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Steps in Quality Improvement

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									   Steps in Quality Improvement
• Identify
   – what do we want to improve, who should do it
• Analyze
   – what do we need to understand / know to
     make the improvement




 QUALITY ASSURANCE PROJECT
 Steps in Quality Improvement
 • Develop
     – “hypotheses” of changes needed,
       interventions to be tried, solutions that may
       lead to improvement
     – ex: intuition, experience, expert advice, trial
       and error, simulation, OR, consensus,
       benchmarking, best practices, evidence
       based medicine, etc.
 • Test / Implement
     – did the intervention result in improvement


QUALITY ASSURANCE PROJECT
    “Old” Quality Improvement cycle
Step 5: Identify the Problem
   Step 6: Define the Problem Operationally
      Step 7: Identify Who Needs to Work on the Problem

                            Step 8: Analyze the Problem
  Re-evaluate & monitor

Step 10: Implement Solutions


Step 9: Choose and Design Solutions to Address the Cause

QUALITY ASSURANCE PROJECT
               Alternatives for
             Quality Improvement
 • “Just do it” - obvious fix interventions
 • PDSA, Rapid cycle PDSA
 • Problem solving with root cause
   analysis
 • Process Improvement



QUALITY ASSURANCE PROJECT
                            “Just do it”
 • Identify: obvious problem, may be
   individual or team work
 • Analyze: obvious cause / fix
 • Develop: may just need a decision maker
 • Test: observe to see if the problem is
   fixed


QUALITY ASSURANCE PROJECT
              “Just do it” Cautions
 • Obvious solution may not work
 • People may not support a change if
   they are not involved in the planning, or
   if the change does not work
 • Even obvious solutions are sometimes
   not acted on - need decisions to be
   made


QUALITY ASSURANCE PROJECT
“Simple” Problem Solving - PDSA
  • Identify: careful problem definition,
    should have data to define the problem,
    probably benefits from a team
  • Analyze: limited analysis - perhaps
    simple process analysis, usually
    informal cause-effect thinking
      – May use expert advice


 QUALITY ASSURANCE PROJECT
       “Simple” Problem Solving
 • Develop: interventions that seem to be
   right; may adopt a solution that has
   worked elsewhere
 • Test: use check step - gather data to
   prove there is an improvement




QUALITY ASSURANCE PROJECT
“Simple” Problem Solving Issues
• If problem definition is not clear, may
  solve the wrong problem
• Adopting others’ solutions is not
  benchmarking - may or may not work
• Need thoughtful analysis, not only
  assumptions of cause
• If problem recurs, consider root cause
  analysis

QUALITY ASSURANCE PROJECT
                Rapid Cycle PDSA
 • A specific intervention - the Nolan
   Model
 • Apply known change strategies with
   limited analysis, small tests of
   improvement
 • Test solutions sequentially


QUALITY ASSURANCE PROJECT
 Continuous
 Improvement




QUALITY ASSURANCE PROJECT
             Root Cause Analysis
 • Identify: thorough problem definition,
   team selection based on process under
   study
 • Analyze: study the current process, do
   cause-effect analysis, systems
   modeling and analysis, customer input



QUALITY ASSURANCE PROJECT
             Root Cause Analysis
 • Develop: hypotheses of cause based
   on analysis; gather data to prove
   hypotheses, then develop solution for
   the proven cause of the problem
 • Test: data gathering to prove the
   solution yielded improvements to the
   extent desired

QUALITY ASSURANCE PROJECT
   Root Cause Analysis Issues
• Can be a lengthy process
• Team needs to understand analysis
  tools and techniques - coaching help
• In spite of this, has been used
  successfully at health worker level in
  developing countries
• Good technique for chronic or complex
  problems

QUALITY ASSURANCE PROJECT
            Process Improvement
 • A work team “owns” the process - this is
   not an ad hoc problem solving
 • The “owning” team may form sub-teams
   to do ad hoc problem solving
 • Incremental improvements over time
   are characteristic


QUALITY ASSURANCE PROJECT
           Process Improvement
 • Identify: the process(es) under study -
   where does it start and stop; may do
   systems analysis; involve those people
   who are involved in the process,
   including customers
 • Analyze: ongoing data collection about
   the routine conduct of the process;
   other tools as needed

QUALITY ASSURANCE PROJECT
            Process Improvement
 • Develop: suggestions for change made
   by people working in the process,
   including customers; may use any
   approach
 • Test: ongoing monitoring plus focused
   data collection if needed based on the
   intervention chosen

QUALITY ASSURANCE PROJECT
   Process Improvement Issues
• “Owners” must really be able to make
  changes - empowerment
• Team monitors the process routinely -
  need ongoing data collection and
  interpretation
• Teams usually need initial coaching
• Very powerful change technique


QUALITY ASSURANCE PROJECT
                     Quality Control




QUALITY ASSURANCE PROJECT
                     Quality Control
 • Quality Assessment
     – non-regular measures
     – often associated with facility-wide measures
 • Quality Monitoring
     – routine data collection and interpretation
     – self-evaluation is powerful
     – may be associated with supervision


QUALITY ASSURANCE PROJECT
                            Monitoring
 “The periodic collection and analysis of
 data for selected indicators that enable
 managers to determine whether key
 activities are being carried out as planned
 and are having the expected effects on
 the target population”



QUALITY ASSURANCE PROJECT
          Purposes of Monitoring
 • Determine if quality goals are met
 • Identify problems or opportunities for
   improvement
 • Ensure improvements are maintained




QUALITY ASSURANCE PROJECT
          What Do You Monitor?
• Something that has an explicit or implicit
  standard to compare with performance
• High risk, high volume, problem prone
• Peer group directs it
• Seniors require it - MOH, PVO
• Client interest
• High visibility - political interest


QUALITY ASSURANCE PROJECT
             What is an Indicator?
 • A measure
 • Points to something that may be of
   interest
 • Derived from standards




QUALITY ASSURANCE PROJECT
                  Self-Assessment
 • Know the standard, know your practice,
   draw conclusions
 • May use instruments, checklists, review
   of records, audio/video tapes
 • May have just the standard or job aids
 • Teams may do self-assessment


QUALITY ASSURANCE PROJECT
            Supervisor Monitoring
 • Hawthorne effect? Just observing
   without feedback
 • Supervisor with feedback
     – individual feedback to the worker
     – may be in-charge or external supervisor
 • Issue: what do supervisors look at? Do
   they evaluate quality of care?


QUALITY ASSURANCE PROJECT
Feedback of Comparative Data
 •   Compare workers with each other
 •   Compare similar facilities
 •   Issues of attribution vs. anonymity
 •   Is a difference significant?




QUALITY ASSURANCE PROJECT
 Feedback of Aggregated Data
• Use local, district, regional, national,
  PVO-wide data
• Group by type of facility, type of worker
• Universe may be large enough to
  compare performance against a mean
• With enough data over time, can
  analyze variance
• Important to uniformly define indicators

QUALITY ASSURANCE PROJECT
               External Monitoring
 •   Licensure
 •   Certification
 •   Accreditation
 •   One-time or cyclical?
 •   May require ongoing data input for
     concurrent analysis between “visits”


QUALITY ASSURANCE PROJECT
                 Clients’ Monitoring
 • Neighborhood / community health
   committees
 • May seek out information: focus groups,
   formal measures of satisfaction
 • Volunteered information: complaints,
   comments, newspapers (not really
   indicators)
 • Issue: how to interpret and use this
   information

QUALITY ASSURANCE PROJECT
        Stakeholders’ Monitoring
 • May have their own indicators, or may
   impose them, or may use other data
     – Program managers
     – Donors
     – Ad hoc visitors
     – PVO headquarters



QUALITY ASSURANCE PROJECT
    What Should be Monitored?
 • Combination of inputs, processes and
   outcomes
 • Impact is desired but difficult to monitor
 • Develop indicators from system model
   and standards




QUALITY ASSURANCE PROJECT
              Issues in Monitoring
 • Incorporate indicators into routine
   supervisory visits
     – consider changing topics over time
     – consider dropping indicators that have
       consistently good results
     – be sure you measure the same things if
       you are comparing results over time



QUALITY ASSURANCE PROJECT
              Issues in Monitoring
 • If supervisors will not do ongoing
   monitoring, help staff to develop their
   own internal methods to check progress
   in improvements
 • How accurate is self-reported
   monitoring?



QUALITY ASSURANCE PROJECT
              Supervision and QA
 • Supervision and facilitative supervision
 • Method of assessing care quality and
   providing feedback in a way that
   identifies opportunities to improve and
   helps staff solve problems
 • Coaching and mentoring practice
 • Data gathering for quality assessment

QUALITY ASSURANCE PROJECT
 Issues of Supervision and QA
• What type of supervision is appropriate in
  decentralized environments?
• Use of checklists vs. general observation
• Stovepipe vs. facility-wide supervision
• Individual vs. service analysis of data
• How much QA do supervisors need to
  know?

QUALITY ASSURANCE PROJECT
  Issues of Supervision and QA
 • How much clinical expertise should
   supervisors have?
 • What should the relationship be
   between project funded supervision and
   routine management / supervision?
 • If supervisors gather quality data, who
   interprets and acts on it?

QUALITY ASSURANCE PROJECT

								
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