Establishing an Effective CQI Program

1. Establishing an Effective CQI Program By: Shannon Bentley, RN,c And Lois Sacher, RN

2. Welcome CQI Team!

3. Each team member will: • Help establish the project objective • Listen to each other’s ideas and acknowledge their point of view • Define project roles and responsibilities together  • Promote responsibility

4. CQI Meeting Agenda Monday, June 22, 2009 • Introduction Julie (0:00-5:00) • Participant Introductions All (5:00-10:00) • Brief Overview Lois (10:00-15:00) • Creating the CQI Program All (15:00-35:00) • Center Success Stories Loydene and Brenda (35:00-55:00) • Wrap-Up Shannon (55:00-1 hour)

5. Introductions • Hello my name is . • My position on center is . • The thing I dislike the most about the service I receive at my personal doctor’s office is .

6. CQI • Improves organization and systems • Most things can be improved! • This philosophy does not subscribe to the theory that “If it ain’t broke, don’t fix it."

7. CQI or QA? • Focus is on human error and eliminating poor performers • Ensure that policies, procedures and protocols make sense • Monitors compliance through periodic audits and inspections • Relies on teamwork and incorporates evidence-based care Source: The NYC Division of Mental Hygiene. Quality IMPACT Basic CQI Course. http://www.nyc.gov/html/doh/downloads/pdf/qi/qi-training.pdf

8. What are you doing—CQI or QA? • Corrective Action Plans (CAPS) • Surveying students on the service they receive in the HWC • Tracking Chlamydia test positives and experimenting with different sex education initiatives

9. Steps in CQI

10. Tools • Brainstorming • Purpose • Time limit • Note taker • Multivoting • Relies on popular opinion • Prioritizing projects or elements of projects Please be creative! There are no bad ideas!

11. Plan Step 1

12. Data Collection Methods: • Surveys of staff and students • Observation • Chart audits • Review of current protocols • Focus groups • Student suggestion boxes • Individual discussion • Use of the SGA/or Wellness Committees

14. Survey Results • Nursing staff’s skills and ability = 3.2 • How well the nursing staff listened to you = 3.0 • Extent to which the nursing staff involved you in decisions about your care = 2.5

15. Target Identification:Wellness Center Complaints

17. Do Step 2

18. What cause are we going to tackle?

20. Possible Interventions • Writing or revising formal policies and procedures • Obtaining new equipment • Create or revise educational materials for students or staff • Student/staff training

21. Study Step 3

22. What does this tell us? Intervention

23. Interpreting Data • Pilot test the system and make necessary revisions • Establish a schedule for follow-up data collection • Analyze and present findings to health and wellness team or supervisor, as appropriate • Identify and implement corrective actions

24. Act Step 4

25. Where should we go with this? • Brainstorm

26. CQI is a never-ending process! Re-evaluate for: • Results • Changes needed in process • New or different goals

27. Policy PRH and Desk Reference

28. PRH Requirements R15. Continuous Quality Improvement • Center health staff shall seek feedback • Quality of care provided, and document quality improvement activities

29. Desk Reference • Seek feedback from students through surveys and utilize the SGA and health and wellness committees to develop a quality management system that works for your center

30. Center Success Stories Loydene and Brenda

31. Gary Job Corps • Wellness Committee • “Top 3” students • Panther Club Staff leader • Student satisfaction surveys • Confidential way in which the students may lodge a complaint  • Development of a quality improvement plan annually

32. Weekly Meetings • Starting a MAR • Updating the Infection Control Plan • Starting weekly power meetings for the nurses • Noting medication orders • Staffing issues

33. Guthrie Job Corps Center Continuous Quality Improvement (Performance improvement) CQI/PI Plan contains: • PAT (Performance Action Teams) • Trial period or pilot testing period • Performance measures • Follow up

34. Performance Examples of data the Wellness Center may choose for monitoring its performance include the following: • Risk Management • Quality control • Patient safety • Medical Records CQI • Performance measurement data on the needs, expectations, and satisfaction of the individuals it serves

35. Guthrie • Collection of performance measurement data by asking Wellness customers (both internal and external) it serves the following: • How the Wellness Center can improve its service • How the Wellness Center can improve patient safety • Patient surveys, student satisfaction surveys, Health Services Committee, other Department concerns/complaints • Performance measures that are related to the following processes: • Significant medication errors • Emergency Protocols • Lab Testing Protocols • State Mandated STD/Communicable disease reporting • Undesirable patterns or trends in performance are extensively analyzed and addressed.

36. Resources

37. Resources • Institute for Healthcare Improvement—This program provides the user with the ability to set up and document individual or team improvement projects, including collection of data, and track/trend changes over time http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods

38. Resources • Center for Evidence-Based Medicine—This website provides the user with tools to implement a project that evaluates practice against evidence-based medicine. http://www.cebm.net/ • Agency for Healthcare Research and Quality provides several resources for tools to help design and support quality improvement programs and projects. http://www.ahrq.gov/qual/pstools.htm • Quality Tools http://www.syque.com/quality_tools/tools/Tools_usage.htm#col