Basic Skills Competency Education for New PI Directors & Coordinators

1. Basic Skills Competency EducationforNew PI Directors & Coordinators Session One January 10, 2007 Sponsored by: MT Rural Healthcare PI Network Co-Sponsored by: Mountain Pacific Quality Health

2. Session One Learning Goals • To discuss basic PI theory and history • To show how PI supports strategic plan implementation • To identify key organization structures for successful PI programs • To describe the different PI program roles and responsibilities • To identify the key elements of a PI Program policy

3. Terminology • Quality Control (QC) • Quality Assurance (QA) • Quality Improvement (QI) • Performance Improvement (PI) • Quality Management (QM) • State Operations Manual (SOM) • Medicare Conditions of Participation (CoP)

4. PI Theory and History • Dr. W. Edwards Deming statistician • Reconstruction of industrial Japan post-WWII 1947, 1950’s • A management & statistical process control consultant • Quality = results of work total cost

5. Deming’s14 Points for Management (1993) • Create constancy of purpose for improvement; • Adopt a philosophy of win-win cooperation; • Rely on statistical evidence that quality is built into a process, not mass inspection of outcomes; • Don’t award business contracts based on cost alone; focus on quality, build loyalty and trust;

6. Deming’s14 Points for Management • Improve constantly, and forever, the system of production, service, planning of any activity; • Institute training for staff skill building; • Adopt leadership aim: help people, machines, gadgets do their jobs better; • Drive out fear and build trust so people can work more effectively;

7. Deming’s14 Points for Management • Break down barriers between departments • abolish competition between departments; • Eliminate slogans, targets asking for “zero defects” or new levels of productivity • creates adversarial relationships; • Eliminate numerical goals, quotas and management by objectives • substitute leadership;

8. Deming’s14 Points for Management • Remove barriers that rob people of joy in their work; • Institute vigorous education and self-improvement program; • Put everybody in the company to work on accomplishing the culture transformation • create a structure from the top down that supports “pushing” every day on the other points.

9. Other Quality Movements • J. M. Juran: Quality circles & coaches, 1979 • P.B. Crosby: “zero defects” at ITT, 1965-1979 • A.V. Feigenbaum: total quality control, 1980’s • Outcomes-based management, 1980’s • Total Quality Management (TQM), early 1990’s • Performance Improvement, late 1990’s- JCAHO

10. The Distilled Philosophy • The performance of any organization can and must be continuously improved; • The quality of decision-making improves when it is based on objective information; • Team work and cooperation are essential; • To settle for anything less is an unacceptable management position.

11. PI and the Strategic Plan

12. Strategy and PI “Quality, after all, is not an end in itself, but the strategic method that the hospital uses to effectively and efficiently perform its mission.” “Total Quality Management in a Hospital”, Wm J. McCabe; QRB April 1992. p 140.

13. Strategic Plans • Customer Needs and Expectations • Patient Care Systems, Processes • Hospital Operations

14. Strategic Plans Customer Needs and Expectations • Internal Customers: direct recipients of work • Patients & their families, staff, medical staff, Board • External Customers: indirect recipients of work • Regulatory surveyors, vendors, community

15. Strategic Plans Patient Care Systems • Identification of new health care markets and developing the ability to serve them • Clinical care delivery • New technology • Patient safety

16. Strategic Plans Hospital Operations • Financial performance • Building/Environment of Care (EOC) • Human Resources • Information Management (EHR, EMR, PHR) • Materials Management • Marketing/Community Relations

17. Strategic Plans Why Should We Care? • Types of performance data collected • Data sources • Measure definitions • Availability of benchmarks • Rigor of statistical analysis • Performance reporting

18. Organization Structure For a Successful Performance Improvement Program

19. Organization Structure What kinds of org structures are needed to: • Ensure everyone is working on same strategies? • Link strategic and operational goals? • Clarify responsibilities for PI from top to bottom? • Who is responsible for doing something with the data?

20. Organization Structure • Bring the PI approach into all decision-making processes (objective, data-based)? • Provide for the independent and objective measurement of performance across the org in support of objective decision-making? • Provide access to needed data?

21. Organization Structure • Provide the PI Dept/Director/Coordinator with the relationships, tools and resources it needs to do its work? • Find opportunities for improvement and work as a team to address them? • Coordinate the plans for multiple PI projects and their resource utilization?

22. Common PI Program Structure

23. Roles and Responsibilities

24. Roles and Responsibilities Adapted from Health Care Quality & Outcomes Management; Aspen Publishers. 1999. pg 1:45.

25. Rolesand Responsibilities Medical Staff/ Director Adapted from Health Care Quality & Outcomes Management; Aspen Publishers. 1999. pg 1:45.

26. Roles and Responsibilities Adapted from Health Care Quality & Outcomes Management; Aspen Publishers. 1999. pg 1:45.

27. Roles and Responsibilities Medical Staff MS Committees: P & T, IC, Credentialing Adapted from Health Care Quality & Outcomes Management; Aspen Publishers. 1999. pg 1:45.

28. Roles & Responsibilities: Board § 485.627(a) C-0241 “ The CAH has a governing body that assumes full legal responsibility to provide quality health care in a safe environment.” • Medical Staff: eligibility and appointments • Medical Staff Bylaws review and approval • Compliance with State and Federal law, and CoPs

29. Roles & Responsibilities: Board • Duty to the community (“fiduciary”) • Monitors implementation of the strategic plan • Routinely reviews key measures of hospital-wide performance (“dashboard report”) • Customer needs & expectations • Patient care systems • Hospital operations

30. Roles & Responsibilities: Leadership • Demonstrates its commitment to the strategic objectives and PI in its actions and decisions • Converts strategic objectives into measurable operational improvement goals (“work plan”): • Customer needs and expectations, internal/external • Patient care systems • Hospital operations

31. Roles & Responsibilities: Leadership • Communicates up, down & across the org; • Deploys goals to the rest of the organization • Educates staff and medical staff about PI; • Shares learning from PI projects, successes, “good tries” • Provides needed resources to do PI: • human, information, time, financial, environment

32. Roles & Responsibilities: Leadership • Eliminates barriers and empowers staff, departments, teams to act to improve; • Routinely reviews & evaluates progress objectively, making operational and strategic adjustments as necessary; • Holds others accountable for achieving operational and strategic improvement goals.

33. Roles & Responsibilities: Providers § 485.631(b)(1) C-0257 “ The doctor of medicine or osteopathy provides medical direction for the CAH’s health care activities and consultation for, and medical supervision of, the health care staff.”

34. Roles & Responsibilities: Providers “Time is a physician’s most valuable resource, and in most cases, it is volunteered.” “Physician time must be directed toward those patient care processes in which the physician has a personal interest.” Total Quality Management in a Hospital”, Wm J. McCabe; QRB April 1992. pg 139.

35. Roles & Responsibilities: Providers • Evaluate and improve the quality of patient diagnosis, treatment and patient outcomes • Evaluate and improve the quality of patient care provided by other members of the medical staff • Evaluate and improve the quality of other patient care services and service providers

36. Roles & Responsibilities: Providers • Evaluate and improve the quality of the medical record • Evaluate and approve contracted patient care services

37. Roles & Responsibilities:Quality Management Team • Composition: “Team” = more than one • Senior organization leaders • Department/service heads • PI Director/Coordinator/staff • Medical staff representative; • Governing Board member • Line staff and/or community member

38. Roles & Responsibilities: Quality Management Team • Conducts the independent assessment of objective evidence concerning the hospital’s overall quality management system: • Is prevention-oriented, proactive • Is fact-based: hard data whenever possible • Uses continuous assessment and improvement cycles to improve all aspects of the organization’s performance

39. Roles & Responsibilities:Quality Management Team • “Independent Assessment” requires the unbiased collection of and gaining information from relevant objective data about: • Critical system, process & outcome measures related to strategic and operational goals • The work of interdisciplinary PI teams • Department/service-level PI activities

40. Roles & Responsibilities:The Quality Management Team • Assessment always ends with decision-making, a plan for moving forward • Primary team decision-making method is consensus; manages conflict • Coordinates resource utilization and allocation for PI activities • Eliminates barriers to improvement

41. Roles & Responsibilities:The Quality Management Team • Educates the organization staff about PI • Educates the community • Annual community report • Periodically evaluates the soundness of the organization’s approach to quality management • Annual progress and program evaluation

42. Roles & Responsibilities:PI Dept./Director/Coordinator • Supports the organization’s strategic plan • Provides data for plan development as requested • Supports the organization’s operation work plan • Provides data for plan development as requested • Provides leadership and guidance for the Quality Management Team (QMT) • Assists in developing the organization-wide approach to performance improvement

43. Roles & Responsibilities:PI Dept./Director/Coordinator • Leads the development and definition of relevant measures of performance • Strategic measures • Operational measures • Others • Independently collects and analyzes objective data for use by the quality management team • Resolves data quality issues • Independently reports performance

44. Roles & Responsibilities:PI Dept./Director/Coordinator • Supports and facilitates medical staff, department, service and/or PI team efforts to improve performance • Provides PI education and training • Identifies and requests needed resources to support, promote, advance the program

45. Roles & Responsibilities:PI Dept./Director/Coordinator “…It is extremely important that quality management is not assigned solely to this department, which has neither the authority nor the resources to change the system… it should not assume, or have delegated to it, the line’s responsibility for managing quality.” “Total Quality Management in a Hospital”, Wm J. McCabe; QRB April 1992. pg 140.

46. Roles & Responsibilities:Departments and Services • Support the organization’s strategic plan • Obtain education about performance measurement and improvement • Gain competence in the use of PI tools • Process and systems analysis • Data collection and assessment

47. Roles & Responsibilities:Departments and Services • Work cooperatively with senior leaders to identify and deploy relevant annual operational goals for each department: • Goals may be converted into specific projects • Leaders provide necessary resources • A time frame for completion/achievement is clearly established

48. Roles & Responsibilities:Departments and Services • Responsibility for achieving goals and/or completing projects is clearly assigned • Relevant measures of performance are developed and defined for each important goal/project • Responsibility for regularly reporting performance is clearly assigned

49. Roles & Responsibilities:Departments and Services • Work cooperatively with other departments, services and staff to improve performance • Discuss progress and performance data with leaders regularly • Discuss progress and performance data with department staff regularly

50. Roles & Responsibilities:Departments and Services • Educate staff about PI • increase staff competence in the use of PI methods and tools • Identify and remove improvement barriers • Celebrate successes and “great tries” • Commit to continuous improvement