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Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

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Page 1: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

© Peers for Progress

Quality Improvement for Peer Support Programs

Page 2: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

© Peers for Progress

OVERVIEW OF QUALITY IMPROVEMENT (QI)

Page 3: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Who Benefits from QI?

Peer Supportee

Receive betterservices

Better access to services

Expectations met

Peer Supporter

Provide better services

More efficient work processes

Stronger bond with supportee

Organization

More cost-effective

Improved services

Improved funding

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Page 4: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Defining Quality Improvement

“Quality improvement (QI) consists of systematicand continuous actions that lead to measurableimprovement” (HRSA)

“Quality improvement is a continuous and ongoing effort to achieve measurable improvements in the efficiency, performance, accountability, outcomes, and other indicators of quality… to achieve equity and improve the health of the community” (NNPHI)

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Page 5: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

3 Key Characteristics of QI

Systematic: methodical, with a purpose

Continuous: cyclical, occurs over and over again

Measurable: able to concretely observe a change

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Page 6: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Why QI is Important

Peer support is dynamic and ongoing. Rapid response and troubleshooting through QI can lead to improved results

QI can make existing community health services more effective and better able to achieve goals

QI=Process-driven, person-

centered, dynamic, & rapid

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Page 7: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

QI vs Monitoring & Evaluation

Similarities

Both investigate if programs are being implemented as intended

Both have the ultimate goal of improving certain health outcomes

Both examine if programs are meeting certain requirements

Differences

QI: “real-time” dataM&E: set times

QI: small, incremental changes with rapid feedback of results to improve efficiency

M&E: broader questions of program design, implementation, and effectiveness

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Page 8: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Evaluation is Linear:What are the results?

1. What are outcomes of

interest

2. Develop ways to

measure the outcomes

3. Collect all measures of

interest

4. Analyze data to

determine outcomes

Evaluation tells you whether outcomes are good

or bad, but not what to do with the results

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Page 9: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

QI is Cyclical: What actions will improve the program?

QI is narrow in scope; focuses on the way certain things are done to be more streamlined and effective

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Page 10: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

When to Use QI?

• A problem arises or presents itself

• What you’re doing is not resulting in the desired outcomes

• External sources ask you to (funders, the community)

• Work processes need to be streamlined

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Page 11: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

General Methodology of QI

1. Identify prioritized problem

2. Determine how to measure change

3. Identify change(s) to make

4. Implement the change(s)

5. Evaluate if the problem improved

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Page 12: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

QI for Healthcare

• In healthcare, the Institute for Healthcare Improvement’s (IHI) Model for Improvement is commonly used

• The MFI has been used to improve a variety of outcomes in: diabetes, HIV, maternal and child health, hospital readmissions, etc.

What change can we make that will result in an improvement?

Plan

DoStudy

Act

How will we know that a change is an improvement?

What are we trying to accomplish?

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Page 13: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Scope of QI Projects Vary

Topic Program or Unit QI

Individual QI

Improvement Project focus Daily work

QI Planning Program-level plan Performance plan

Processes Program activities Daily activities

Goals Program plan Individual goals

Source: Public Health Foundation© Peers for Progress

Page 14: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

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QI MODEL APPLICATION

Individual QI

Page 15: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Individual QI Example

• Peer supporters are required to conduct bi-weekly face-to-face meetings at the clinic with their supportees during the first 3 months starting from an introduction

• An overall 40% of contact rate reported by the 5 peer supporters during month 1.

• How to use Model for Improvement to improve meeting rates?

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Page 16: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Action Steps 1-3

What change can we make that will result in an improvement?

How will we know that a change is an improvement?

What are we trying to accomplish?

• Increase the reach of peer supporter to 60% during month 2

• Peer supporters will report more successful contacts

• Calling instead of face-to-face meeting, meeting in different places, shorter meeting times, etc.

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Page 17: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Plan Step

• Narrow down all the possible changes to ONE you/peer supporters think will be best

– Peer supporters suggest flexible meeting places instead of the clinic (e.g., coffee shop)

• Determine when and how you will notify peer supporters of the change

– Make announcement at weekly team meeting that the change will start the next day for another month

• Determine how you will know if/how frequently peer supporters used the change (monitoring)

– Add a column of meeting locations to current contact note

Plan

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Page 18: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Do Step

• Carry out the plan

– Have peer supporters suggest a different meeting place for one month

– Make sure peer supporters collect the necessary data by using the revised contact note (e.g. how many attempts, how many times met, meeting locations)

Do

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Page 19: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Study Step

• Study: did this improve?

– Compare how many times peer supporters were able to meet before and after the change

– Summarize what happened and what was learned

– Look at available monitoring data i.e., peer supporter contact notes, to see if change was used by peer supporters

– Talk to peer supporters to see what they thought of the change

Study

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Page 20: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Act Step

• Plan the next step– If changing location did not improve meeting rates,

and you’re certain peer supporters used this changeTry other changes that were thought of in “Plan” phase

– Talk with peer supporters: do they have ideas for how to improve reach rates? Were there other issues that were brought up that could be improved?

– If change worked, institutionalize it by changing the intervention protocols to allow flexible meeting locations

Act

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Page 21: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

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QI MODEL APPLICATION

Program- or Unit-level QI

Page 22: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

USAID CHW AIM Toolkit

• Organizations may already have QI tools and forms that call for QI initiatives for peer support programs such as the USAID Community Health Worker Assessment and Improvement Matrix (CHW AIM) (Crigler et al., 2013)

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Page 23: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

USAID CHW AIM Toolkit Cont’d

• CHW AIM is a guided self-assessment through a workshop: 15 programs components are scored on 4 levels of functionality, then action plans for weaknesses are made based on results

• Toolkit lays out 4 steps: adapt, plan, conduct, and follow up

• Tools are structured in a way that can prompt periodic assessments and establish organizational benchmarks for quality improvement initiatives.

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Page 24: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

When using tools like the CHW AIM Toolkit…

• Adaptation to reflect program goals, population needs, and local contexts is critical!

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Page 25: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

USAID 15 Components for Effective CHW Programs

Recruitment CHW Role Initial Training

Continuing Training

Equipment & Supplies

Supervision Individual Performance Evaluation

Incentives Community Involvement

Referral System

Opportunities for Advancement

Documentation& Information Management

Linkages to Health Systems

Program Performance Evaluation

Country Ownership

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Page 26: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Adapt and Plan Steps

• Tailor organization’s QI tool to peer support program guidelines, local context through stakeholder meetings

- Ex. Country ownership may not be applicable to your peer support program

• Assessments through site visits, and a workshop (the main approach)

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Page 27: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Score program components based on functionality criteria. Calculate overall functionality of program to identify areas that need improvement (Ex. Recruitment)

Level of Functionality: 1 = non functional 2 = partially functional 3 = functional 4 = highly functional

Functionality criteria examples for recruitment:1 – Community plays no role in recruitment2 – Community only approves of final selection3 – Community participates in final selection4 – Community participates in entire recruitment process

Conduct Step : Identify your prioritized problem

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Page 28: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Conduct step: Determine how to see improvement

• Ex. Recruitment

– Currently, the selection of peer supporters (CHWs) is based on clinicians’ recommendations. However, the recommendation/selection criteria are not commonly agreed. There is no standardized process in place.

– Scored as Level 1: Non functional

– Goal: 70% program-wide implementation rate for a new set of standardized selection criteria and process.

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Page 29: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Conduct step: Identify a change(s) to make

• Develop an action plan- Establish a committee consisting of two

providers and a peer supporter supervisor- Committee will develop a survey to collect

feedback from providers, peer supporter supervisors, patients and peer supporters to identify selection criteria and process

- Provider committee members will be the champions for implementing the new set of selection criteria and process.

- Try for a month and then review the results

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Page 30: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Follow-up step: Implement the change

• Implement the change planned for in the previous step- Selection criteria: Clinical status (e.g., A1C <

7.5%), willingness to help others, willingness to work with providers, and good communication and support skills

- Process: 2 steps (Provider recommendations and then interview by the supervisor of peer supporters)

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Page 31: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Follow-up step: Evaluate if the problem has improved

• Get needed data to see if change worked- Use a recommendation form and interview

questionnaire to track implementation- Survey providers and supervisors of peer

supporters again to get feedback• Review and revise the action plan as necessary• Scale up or institutionalize change if it worked.• If it didn’t work, refine your change or try

another strategy

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Page 32: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Model for Improvement USAID CHW AIM Toolkit

Target organizations Can be applied within any organization

Ministries of health, donors, NGOs, other organizations that manage CHW programs

Target populations Any population Global, underserved

Target conditions Any condition Primarily maternal, newborn, and child health, HIV, and TB. Can be adapted for others

Special considerations Special attention should be given to the “Act” step, which can be forgotten

Identifies program improvement areas through workshop

Model for Improvement vsUSAID CHW AIM Toolkit

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Page 33: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

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KEYS TO EFFECTIVE QI FOR PEER SUPPORT PROGRAMS

Page 34: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

What is Common to QI methods?

• Focus on improvement

• Acting, measuring, and evaluating to improve

• Requires strong leadership, creativity and innovation

• Involves employees and team members

• Effective team development

• Commitment to improvement

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Page 35: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Many QI Models Exist

• Plan-do-check/study-act (PDCA/PDSA)

• FOCUS-PDSA

• FADE

• IMPROVE

• Lean

• Six Sigma

• Kaizen

• Total Quality Management

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Page 36: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

QI Tips

• Focus on general QI methodology

• Get ideas for changes from peer supporters

• Set clear and measurable goals with a timeline

• Choose QI projects with favorable impact vs effort in mind

• Measure what’s necessary; don’t get overwhelmed with measures

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Page 37: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

QI Tips Cont.

• Select a multi-disciplinary team with the necessary expertise

• Pay careful attention to data collection and quality

• Make sure changes are documented – key step that is frequently missed

• Discuss changes and results with team

• Have a back-up plan for unexpected results

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Page 38: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

Resources

• 5-SPICE Framework for CHW Quality Improvement

• Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook

• Public Health Improvement Resource Center

• National Network of Public Health Institute’s Quality Improvement Section

• IHI’s Resources for Public Health Quality Improvement

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Page 39: Quality Improvement for Peer Support Programspeersforprogress.org/.../150319-quality-improvement-presentation.pdf · Defining Quality Improvement “Quality improvement (QI) consists

References• Deboit, B. & Mallen, B. (n.d.). Quality improvement in public health: An overview

[PowerPoint slides]. Retrieved from http://nnphi.org/CMSuploads/IA-QI.Overview-4.11.pdf.

• Crigler L, Hill K, Furth R, & Bjerregaard D. (2011). Community Health Worker Assessment and Improvement Matrix (CHW AIM): A Toolkit for Improving Community Health Worker Programs and Services. USAID Health Care Improvement Project, University Research Co., LLC (URC).

• Institute for Healthcare Improvement. (2014). How to improve. Retrieved from http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx.

• National Network of Public Health Institutes. (2010). Quality improvement. Retrieved from http://nnphi.org/tools/public-health-performance-improvement-toolkit-2?view=file&topic=59.

• Tews, D.S., Heany, J., Jones, J., VanDerMoere, R., & Madamala, K. (2012). A practitioner’s quality improvement guidebook 2nd ed. Retrieved from http://publichealth.yale.edu/ctriphtc/resources/445_125142_2012_02_28_Guidebook_web.pdf

• U.S. Department of Health and Human Services, Human Resources and Services Administration (n.d.). Quality improvement. Retrieved from http://www.hrsa.gov/quality/toolbox/methodology/qualityimprovement/.

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