risk nature of population and setting 2. Develops reporting system that does not place blame 3. Involves all staff in identifying solutions (interventions) 4. Directs resources to address safety concerns and 5. Demonstrates commitment to safety at all levels of the organization
Culture of Safety and Quality
“Improvements in patient safety will hinge as much on significant shifts in the culture of health care as on specific changes in the process of providing care.” There is no “best blueprint” for “culture”. A (desired) culture … does not just evolve; it is created.
Authors: Douglas McCarthy, M.B.A., and David Blumenthal, M.D.; Summary Writer(s): Linda Prager and Deborah Lorber March 27, 2006 | Volume 34
Culture of Safety and Quality
Thru safety we achieve the assurance of quality.
Agenda • Concepts of Quality • Quality Challenges • Culture • QA&A • Shared Governance and Accountability • Collaborative: • Decision Making • Problem Solving
Quality Assessment and Assurance • Keys to Quality Assurance: – Everyone is responsible for quality – TQM, TPS, CQI, HRO, PI, etc.
• Objectives: – Define and meet residents’ needs/requirements – Maximize resident satisfaction – Achieve the lowest possible cost
• Notes: – We seek to increase quality but decrease expenses – There is almost always a conflict between cost-cutting and continuous improvement
Quality Assessment and Assurance •
Be Careful: Compliance improvement v. Quality improvement
•
Four components to the "ideal" care model: – Clinical systems 1. Staff knowledge and understanding of clinical information 2. Provide staff with clinical tools and protocols
– Organizational systems 3. Process to ensure staff use of info, tools and protocols 4. Monitor care outcomes by using CQI
Assisting Nursing Homes Improve Quality of Care, Academy for Health Services Research and Health Policy, 2002
Quality Assessment and Assurance Frontline staff should: – – – – –
Participate in QA&A Identify and solve problems Help design and implement clinical tools and protocols Work as a team and Recognize a Champion
• Facility QA&A program should: – Establish and utilize best practices – Establish and utilize clinical provider tools – Gather and utilize resident clinical information Assisting Nursing Homes Improve Quality of Care, Academy for Health Services Research and Health Policy, 2002
Quality Assessment and Assurance The QA&A Triangle Defining Quality
QA Improving Quality
Measuring Quality © QA Project, 2000
Agenda • Concepts of Quality • Quality Challenges • Culture • QA&A • Shared Governance and Accountability • Collaborative: • Decision Making • Problem Solving
Shared Governance and Accountability
Change never can be fully anticipated or planned for; it evolves. The key to handling change is to be open to it and to find ways to work in concert with it. Implementing Shared Governance Web-Book, 2005, Tim Porter-O’Grady
Shared Governance and Accountability •
Governance … aka. (Shared / Integrated / Clinical Compliance, Magnet Status, Journey to Excellence)
– The management structure/culture – Authority v. Accountability C:\My Documents\Professional\Quality Assurance\Governance and Accountability\American Nurses Association - Shared Governance Hartford Hospital's Experience.htm; Shared Governance: Hartford Hospital's Experience -- Laura Caramanica, PhD, RN
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Shared Governance … dynamic … “staff + leader” partnership … a philosophy/structure based on: – Democratic and representative principles … (Implementing Shared Governance Web-Book, 2005, Tim Porter-O’Grady)
– Collaboration and shared decision-making – Shared accountability for QA&A (care, safety, and enhancing work life) (v. responsibility) C:\My Documents\Professional\Quality Assurance\Governance and Accountability\Vanderbilt Nursing, Shared Governance.htm
Shared Governance and Accountability Seven Standards of Shared Governance -- a way of thinking that upholds seven basic criteria for a “profession in a free society”: 1. Defined and organized body of specialized knowledge 2. Consistently enlarging knowledge and processes 3. Professionally based culture – attracts individuals with intellectual and personal qualities 4. Educated practitioners (institution of higher learning) 5. Knowledge and practices apply to human and social welfare 6. Has some form of social and legal sanction 7. Functions autonomously, formulates own professional policy and controls (Flexner, 1915/2001)
Shared Governance and Accountability Traditional nursing structures (bureaucracy): – Staff tend to focus on the tasks of care delivery – Management tends to focus on the decisions of nursing
In shared governance, the structures (linkages, networking and integration) are established so that: – Decisions affecting care are kept closer to the bedside – Staff are accountable for the care delivery – Managers are accountable for providing support
Accountability is based on work roles, for example: – Care Delivery -- Quality – Education/Training -- Staff Management -- Executive/Coordinating C:\My Documents\Professional\Quality Assurance\Governance and Accountability\American Nurses Association - Shared Governance Hartford Hospital's Experience.htm; Shared Governance: Hartford Hospital's Experience -- Laura Caramanica, PhD, RN
Shared + Governance + Accountability “There are no unilateral decisions in health care.” (Bocchino, 1990) • “Shared” because no one will get to tomorrow alone. • “Governance” ties the activities of care delivery into the governing, ruling, decision-making model. • “Accountability” results from involving clinicians in the care decisions and care delivery Shared Governance and Accountability is not just a structure. It becomes a way of thinking and managing. It is not just what managers do but who they are.
•Implementing Shared Governance Web-Book, 2005, Tim Porter-O’Grady
Shared Governance and Accountability Shared Governance – Why Bother? – Enables change, growth and empowerment. – Facilitates the creating and management of change. – Is a road to the maturing of the care delivery profession. – Treats teams as the basic unit of work. – Focus on team processes not individual roles/behaviors.
NOTE: It is not an end in and of itself and it is not the future.
•Implementing Shared Governance Web-Book, 2005, Tim Porter-O’Grady
Shared Governance and Accountability Thoughts: • First: Time is a familiar barrier. • Second: Shared governance isn’t an “invitation” but an “expectation”. • Third: You must make adjustments as “it” evolves. • Fourth: Not all decisions can be made through consensus; define how decisions will be made
C:\My Documents\Professional\Quality Assurance\Governance and Accountability\American Nurses Association - Shared Governance Hartford Hospital's Experience.htm; Shared Governance: Hartford Hospital's Experience -- Laura Caramanica, PhD, RN
Agenda • Concepts of Quality • Quality Challenges • Culture • QA&A • Shared Governance and Accountability • Collaborative: • Decision Making • Problem Solving
Collaborative Decision Making Formally or Informally
Issue or a Risk
SIDEBAR 1: Complexity
"Any intelligent fool can make things bigger (and) more complex... It takes a touch of genius, and a lot of courage, to move in the opposite direction.” - Albert Einstein
SIDEBAR 2: Value?
Solution Acceptability
RESIDENT CARE
Collaborative Decision Making Moving Forward
Issue or a Risk
Collaborative Decision Making Defining Collaborative Decision Making (CDM) • Problem solving (personal and professional) • Making decisions with others (little or big) • A regular part of our lives • Negotiating – "Negotiation is a basic means of … back-and-forth communication designed to reach agreement when you and the ‘other side’ have both shared and opposed interests.” http://www.directionservice.org/cadre/section5.cfm#STEPS%20IN%20THE%20COLLABORATIVE%20PRO CESS; Collaborative Problem Solving: Steps in the Process by Rod Windle and Suzanne Warren
Collaborative Decision Making CDM Goals: – – – –
Define issues Generate options Identify solutions Reach agreement
NOTE: Not always (seldom) a linear process … the “best next step" maybe backwards or sideways
http://www.directionservice.org/cadre/section5.cfm#STEPS%20IN%20THE%20COLLABORATIVE%20PRO CESS; Collaborative Problem Solving: Steps in the Process by Rod Windle and Suzanne Warren
Collaborative Decision Making First steps in CDM: •
Identify: 1. TEAM: Assign/recruit/notify stakeholders/members 2. GOALS: What do we hope and need to accomplish 3. ROLES: Facilitator, record and time keeper * 4. RULES: Set general ground rules *
Collaborative Decision Making The Facilitator • Listen (content, intent, sentiment, between the lines) • Share (responsibility, information, laughter, expertice) • Focus (on the task, process and time) • Support (ideas, thoughts and feelings) • Respect (perceptions, differences, privacy)
•Collaborative Nursing Practice: Facilitator’s Guide, March 2006 1st edition
Collaborative Decision Making Sample Ground Rules 1. Meet each Thursday in the DON’s office. 2. Members will be prepared, and attend consistently/timely. 3. All members have an equal right to be heard. 4. The “100 mile rule” applies. 5. Violators must bring refreshments to the next meeting. 6. Quorum … 7. Minutes …
Collaborative Decision Making
Next Steps 5. Inter-disciplinary (v. multi-disciplinary) 6. Identify/define the issues (e.g. at risk for fall, scheduling issues, non-compliance) 7. Generate ideas (brainstorm ideas from ALL angles) * 8. Develop objective criteria for deciding (Evaluate, Select, Combine, Agree) *
http://www.directionservice.org/cadre/section5.cfm#STEPS%20IN%20THE%20COLLABORATIVE%20PRO CESS; Collaborative Problem Solving: Steps in the Process by Rod Windle and Suzanne Warren
Collaborative Decision Making Generate Ideas Using Brainstorming • GOAL: Generate as many ideas/options as possible • CAUTION – We’re: NOT accustomed to “inventing” options ... TOO quick to critique and judge ... WHICH: – Curtails the flow of ideas – People become unwilling to risks new ideas – Suppresses creativity
• Remember, this is not the time for evaluating the suggested ideas/options. http://www.directionservice.org/cadre/section5.cfm#STEPS%20IN%20THE%20COLLABORATIVE%20PRO CESS; Collaborative Problem Solving: Steps in the Process by Rod Windle and Suzanne Warren
Collaborative Decision Making Rules of Brainstorming – Generate Ideas: don’t debate their value – Record All Suggestions: don’t stifle the flow – No Criticism: judging is not allowed – Be Free-wheeling: use creativity, imagination, take risks – Go for Quantity: the more and varied the ideas the better – Encourage: all angles, dovetailing, piggybacking, revising – Combine and Expand: modify and build on other's ideas
http://www.directionservice.org/cadre/section5.cfm#STEPS%20IN%20THE%20COLLABORATIVE%20PRO CESS; Collaborative Problem Solving: Steps in the Process by Rod Windle and Suzanne Warren
Collaborative Decision Making A Brainstorming “Must” Your Open Mind -- be FLEXIBLE: – Willing to consider new ideas – Willing to revise your thinking
Don’t loose sight of where you’re going, but remember -- collaboration creates synergy and identifies new ideas and options.
http://www.directionservice.org/cadre/section5.cfm#STEPS%20IN%20THE%20COLLABORATIVE%20PRO CESS; Collaborative Problem Solving: Steps in the Process by Rod Windle and Suzanne Warren
Collaborative Decision Making Then, decide On Objective Criteria After brainstorming, agree upon criteria by which the ideas/options will be evaluated. Examples: – (Immoral, illegal, unethical) – Budgetary constraints – Best practices – Residents’ rights – Accepted standards (federal/state, medical/IC, budgetary, legal, scientific, procedural). http://www.directionservice.org/cadre/section5.cfm#STEPS%20IN%20THE%20COLLABORATIVE%20PRO CESS; Collaborative Problem Solving: Steps in the Process by Rod Windle and Suzanne Warren
Collaborative Decision Making Decide On Objective Criteria (cont’d.) This: – Helps to avoid a contest of wills – Keeps the focus on solutions and avoids defending a particular option – Enables parties to change their perceptions without "losing face" – Creates agreements that are fair and wise
http://www.directionservice.org/cadre/section5.cfm#STEPS%20IN%20THE%20COLLABORATIVE%20PRO CESS; Collaborative Problem Solving: Steps in the Process by Rod Windle and Suzanne Warren
Collaborative Decision Making Evaluate and narrow the options; reach agreement Thumbs or Stars – Apply the criteria – Go item by item – Some can be eliminated with unanimous thumbs down – Some “partially meets” may be worth combining
http://www.directionservice.org/cadre/section5.cfm#STEPS%20IN%20THE%20COLLABORATIVE%20PRO CESS; Collaborative Problem Solving: Steps in the Process by Rod Windle and Suzanne Warren
Collaborative Decision Making Two Quick Thoughts 1. Throughout the process: – Continually refer back to the identified goals and the objective evaluation criteria.
2. When an agreement is reached, ask: – "Is this the best job we can do? Is there room for improvement? Do we have a “maximized solution” or is it only marginally acceptable?"
http://www.directionservice.org/cadre/section5.cfm#STEPS%20IN%20THE%20COLLABORATIVE%20PRO CESS; Collaborative Problem Solving: Steps in the Process by Rod Windle and Suzanne Warren
Agenda • Concepts of Quality • Quality Challenges • Culture • QA&A • Shared Governance and Accountability • Collaborative: • Decision Making • Problem Solving
Collaborative Problem Solving Two Adapted Tools From the Toyota Production System – Value Stream Mapping and – A3 Problem Solving Report
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Identify the areas in need of improvement
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Better understand the problem
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Identify which changes will improve the problem
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Develop, implement and monitor a solution strategy
Pragmatic Problem-Solving For Healthcare: Montana State University, Bozeman, MT 59717, 2005
Collaborative Problem Solving FACILITY: Community Medical Center (CMC), Missoula, MT • Three year study (2001-2004) • 146-bed acute care • High turnover; facility-wide growing manpower shortage • Many existing employees were working long hours Variety of Departments: Therapy ER
Pharmacy Registration Financial Services
Diagnostics IT
Pragmatic Problem-Solving For Healthcare: Montana State University, Bozeman, MT 59717, 2005
Collaborative Problem Solving CONCLUSIONS: Staff 1. Observed the problem first hand 2. Did basic RCA 3. Improved patient outcomes and efficiency by redesigning the process KEY OUTCOME: The staff became actively involved in solving problems on their own in clinical and non-clinical areas.
Pragmatic Problem-Solving For Healthcare: Montana State University, Bozeman, MT 59717, 2005
Collaborative Problem Solving A3 Problem Solving Process Steps 1. Observe and document the current state 2. Hand sketch the current state 3. Brainstorm and RCA 4. Hand sketch the target state 5. Implement Evaluate results and make modifications
Pragmatic Problem-Solving For Healthcare: Montana State University, Bozeman, MT 59717, 2005
Collaborative Problem Solving
Pragmatic Problem-Solving For Healthcare: Montana State University, Bozeman, MT 59717, 2005
Collaborative Problem Solving
Pragmatic Problem-Solving For Healthcare: Montana State University, Bozeman, MT 59717, 2005
Collaborative Problem Solving Results: – Improved patient care – Set up time and the documentation time decreased from an initial 20 to 25 minutes to 5 minutes – Actual patient care time increased from 20 to 25 minutes to approximately 40 minutes – 80% improvement in billable time and increased revenues
Pragmatic Problem-Solving For Healthcare: Montana State University, Bozeman, MT 59717, 2005
Collaborative Problem Solving
Root Cause Analysis
Root Cause Analysis (RCA)
DEFINITION / DESCRIPTION • A formal structure to learn from the past • Retrospectively and systematically searches out contributing and root causes that underlie near miss, adverse or sentinel events • A qualitative tool that is complementary to other techniques employed in error reduction
(Personal Observations)
Root Cause Analysis (RCA) How do you do RCA? • GATHER DATA “What happened?” (structured interviews, documents review, field observation; generate a sequence or timeline of events preceding and following the event)
• ANALYZE DATA “Why did it happen?” (Five times) (examine the sequence of events to determining the common underlying factors; identify both active and latent failures) Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Chapter 5. Root Cause Analysis
• IDENTIFY THE CONTRIBUTING and ROOT CAUSES
Root Cause Analysis (RCA) TWO MAJOR CATEGORIES OF ERROR • Active: Humans • Latent: Systems Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Chapter 5. Root Cause Analysis
TWO MAJOR CATEGORIES OF EVENTS • Adverse: Small/medium errors … • Sentinel: Leads to or has the potential to lead to death, serious injury (Sentinel Events: Evaluating Cause and Planning Improvements. JCAHO 1998)
NOTE: Sentinel events tend to be preceded by near-miss events (i.e. warnings, pre-cursors) Using Root Cause Analysis to Make the Patient Care System Safe by: John Robert Dew, Ed.D.
Its cardinal rule of RCA to avoid of placing individual blame. Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Chapter 5. Root Cause Analysis’
Root Cause Analysis (RCA)
Identify a Risk Human Factors
Root Cause Analysis (RCA)
Training
Human Factors
Identify an Opportunity for Improvement
P&P
Environmental
Equipment & Materials
"Ishikawa" / “Fishbone”
Root Cause Analysis (RCA)
LIMITATIONS: • Occurrence of accidents is unpredictable • It is difficult to know if the root cause has been identified (Dryer fires) • Hindsight bias (“I told you so”; “I knew it was going to happen”; “Hindsight is 20/20”) • Low priority (Compared to staffing, management, IT, census) • Perceptions (Time-consuming, labor intensive, $$)
Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Chapter 5. Root Cause Analysis
In Review • Concepts of Quality • Quality Challenges • Culture • QA&A • Shared Governance and Accountability • Collaborative • Decision Making • Problem Solving
Thank You for Your Time!
May 2009
