Quality Management Branch

2. Quality Management Branch Cady Clark, MSN, RN Branch Manager Claudia Himes-Crayton, BSN, RN Patricia Palm, MS, RNC Nurse Consultants

3. Objectives • Describe the functions of the Quality Management Branch • Define “Quality” terminology • Describe and discuss the Quality Management Continuum

4. Branch Personnel Quality Management Staff Nurses Nutritionists Case Manager WIC Fiscal Monitors

5. Quality Management Triangle Defining Quality QM Improving Quality Measuring Quality

6. Quality Quality is the degree to which a service meets or exceeds established professional standards and user expectations.

7. Quality Assurance Quality Assurance (QA) refers to a broad spectrum of evaluation activities aimed at insuring compliance with minimum quality standards.

8. Quality Improvement Quality Improvement (QI) refers to activities aimed at improving performance and is an approach to the continuous study and improvement of processes of providing services to meet the needs of the individual or population.

9. Four Core Principles of Quality Management (QM) • Focus on the client • Focus on systems • Focus on measurement • Focus on teamwork

10. QUALITY Building It Into Your Agency

11. A Quality Management Program • Is organization-wide. • Is designed to objectively, systematically • evaluate the quality and appropriateness of client care • identify and resolve problems in care and performance • make changes to improve care and clinical performance.

12. The Role of Management • “The support of top management is not sufficient. They must get involved; they must act.” W.C. Deming

13. Mission Committee Roadmap (Work Plan) Tools Timeframe Responsibility Process The Components of a Quality Management Plan

14. The Mission • An agency’s mission and philosophy must support quality management processes

15. Quality Management Committee • The role of the Quality Management Committee is to monitor all aspects of service delivery.

16. A Quality Management Committee • At a minimum, the QM Committee should include: • The Executive Director or CEO • The Medical Director • The Director of Nursing or Clinical Manager • Representatives of all functional areas, such as medical records, clerical support, pharmacy and laboratory.

17. The Quality Management Committee • Must identify other members of the agency that will be involved in quality assurance activities and how they will relate to the QM Committee.

18. The Quality Management Committee • Must determine the following: • The scope of the QM Committee’s duties • The frequency of meetings • The responsibilities of the members • The purpose of the Committee, and • The processes that will be used to identify opportunities for improvement.

19. The Quality Management Committee • Meets periodically to discuss QM issues • Records the minutes of QM all meetings • Evaluates results of ongoing QM activities • Recommends corrective actions or quality improvement activities • Ensures corrective actions are implemented • Evaluates results of corrective action • Assures evaluation of administration, clinical, & facility

20. A Roadmap (Work Plan) • The QM Plan must identify the areas of operation that will be reviewed. • The Plan must identify the frequency of reviews. • The Plan must identify what sources of information will be reviewed.

21. Measuring Quality • Methods which may be used to assess quality • Observation of service delivery • Audit of client records • Mystery client method • Clinic staff interviews • Data collection and analysis • Client satisfaction surveys

22. Tools • Review tools must be developed and used: • To ensure the review process is standardized • To document findings of the reviews • To assist in the identification of trends • To set acceptable thresholds

23. A Timeframe • Time periods, frequency of activities, and size of sample must be defined. Example: • Number of client records will be reviewed quarterly. • 100% of staff will be observed for skill and technical expertise annually.

24. Responsibility • The individual(s) who will conduct activities should be identified. Examples: • The Laboratory Director will observe 100% of laboratory staff every 6 months to ensure adherence to proper testing technique. • The Director of Nurses will review a set percentage of all family planning client records each quarter.

25. The Quality Management Process • The process by which findings and results of activities will be communicated to and used by the QM Committee to identify problems and successes and to improve services must be clearly identified and defined.

26. The QM Process Must Include: • A method to identify, track and monitor outcome measures and indicators which includes: • How outcomes will be tracked • Who will track them • Who, how and how often they will be tracked • Who, how and how often they will be reported • The changes and trends that occur

27. The QM Process Must Include: • A standard for implementing corrective actions that ensures accountability for the implementation • A follow-up and review system that measures the effectiveness of the corrective actions

28. Identify Values Reassess Choose Indicators Enact Solutions Assess Propose Solutions Evaluate Identify Problems

29. QMB Website http://www.dshs.state.tx.us/qmb

30. Who to Contact • Cady Clark Cady.Clark@dshs.state.tx.us (888) 963-7111 ext. 2187