Quality Improvement Jean Johnson, PhD, RN, FAAN Dean and Professor George Washington University This program generously funded by the Robert Wood Johnson Foundation American Association of Colleges of Nursing. © 2013 - All Rights Reserved.

Quality Improvement Use of data to monitor the outcomes of care processes and use of improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems (Cronenwett et al., 2007).

American Association of Colleges of Nursing. © 2013 - All Rights Reserved.

Key Message •

Improving patient care requires a systematic process of defining problems in order to identify potential causes and develop strategies to improve care. This process requires the ability to measure care. We can only improve care if we measure how well we are doing and compare our performance against others.

American Association of Colleges of Nursing. © 2013 - All Rights Reserved.

Learner Objectives •

Describe the National Quality Agenda

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Analyze the QI Process and Quality Measures

•

Describe Policy Issues related to QI

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National Quality Strategy: Better Care, Healthy People/Communities, Affordable Care • National Priorities Partnership  Brought together by National Quality Forum  51 major national organizations  achieve better health, and a safe, equitable, and value-driven healthcare system

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Partnership for Patients    

Public private partnership, auspices of CMS Hospital engagement network Community-based transitions program Patient and family engagement

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Roots of Patient Safety and Quality • • •

Florence Nightingale 1854 Avedis Donabedian 1966 Institute of Medicine Reports  To Err is Human: 1999  Crossing the Quality Chasm: 2001

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Don Berwick 1991 Value based purchasing 2010

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Payment Levers for Change • •

Value = Cost + Quality Centers for Medicare and Medicaid--hospitals  Adverse Events (Never Events): Objects left in after surgery, air embolisms, blood incompatibility, pressure ulcers, falls in the hospital  Move from paying for reporting to paying for quality

• • •

Accountable Care Organizations Bundled Payments Medical Homes

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Framework for Quality Concepts

Framework for Measurement

Measures of STEEP

Safe

Efficient

Timely

Effective

Structure • • •

Number/patient ratio Written policies Safe equipment

Pt Centered

Process • • •

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Equitable

Medication administration Procedure for wound care System to monitor ICU patients

Outcome • • • •

Length of stay Mortality Morbidity Patient satisfaction

Overview of Quality Improvement QI Process: Monitor, identify problems, identify cause and conduct PDSA Measures/ Observation

Problem Identification

(Monitoring, benchmarking)

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Cause of the problem

PDSA

(small test of change) Plan Do Study Act

Nationally Recognized Quality Measures • Joint Commission Oryx • Compare websites (hospital, nursing facility, home • • • • •

care) Centers for Medicare and Medicaid required reporting measures National Quality Forum Nursing-Sensitive Care HEDIS Patient Centered Health Home Accountable Care Measures

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Compare Websites and Other Sources of Public Information • • • •

Hospital Compare — CMS Website Nursing Home Compare — CMS Website Oasis (Home Care) — CMS Website Patient Centered Medical Homes — NCQA Website

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Nursing Sensitive Measures • • • • • •

National Quality Forum Nursing Sensitive Measures ANA National Database for Nursing Quality Indicators (NDNQI) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Collaborative Alliance for Nursing Outcomes (CalNOC) Military Nursing Outcomes Database (MilNOD) Veterans Administration Measures

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Criteria for Measures • • • • • • • •

Important to consumers and/or for internal quality improvement Based on agreed definitions, and described exhaustively and exclusively Accurate (reliable, valid and risk adjusted)—large enough number of events Can be influenced by the provision of high quality care by nursing staff Collectible Variation essential/discriminates well Evidence-based Timely

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Variation •

• •

Types of Variation  Common cause/inherent (small changes in the nurse/patient ratio but meets standard) • Due to the process itself • Variation will remain the same from day to day  From sources outside the process and variation will differ from standard (not having a sufficient nurse to adequate nurse/patient ratio) Outliers Benchmarking - establishes standard for comparison

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Benchmarking/Setting the Bar • • •

Definition: Comparing process or outcome metrics of the best, high performing organizations with similar processes and outcomes Benchmarks may be set internally as something to strive for Use national data sets for some benchmarks; there may be cases in which everyone is doing a poor job

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Collection of QI Data to Identify Problems • •

Work with QI team Use and review reports  Run chart  Flow chart  Control chart

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Establish data timelines

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Identifying Cause(s) of the Problem •

Root cause analysis: Systematic approach to get to the true root causes of our process problems  Five whys  Brainstorming  Cause and Effect Diagram (Fishbone Diagram)

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Small Test of Change

From the Royal Children’s Hospital, Melbourne Australia

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Policy Issues Related to QI •

Understand the politics of quality and reporting  Federal  State  Institution

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Participate in policy decisions about use of indicators—providing comment, at the table

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Role Expectations • Master’s level:    

Defines a question Input into measures to be used Input/establish benchmark Input/manage invention process and data collection

• DNP  Above plus: • Manage QI activities, i.e.-chair QI committee • Input/lead systems change based on QI processes

• PHD    

Work with clinicians to identify relevant questions Define research methods and process Conduct research/PI on projects Participate in implementation of findings

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Integration of QI Concepts

Provider Competencies • • • • • •

Safety Evidence Based Quality Teamwork Patient Centered Informatics

IOM Aims National Quality Strategy

• • • • • •

Safe Timely Effective Efficient Equitable Patient Centered

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Measurement Format • Outcome • Process • Structure

Improved Patient Safety

Teaching Strategies •

• • •

Have students review data from a clinical site (acute care, nursing homes, home care, primary care), compare the data to benchmarks, identify at least one measure that is below benchmark and develop a plan to improve this measure Assign students in outpatient practices to review requirements for patient centered health home and create a plan to achieve that designation Have students analyze HEDIS data, identify one problem and create a plan of correction Have students analyze the quality culture in their clinical site and create a plan to enhance a quality culture

American Association of Colleges of Nursing. © 2013 - All Rights Reserved.

Not all change is improvement, but all improvement requires change. Institute for Healthcare Improvement

American Association of Colleges of Nursing. © 2013 - All Rights Reserved.