Quality Improvement/Assurance Plan A collaboration between the National Center for Farmworker Health, Inc. and Migrant Clinicians Network This training is possible through grant # U30CS09737 from HRSA, BPHC, and its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA
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Quality Improvement/Assurance Plan Improvement/Assurance Plan ... Environmental/ occupational health ... Workplace Hazard Assessment (every two years)
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Quality Improvement/Assurance Plan
A collaboration between the National Center for Farmworker Health, Inc.
and Migrant Clinicians Network
This training is possible through grant # U30CS09737 from HRSA, BPHC, and its contents are solely the
responsibility of the authors and do not necessarily represent the official views of HRSA
Training webinar presented by:
4/16/2015 NCFH 2
Hilda Bogue, RN, MS, CHES
Research & Development Director
National Center for Farmworker Health
Candace Kugel, FNP, CNM
Specialist in Clinical Systems & Women’s Health
Migrant Clinicians Network
Outline
Learning objectives
PHS Section 330 Program Background
Quality Improvement/ Quality Assurance (QI/QA) and
Migratory/Seasonal Agricultural Workers (MSAWs)
Resources & Technical Assistance
4/21/2015 NCFH 3
Objectives
Participants will be able to:
1. Identify the required elements of QI/QA
2. List two issues to consider when including MSAWs
in QI/QA initiatives
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PHS Section 330 Program Background 1 Need 11 Collaborative Relationships
Minutes approved ______________________________________________________ __/__/____ (Signature of committee chair) (Date)
All policies, procedures, and forms reprinted are intended not as models, but rather as samples submitted by ECRI Institute member and nonmember institutions for illustration purposes only. ECRI Institute is not responsible for the content of any reprinted materials. Healthcare laws, standards, and requirements change at a rapid pace, and thus, the sample policies may not meet current requirements. ECRI Institute urges all members to consult with their legal counsel regarding the adequacy of policies, procedures, and forms.
QI/QA
Assessing the Elements
Data Systems
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Good News Bad News
Electronic health record with
reporting/dashboard software
No IT involvement or expertise
Tablets for patient satisfaction
surveys
EHR vendor problems
EHR data verified by sampling Garbage in, garbage out
Participation in an EHR network
with other health centers
No interface with lab, hospital
PCMH recognition No EHR
Data Systems
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QI/QA
Assessing the Elements
QI/QA Reporting
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Good News Bad News
Charts on the walls! Blank looks, especially from clinical
staff
Dashboards Data collected but no analysis or
improvement efforts
Clinical measures data broken
down by provider
Data not verified/not accurate
QI/QA Reporting
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QI/QA
Assessing the Elements
Improvement Projects
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Good News Bad News
PDSA documentation “The high no-show rate was
discussed”
Organization-wide involvement in
improvement projects
Patients aren’t asked for input
Work groups assigned to projects
Data driven!
PDSA Documentation
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PDSA Worksheet for Testing Change
Institute for Healthcare Improvement
Aim: (overall goal you wish to achieve)
Every goal will require multiple smaller tests of change
Describe your first (or next) test of change: Person responsible
When to be done
Where to be done
Plan
List the tasks needed to set up this test of change Person responsible
When to be done
Where to be done
.
Predict what will happen when the test is carried out
Measures to determine if prediction succeeds
Do Describe what actually happened when you ran the test
Study Describe the measured results and how they compared to the predictions
Act Describe what modifications to the plan will be made for the next cycle from what you learned
QI/QA
Assessing the Elements
Board Involvement
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Good News Bad News
Board member participation in
QA/QI Committee
Blank looks from Board members
Functioning Board Quality
Committee
No QM knowledge or training
Regular reporting of QI/QA
activities to Board
Lack of support from CEO
CMO attends all Board meetings Did the Board approve that policy?
The Path to Success
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A Sample Path--BMI
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Percentage of patients aged 2 until 17 who had evidence
of BMI percentile documentation
AND who had documentation of counseling for nutrition