PERFORMANCE IMPROVEMENT PROCESSES Chapter 4 1. Quality Management & Performance Improvement Quality Management Trilogy – Quality Planning – Quality Control.

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PERFORMANCE

IMPROVEMENT

PROCESSES

Chapter 4

Quality Management & Performance Improvement

• Quality Management Trilogy– Quality Planning– Quality Control / Measurement– Quality Improvement

• QM/PI Function – Design– Monitor– Analysis– Improve

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JURAN MODEL

• Quality Planning (Strategic Leadership)

• Quality Control/Measurement(Measurement)

• Quality Improvement (Performance Improvement Processes)

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PERFORMANCE IMPROVEMENT PROCESSES

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PIProcess

Quality Planning

QualityControl

QualityImprovement

Design Monitor Analyze Improve

Read Through IV pages 2-4 for more information

PI Process Identify team Use systematic approaches Formulate an action plan Test action as appropriate Commit to implementation Implement Improvement sustainment Evaluate effectiveness Document improvement plan & result Communicate/disseminate information across

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PI Models/Modalities

• Shewhart Cycle (PDCA or PDSA)

• Juran’s QI Process

• Six Sigma

• Lean Management

• Others

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Review IV pages 29-41 to determine the applicability of each model

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• Improvement is a continuous process• As you complete 1 PDCA cycle it often leads

you into another one

Continuous Process

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PERFORMANCE-BASED QM TOOLS

• Performance Measures/Indicators/Metrics– Assess the degree to which appropriate and expected course of action is

being followed– Assess the degree to which the expected outcome is met

• Standards – Expected performance

• Guidelines– Set of specifications for care and processes that pertain to the functions of

a healthcare organization

• Performance Database– Standardized data elements and definitions, accuracy/completeness and

capacity for statistical analysis, aggregation, display, and trending9

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• Garbage in = Garbage out

• Must plan what to collect, how to collect it, and what to do with it after it has been collected– Different kinds of data are analyzed differently– Count vs. Continuous (measured) data

• Data must be translated into meaningful information

• Must collect data to determine where you are now • Will recollect data after the changes are made to

determine if you have met your goal

Data, Metrics, Tools

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Metrics – What to Measure

• Determined by what you want to know about something– Process– Outcome

• Could be determined by:– Regulations, – Accreditation standards, – Governing Board & other leader determinations, or – By knowing your weak areas within your department– Organization Strategic Plan

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• In the case of Patient Flow, common metrics are:– Time in and time out of department/area– Wait time– Door to treatment time– Length of Stay information– Variation of care from pathway or protocol

Metrics – What to measure

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• MUST be specific as to what you want to measure• Specific definition of the measure – Numerator/Denominator (Rate Based)

• Get data from same sources each time– i.e. : Medical Records logs vs. Risk Management logs

Metrics – What to measure

INDICATOR CHARACTERISTICS

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Assess an outcome or process

Measure any of the important

functions

Rate-based indicators• Numerator and

denominator

Specifies the focus of data collection

Sentinel Event indicators• Serious or significant

events

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Process Measures

• Assess the process that is used to produce an outcome

• Interrelated steps carried out for patient care or services

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Outcome Measures

• What happens or does not happen after the process

is completed

– Must determine if the focus is on the process or the

outcome

– If the outcome has not been obtained, then must go back

and measure the process

– Can have effectiveness but the financial cost is too high

Performance Measures Selection and Development

Identification of who will select or develop indicators

Identification of organization functions & key processes

Identification of purpose and intent of useAssure that information is readily availableEnsure reliability & validityDocument an information set for each indicator

• See Pages 39 -60 for more information

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Goals, Triggers & Thresholds

• Goals: – What you want to reach or get to

• Triggers: – Determines when to look in more depth or prioritize for

improvement– Sentinel event, expected performance rate, etc.

• Thresholds:– a level, point, or value above which something is true or will

take place and below which it is not or will not

Clinical Standards

• Standards and Implications– What can be expected from a healthcare encounter– If outcome is not met, then must re-evaluate the

process and make improvements as appropriate– Integrate standards into practice and performance

appraisal– National, Accreditation/Regulatory, Local

(Community), Organization Standards

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Clinical Guidelines / Pathways

• Clinical Pathway & Practice Guideline Development– Statements to assist practitioner and patient make

decisions about healthcare for specific clinical circumstances

• Practice Guidelines– Clinical algorithms used to support clinical pathways

Physician Role p. 61 Nursing Role p. 61-62

Pathways/Guidelines

• Suggested practice

• May be: – Evidence-Based– One way to do it– Consensus

• National Guidelines Clearing House (www.guideline.gov)– Public source of evidence-based clinical practice guidelines

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Evidence –Based Practice

• Evidence –Based Medicine/Practice (EBM)– Research based review of practices that indicate

statistically significant differences between practices

– Integration of individual experience with best available external clinical evidence from systematic research

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Severity of Illness

• “Degree of risk of immediate death or permanent loss of function due to a disease”

• Severity of Illness Systems – Computerized Measurement adjusts ICD-9/10 codes based

on severity or extent of illness

– GOAL: Group patients into homogeneous categories that reflect the extent or seriousness of the disease process

Organization Wide Monitoring & Analysis

• Types of Review

– Prospective

– Concurrent

– Retrospective

– Focused

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Clinical Review Processes

• Clinical Reviews: (Medication, Blood, Procedures, Mortality, etc.)– Indications / Appropriateness (physicians)– Preparation / Dispensing– Administration / Performance– Monitor Effects– Patient education (with procedures)

• Sample Size– 5% or 30 which ever is greater

SPECIFIC REVIEWS• Medication Use Review

• Infection Prevention

• Service Quality – patient satisfaction,

– complaints,

– employee satisfaction

• Practitioner Performance Review

26Refer to IV pages 76 - 88 for more information on these reviews

Specific Departmental Reviews

• Physician Group Reviews– Pathology,

– Radiology,

– Emergency

– Etc.

• Pharmacy Reviews,

• Nursing Reviews– National Database for Nursing Quality Indicators (NDNQI)

– Also see pgs. 106 - 107

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Root Cause Analysis (RCA)

• Done AFTER a bad event

• A systematic process for identifying the most basic or causal factor(s) underlining variation in performance

• Action Plan developed MUST be implemented and outcomes monitored

• RCA to be conducted – intensive analysis– Ask ‘Why’ at least 5 times

• Problem must be defined as succinctly as possible– Interview all involved in the event

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RCA• The best tool out there is The Joint Commission’s RCA format

– http://www.jointcommission.org/sentinel_event.aspx

• PART 1 – Incident itself• Areas to evaluate

– Flow chart of this incident– Human factors– Equipment factors– Controllable environmental factors– Uncontrollable external factors– Other factors

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RCA

• Part 2: Facility Wide• Areas to evaluate– Other areas in organization where this could happen– Human Resource/Staffing issues– Information Management/Communication issues– Environmental Management issues– Leadership issues – • Corporate culture – Risk reduction• Encouragement of communication• Clear communication of priorities

– Technology issues

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RCA

• Part 3: Action Plan– Defines action based on each root cause identified

– Must specify time frames & who responsible

– Must be implemented

– Must follow-up and assure compliance AND sustainment

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Failure Mode Effectiveness Analysis (FMEA) (HFMEA)

• Proactive – done BEFORE something bad happens

• Identifies and improves steps in a process to reasonably ensure a safe and clinically desirable outcome

• Failure Modes: – Different ways that a process can fail to function or provide

desired results

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FMEA• Steps:

Describe and understand the process • flowchart current process (macro)

Brainstorm potential failure modes• Consecutively number each potential failure point

Identify the potential causes of each failure mode

List potential effects (adverse outcomes) of each failure mode

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FMEA

• StepsAssign ratings for each effect – Scale of 1-10• Severity• Frequency/occurrence• Detection

Calculate the Risk Priority Number for each effect• Severity x Frequency/Occurrence x Detection• Highest Risk Priority Numbers are tackled first

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FMEA Worksheet Failure Mode Failure Causes Failure Effects Occurrence Detection Severity RPN

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2

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1-10 1-10 1-10 O x D x S

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FMEA

• STEPSTake action to eliminate or reduce the high risk failure

modes

Identify performance measures to monitor the effectiveness of the redesigned process

BENCHMARKING

• Finding best practice and trying to look more like that practice

• Identify Benchmarking Needs

• Benchmarking System/Steps

• Using Benchmark Data

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Credentialing Process• Credentialing – Verifying the letters after your name• MD, Board Certification, Education, etc.

• Frequency – Managed Care – every 3 years– All Others – every 2 years

• Process– Application– Primary Source Verification

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Credentialing Process

• Primary source verification– Everything that is put in the application must be primary

source verified– Verified that the fact is true by contacting the issuing

organization for verification– May not accept a copy of the diploma / certificate / card,

etc.

• Centralized credentialing– One organization primary verifies credentials for multiple

facilities (CVO)– Could be part of a healthcare system or independent

company

Clinical Privileges• Defines what the practitioner can do in this specific

healthcare organization

– If the facility does not have the capability of doing something, then the practitioner may not have privileges to do it

• Delineation of privileges based on criteria– Must have criteria for each privilege awarded– By department & specialty– By new practitioner or experienced practitioner– By board certification or not 40

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Clinical Privileges• Privilege status– Provisional– Active– Consulting– Temporary– Emergency– Others

• Continuing education

• Occurs after credentialing information is gathered and goes through approval process with credentialing information

Appointment/Reappointment• Membership– Eligibility– Non-physician LIPs

• Initial appointment– Primary source verification of all information about

practitioner

• Reappointment – Time frame varies by type of organization– Primary source verification of all information that expires

and/or any new information obtain during the reappointment process

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Ongoing Professional Practice Evaluation (OPPE) (TJC & HFAP)

Like a report card Selective measurement and analysis of a practitioner’s

performance based on the privileges the practitioner holdsTo identify professional practice trends and opportunities

for improvement Medical staff determine how the process is

conducted in that organization Practitioner is compared to others with similar

specialties and privileges

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• Some measures can be the same for all practitioners– Volume– Infection rate– Etc.

• Other measures must be specialty specific

• Data is to be collected & reported to the physician and to the department director more than once a year – Usually every 9 months

• Data collected should be discussed between the individual and the department director to identify areas of excellence and areas where improvement are needed

OPPE

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• It can be utilized in preparing the practitioner’s evaluation and reappointment materials

• Collectively in the department, this data can be utilized to identify opportunities for improvement for the entire department

• It can also be utilized to identify educational needs within the department

OPPE

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• Items must be objectively measureable

• Criteria should be developed that is utilized by the entire medical staff on items that pertain to all– Medication errors– Blood usage– Etc.

• Criteria should be developed that is utilized within a specialty for those items unique to them

OPPE

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• Records of OPPE should be kept in a separate file per physician from those of the credentialing information

• The OPPE information can be utilized in performance evaluations and reappointment but should not be kept min the same file due to confidentiality

• Some of the information from the physical profile may be utilized for the OPPE but they should be 2 different documents with differing information

OPPE

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Focused Professional Practice Evaluation (FPPE)

• Medical staff determine how the process is conducted in that organization

Privilege specific, time limited process to validate practitioner competency when new privileges are given to the practitionerNew applicantsNew privileges

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FPPE

• Also utilized when it is necessary to take a focused look at any practitioner’s practice

• Peer Review will be discussed in a few minutes

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Practitioner Profile• Practitioner-specific data and information

summaries used in reappraisal process, in conjunction with re-credentialing ands re-privileging

• Must be completed for all practitioners who are credentialed & privileged by the medical staff– Includes physicians, dentists, advance practice practitioners, etc.

• Opportunity to summarize all the practitioner has done since last appointment and often includes comparisons to peers

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Practitioner Profile

• Could include the OPPE and FPPE findings

• Frequently includes other factors:– Volume– Peer Review aggregated results– Utilization management findings – Patient safety information– Complaints and compliment summary– QI involvement

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Peer Review

• Review of a practitioner’s practice by a peer of the practitioner

• Intensive in-depth review• Typically has an initial screening to determine if

criteria has been met• If criteria not met, then sent to the appropriate

group for peer review of the practitioner or the patient’s case.

• Each medical staff determines how peer review will be done in that organization

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– The purpose of Peer Review is to identify patterns outside recognized standards, behavior problems, or other circumstances which endanger the safety or care of patients.

• Also for upgrading the practitioner’s clinical knowledge, enhancing his/her medical practice, reducing medical errors and improving patient safety and care.

Peer Review

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Peer review is used to protect patients, assure due process to the practitioner under investigation and preserve the immunity of the hospital and medical staff.

The peer review should be conducted by peer reviewers, actively practicing in the appropriate specialty or specialties.

Documentation of the peer review must be maintained in the practitioner’s quality file, not their credentialing file.

Peer Review

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• The peer reviewers should analyze the cases for the following factors (as directed or limited by the hospital):

Clinical management

Timeliness of medical interventions

Adherence to hospital’s critical pathways and/or other established guidelines for medically appropriate care and evaluation of any variations

Peer Review Process

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• The peer reviewers should analyze the cases for the following factors (as directed or limited by the hospital):

Medical record documentation

Follow-up case management

Professional conduct

Others as requested by the hospital

Peer Review Process

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Peer Review Findings

• Usually ranked, such as1= Peers would have managed care in the same manner2 = Patient outcome unaffected by the variance in practice3 = Peers would have managed care differently4 = Negative outcome resulted from variance

• If ranked a 3 or 4, there must be some action to work with the practitioner to make improvements in care, or removal of privileges, or suspension from medical staff, or other results

PATIENT/ MEMBER ADVOCACY AND FEEDBACK

• Patient/Member Rights and Responsibilities

– Patient Rights & Responsibilities

– Organization Responsibilities

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Complaints and Grievances

• Complaint – an oral or written expression of dissatisfaction, generally about patient care– Usually while the patient is still receiving services

– Must be quickly resolved

– If not, turns into a grievance

• Grievance – formal expression of dissatisfaction, usually written but may be oral, generally about quality of care– Usually after the patient leaves the care of the organization

– CMS timelines

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PI Reporting• Communicate the measurement, analysis, and

improvement activities to all those who have an appropriate need to know

• Need enough information to be able to make decisions and to be able to identify and make improvements as needed.

• Remember confidentiality and nondisclosure of information

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PI Reporting

• Summary Reports – Periodic aggregate and trend reports– Team reports– Minutes of meetings– Transparency

• Display or report information in manner that the reader will understand– Identify the areas that need improvement or where

improvements have been made– Indicate when actions have occurred– If a special cause variation – include what the occurrence was

or some other notation such as the cause

EVALUATION OF QM/ PI

• Evaluation of PI Processes and Outcomes– At least annually, but ongoing evaluation is better

– Process effectiveness

– Outcome effectiveness

– Component process effectiveness

– Other methods & tools

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