Quality Improvement Strategies

1. Quality Improvement Strategies Root Cause and Subgroup Analyses

2. Root Cause Analysis A way of looking at unexpected events and undesirable outcomes to determine all of the underlying causes and recommend changes that are likely to improve them. 2

3. Root Cause Analysis • Also known as causal/barrier analysis. • The causes/barriers identified are the reasons (root causes) why the study indicator results are not meeting performance standards. 3

4. Root Cause Analysis Root cause analysis should: • Primarily focus on systems and/or processes. • Identify changes that can be made in systems and/or processes. 4

5. Root Cause Analysis Data analysis Root cause analysis Subgroup analysis Develop and implement solutions 5

6. Root Cause Analysis • Will help the organization understand the barriers to achieving desired outcomes. • Allows interventions to be streamlined and focused to address the barriers. • Required for PIP documentation (critical element). 6

7. Root Cause Analysis Tools • Brainstorming • Survey • Focus Group • Process Map/Flow Chart • Fishbone Diagram • Scatter Diagram • Pareto Chart • Run Chart 7

8. Subgroup Analysis Why perform a subgroup analysis? • Determine if any subgroup within the population has a disproportionately lower rate that negatively affects the overall rate. • Develop targeted interventions to the identified subgroups, allowing the implementation of more precise, concentrated interventions. 8

9. Population Subgroups • Race/Ethnicity • Age • Gender • Geographic Location • Provider 9

10. Factors to Consider • Are the data elements for the subgroups • Available? • Accurate? • Complete? • Is the size of the subgroup • Adequate for analysis? • Require grouping? • Require additional subgroup analysis? • Are the subgroups reasonable, i.e., do they make sense? 10

11. Measure-Specific Examples Follow-up after discharge for a mental illness • Age • Race and ethnicity • Geographic location • Zip codes • Can be used as a proxy for race/ethnicity 11

12. Measure-Specific Examples Coordination of Care • Geographic location • Provider • High volume • Specific provider practice 12

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14. Initial Subgroup Analysis Before implementing improvement strategies: • Identify disparities, i.e., do performance rates vary by subgroup? • Determine the impact of the disparity on the overall rate. • Identify subgroup-specific barriers, if applicable. • Root cause analysis • How can systems or processes be changed to improve performance? 14

15. Ongoing Subgroup Analysis After implementing improvement strategies: • Evaluate the effectiveness of the performance improvement strategy for all subgroups. • Monitor using interim measurements. • Consider rapid cycle improvement to test for changes in rates and make “real-time” refinements. • Reevaluate barriers. • Root cause analysis. • Revise or standardize interventions. 15

16. Activity VII-Implement Interventions and Improvement Strategies • Ensure that the root cause analysis process is completely documented in Activity VII. • Document when it was completed. • Include who was involved (e.g., quality improvement committee, work group, etc.). • Provide the tools that were used (e.g., fishbone diagram, brainstorming, etc.). 16

17. Activity VIII-Analyze Data and Interpret Study Results • If subgroup analysis is completed, document this in Activity VIII. • Include the outcome of the analysis as well as the follow-up activities planned as a result. • Subgroup analysis is not required; however, it is recommended as a way to target interventions. 17

18. PIP due dates • PIPs due to HSAG on 12/14/11. • Address all Partially Met and Not Met scores from last year, as well as all Points of Clarification. • Reference the PIP Summary Form Completion Instructions for guidance. • HSAG is available to provide technical assistance. Contact ddriscoll@hsag.com to request. 18

19. Questions/Comments 19