Quality Improvement in Arizona CAHs—System and Practice Refining and Measuring Your Process

1. Quality Improvement in Arizona CAHs—System and PracticeRefining and Measuring Your Process Andrea B. Silvey, PhD, MSN Chief Quality Improvement Officer Health Services Advisory Group

2. Objectives • Refine Aim statements. • Refine process flow charts. • Identify key leverage point(s) for monitoring process performance. • Identify potential process measures. 2

3. Overview of Kansas Hospital Association Quality Health Indicators Project Joyce A. Hospodar, MBA, MPA Senior Program Coordinator The University of Arizona Mel and Enid Zuckerman College of Public Health Rural Health Office 3

4. Demonstration ofProject Web Page http://www.hsag.com/services/special/cahs.aspx 4

5. Review of Homework Aim Statements Process Flow Charts 5

6. Effective Aim Statements Answer the question, “What are we trying to accomplish”? Communicate the expectations Are time specific Are measureable Define the specific population or populations affected Are clear and unambiguous Can be used in your elevator speech They aim BIG 6

7. Example Aim Statement for Infection Monitoring and Reporting By August 31, 2010, the infection control officer’s log of infections and communicable diseases will document 100% of the reportable incidents related to all hospital staff and patients, including infections up to 30 days post-operative for all inpatient and outpatient surgeries. 7

8. Targeting the Aim Statement • [Our hospital] would like to improve infection surveillance through more consistent analysis, interpretation, and recording of infection control data (such as laboratory and other clinical reports) to identify and act on emerging trends. • Identify all specific lab and clinical reports included in the term ‘infection control data’ • Clarify: what is meant by analysis? interpretation? • Specify where data should be recorded What are the processes that might need to be improved? 8

9. Homework Aim Statement • By August 31, 2010, the infection control officer’s log of infections and communicable diseases will document 100% of the reportable incidents related to all patients. 9

10. The Difference Between a Team Charter and an Aim Statement • An AIM statement is part of a team charter and addresses what the team intends to accomplish and how it will know if it’s effective in its work. • In addition to the Aim statement, a charter also includes information to structure and organize what the team is going to do, how it will go about its work, and how it will communicate its barriers, needs, activities, and results. 10

11. Refining the Process Flow Chart • Name of process. • Process owner. • Process output/product. • Who is involved in delivering the process. • Who cares about the process (stakeholders). • Extent of the process to be mapped (level of detail). • Activities that define the process. • Start point. • End point. 11

12. Homework Aim Statement The process [this hospital] has chosen to improve is the reporting of healthcare acquired infections (HAI). The individuals involved in this process will include the Infection Control Nurse, Director of Professional and Support Services, CEO, lab personnel, and the Hospitalist. The process that is currently in use is to receive the lab reports and to verify whether the infection was acquired in the hospital or if the patient arrived with the infection. In addition to the staff currently involved, nursing staff will be trained to look for indications of infection and to report this to the Infection Control Nurse. This process change will improve the timeliness and accuracy of the reporting of HAIs. 12

13. Exercise: Refining AIMs • Utilizing the Criteria for Effective Aim Statements, come up with a list of questions that will get the information necessary to clarify the Aim. Develop suggestions that will make the statement more specific and actionable. 13

14. Understanding and Refining the Process • Name of process • Start point • Extent of the process to be mapped (level of detail) • Who cares about the process (stakeholders) • Who is involved in delivering the process • Activities that define the process • End point • Process output/product 14

15. Aim Statement By August 31, 2010, the infection control officer’s log of infections and communicable diseases will document 100% of the reportable incidents related to all patients. 15

16. Key Leverage Point(s) • Intermediate points in the process at which monitoring will be easiest to accomplish and will give you most pertinent information as to whether your Aim is being accomplished. • The key focal point(s) for designing interventions that will have maximum impact on improving the process. 16

17. Exercise: Identifying KeyLeverage Points • In your group, discuss what you think are the key leverage points in the process and explain why. Select a spokesperson who will report back to the larger group. 17

18. By August 31, 2010, the Infection Control Preventionist will achieve 100% compliance with the initiation of timely and appropriate Isolation Precautions for all admitted patients. 18

19. Aim Statement Reduce the number of patients to zero who are treated inappropriately for infections in both the Emergency Department and the Hospital Inpatient Unit, with a target date of October 1, 2010. 19

20. Just for FUN!! http://www.youtube.com/watch?v=Zhoos1oY404 • How do you think he went about perfecting his process??? • What kind of measures do you think he used? • Where were his leverage points? 20

21. About Measures Measures can be used for learning. Measures can be used for judging. All measures have limitations, but the limitations do not negate their value. Measures are one voice of the system. Hearing the voice of the system gives us information on how to act within the system. Measures tell a story; goals give a reference point. 21

22. Measurement Guidelines Types of measures Tips for developing measures Measure specifications 22

23. Types of Measures Outcome Process Relative Absolute Rates Percentages Counts 23

24. Tips for Developing and Using QI Measures The key measures should clarify the Aim and make it tangible. Keep it simple; be careful about overdoing process measures. Seek usefulness, not perfection. Small samples over time should be used to determine if the process is improving. Collect data in segments at key leverage points in the process. 24

25. How does our process perform? Measure Variation Is it stable? Is it predictable? Process Performance Does it meet our performance expectations? 25

26. Measure Specifications Denominator What aspects of the process are you going to measure? What will you look at? Numerator What are the criteria for successful completion of that aspect of the process? 26

27. Exercise: Identify Potential Process Measures Utilizing the Tips for Developing and Using Measures, develop a measure to monitor how well your process is performing. 27

28. Take-Home Messages An AIM statement is part of a team charter and addresses what the team intends to accomplish and how it will know if it is effective in its work. In addition to the Aim statement, a charter also includes information to structure and organize what the team is going to do, how it will go about its work, and how it will communicate its barriers, needs, activities and results. Clear Aims and detailed process flow charts are essential for developing effective measures. Effective measures should focus on monitoring key intervention point(s) that have maximum leverage for improving the process. 28

29. Homework for WebEx#2 (2/23/10) • Refine Aim statement and draft a team charter. • Refine process flow chart and identify key leverage points. • Draft measure(s) to monitor the process. 29

30. Next Steps:Who Does What by When 30

31. Contact Information Andrea B. Silvey, PhD, MSN Chief Quality Improvement Officer Health Services Advisory Group (602) 665-6135: direct line asilvey@hsag.com 31

32. Over 1 million drug-related injuries occur every year in health care settings. The Institute of Medicine estimates that at least a quarter of these injuries are preventable. To find out how to prevent medication errors, go tohttp://www.hsag.com/drugsafety/. www.hsag.com 32