Continuous Quality Improvement Efforts for MCAH Populations

Transcription

1 Continuous Quality Improvement Efforts for MCAH Populations FAMILY HEALTH OUTCOMES PROJECT This project was supported by funds received from the State of California, Department of Public Health, Maternal, Child and Adolescent Health Division

2 Learning Objectives Participants will be able to: Understand the definition(s) of quality assurance (QA), quality improvement (QI), continuous quality improvement (CQI) and Program Fidelity Assurance and particular utility of each Articulate how QA, QI and CQI relate to and emerge from the CA MCAH planning and evaluation processes. Articulate how these differ from program evaluation Describe 3 models for implementing CQI: 1. Health Resources & Services Administration/Institute of Medicine (HRSA/IOM) 2. Public Health (PH) Accreditation Board 3. HRSA Office of Adolescent Health

3 Learning Objectives Cont. Articulate the benefits and challenges to implementing a CQI program Describe some program models utilizing CQI Model for QI for statewide Home visiting program YMCA of Greater Seattle Youth program CQI model Evaluating mental health programs for trauma informed care in Chicago, IL Prenatal Care Model for CQI for Access to Care: Case Study Articulate lessons learned

4 Definitions of Quality Assurance Assuring quality of community health programs/health services = constantly measuring the effectiveness of health service providers and the programs and organizations that provide services Institutionalized activities and programs intended to assure or improve the quality of services/programs in either a defined medical setting or a program Often measure compliance with state, national or professional standards/policies/ licensing etc.

5 Examples of Quality Assurance Activities Annual monitoring of kindergarten immunization rates Annual child abuse and domestic violence training with pre-post test Chart review for compliance with recommended preventive services, i.e. blood pressure, lab tests, pap smears Utilization review of patient care necessity, quality, appropriate, LOS

6 HRSA and IOM definitions HRSA: Quality improvement consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. IOM: Quality in healthcare = direct correlation between the level of improved health services and desired health outcomes of individuals & populations.

7 HRSA Basic Model

8 Definition of QI In Public Health Quality improvement in public health is the use of a deliberate and defined improvement process, such as Plan-Do-Check-Act, which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community. This definition was developed by the Accreditation Coalition Workgroup (Les Beitsch, Ron Bialek, Abby Cofsky, Liza Corso, Jack Moran, William Riley, and Pamela Russo) and approved by the Accreditation Coalition on June 2009.

9 Program Evaluation Should be done when initiating a new service or program to determine effectiveness Requires a program logic model that defines inputs, resources, activities as well as process and program outcomes as well as health/public health outcomes Requires Adequate expertise Staff and financial resources Staff and partner buy in Evaluation tools

10 Poll Question 1 Carol Hathaway, the Perinatal Services Coordinator (PSC) from Happy County is headed to Dr. Welby s office to review a sample of charts from the doctor s patients receiving CPSP services. PSC s conducting chart reviews is: Quality Improvement Program Evaluation Quality Assurance All of the above None of the above

11 They Are Not the Same Quality Assurance Reactive Works on problems after they occur Regulatory usually by State or Federal Law Led by management Periodic look-back Responds to a mandate or crisis or fixed schedule Meets a standard (Pass/Fail) Quality Improvement Proactive Works on processes Seeks to improve (culture shift) Led by staff Continuous Proactively selects a process to improve Exceeds expectations

12 They Are Not the Same Program Evaluation Assess a program at a moment in time Static Does not include identification of the source of a problem or potential solutions Does not measure improvements Program-focused A step in the QI process Quality Improvement Understand the process that is in place Ongoing/dynamic Entails finding the root cause of a problem and interventions targeted to address it Focused on making measurable improvements Customer-focused Includes evaluation

13 Continuous Quality Improvement A formal ongoing cycle of activities that includes Measuring inputs Monitoring processes Monitoring outcomes Reviewing results Creating a remediation plan Monitoring the implementation plan

14 Continuous Quality Improvement Source:

15 Definition of Program Fidelity HRSA Office of Adolescent Health Definition: Degree to which a program is implemented with adherence to its core components the key ingredients related to achieving the outcomes associated with the program model 2 categories of core components: 1. Program Content 2. Program Delivery Ideally, program developers and evaluators determine a program s core components Core components can include program content only, or program delivery methods only, or both

16 Program Fidelity Process

17 Poll Question 2 You just finished conducting your first Blue Dot campaign with stakeholders from your local MCAH Advisory Board. You are interested in learning if the campaign impacted your stakeholders view of how important it is to address perinatal mood and anxiety disorders in pregnant and postpartum women. To get a better understanding of the impact on stakeholders, you should conduct a Quality Improvement Project Quality Assurance Project Program Evaluation Project All of the above None of the above

18 Benefits CQI processes provide: Real-time monitoring Critical information on fidelity of program to an evidence based model Information on program s acceptability to target population Information on whether alterations have been a success Overall provides feedback to and engages staff in more effective efforts to manage program and improve performance

19 Challenges Requires significant targeting of resources and expertise Requires resources to collect and analyze data throughout project cycle Sometimes results in fewer resources available for program implementation Rigid program model can limit ability of staff and community members to make alterations that better serve a particular community

20 Poll Question 3 Carla has been leading safe sleep workshops for local daycare providers in Happy County for the last two years. The workshops take place over a weekend, but Carla has recently noticed that attendance on day 2 of the workshop has dropped off. Now, upwards of 30% of attendees are not earning their workshop completion certificates. If Carla wants to increase attendance on day 2, what type of project should she initiate? Program Evaluation Quality Improvement Quality Assurance All of the above None of the above

21 Statewide Home visiting CQI Program Program goals are to improve parenting skills and connect families to needed services and improve health of service population Evaluation system is designed to: 1. Integrate evaluation into daily workflow 2. Utilize standardized screening & evaluation tools 3. Facilitate culture of CQI in program management 4. Facilitate scientifically rigorous evaluations

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23 Question One What are the key elements in this process? Are there more that one functions within this comprehensive overview?

24 YMCA of Greater Seattle's CQI initiative Youth Program Quality Intervention (YPQI) model helps improve youth program quality by providing research-based standards & a process for achieving those standards Randomized trial research has found intervention to be effective at improving program quality Designed to be used with Youth Program Quality Assessment (YPQA), a research-based instrument to assess quality of service at point where staff and youth interact Five step process: prepare, assess, plan, improve, repeat

25 YPQI Step YPQI Elements The Y s 2010 Plan What Actually happened Prepare Identify Leadership Identify two project leads. Two mid-level executives shared the leadership role; each brought experience implementing the YPQI model at a pilot site. Leads completed trainings offered by the Weikart Center in preparation for the role. Develop Project Plan, Budget, Timeline Leads make decisions based on local considerations and resources about how the process will take place. Program participants included teen and young adult programs, Y branches and camps. A spring and fall assessment schedule was set. Project Communication Two leads share communication work, with one managing school-based programs and the other managing branch-based programs (ongoing). Both leads introduce YPQI to staff and manage buy-in process. Leads introduced staff to the process via invitations to initial trainings (December 2009 January 2010). One lead held monthly meetings with school-based staff and bi-weekly meetings with site supervisors. One lead was on leave March August 2010, decreasing communication with branch-based programs.

26 YPQI Step YPQI Elements The Y s 2010 Plan What Actually happened Assess Training to Conduct Self- Assessment Thirty staff representing twenty- six programs to participate in initial training to use YPQA tool (January 2010). Forty staff participated in optional training (January 2010). Training for External Assessors Ten management-level staff and staff with YPQA experience to be trained to be external assessors (January 2010). Thirteen staff were trained to be external assessors (January 2010). Baseline Self- Assessment and External Assessment Twenty-four school-year programs to conduct at least one self-assessment and invite one external peer assessment by a colleague (February April 2010). Twenty school-year programs conducted a total of twenty-nine self- assessments and twenty-four peer assessments (March June 2010). No summer programs conducted baseline assessments. Two summer programs to conduct at least one selfassessment and invite one peer assessment (July August 2010).

27 YPQI Step YPQI Elements The Y s 2010 Plan What Actually happened Plan Action Planning Invite all participating staff to Planning with Data workshop (April 2010). Twenty-four sites complete action plans (mid-may 2010 due date). Approximately twenty-five staff attended Planning with Data workshop (April 2010). Fourteen action plans completed (July 2010). Improve Youth Work Methods Trainings Staff participates in Voice and Choice and Reframing Conflict workshops (November 2010). Thirty-three staff participated in Voice and Choice or Reframing Conflict workshops (November 2010). Coaching for Managers or Staff Coaching is informal, delivered by initiative leads and staff supervisors (ongoing). Informal coaching was delivered by initiative leads and staff supervisors, but not tracked (ongoing).

28 YPQI Step YPQI Elements The Y s 2010 Plan What Actually happened Repeat Post-Initiative Assessment Twenty-four school year programs complete a second peer and selfassessment (November 2010). Eighteen school year programs completed a second wave of assessments, with twelve self- and nine peer observations conducted and scored (November 2010). Continuous Quality Improvement Twenty-four sites complete or update action plans after the post-assessment, kicking off a continuous quality improvement cycle (December 2010). Thirteen action plans completed (December 2010).

29 Question Two What are the differences between this type of schematic and the previous one? What is missing? What is added? What would be most useful from your point of view

30 Making Change Last: Taking a Trauma-Informed System from Theory to Continuous Improvement 2011 System of Care Community Training of Federal Substance Abuse and Mental Health Services Administration, Chicago, IL CQI designed to: 1. Educate providers on trauma-informed principles and difference between trauma-informed and trauma-specific service 2. Assess and measure whether services are trauma-informed 3. Identify technical assistance needs with stakeholders based on assessment outcomes 4. Understand how youth and family define quality 5. Demonstrate how CQI can sustain a system of care provided by DHHS, in partnership with family and youth

31 Involving Youth and Family Phase Planning Pilot Testing Implementation Role of Youth and Family How? Youth and Family... Create framework and questions; provide feedback and suggestions. Test and refine questions, methods and framework. Ensure data collection is family and youth friendly. Review responses and suggest best practices to ensure family/youth are reached. Interpret results....identified what is most important to them....made sure key components include youth and family priorities....drafted definitions and questions....helped an evaluator to conduct key informant interviews....brainstormed ways to reach family and youth....pilot tested final data collection instruments....suggested changes....provided technical assistance to agencies....helped youth/families respond to the assessment....reviewed quarterly report on the number of responses....made suggestions based on report....reviewed final data results.

32 Statewide CQI Plan Additional Technical Assistance as needed Conduct TIAA Assessment Agency and DHHS Review Results Implement CQI Plan / Plan Do Study Acts Prioritize Areas of Need Technical Assistance from Thrive Consultants/ Use of Guide to Trauma- Informed Organizational Development Create Continuous Quality Improvement Plan for DHHS Contract Guidance from DHHS Regional Coordinator leads to initial contact with Thrive

33 Prenatal Care Model for CQI for Access to Care: HRSA Case Study Happy Farms Health Center: full-scope, primary care, & inpatient services to a large, sparsely-populated agricultural region. One main site & two small satellite sites located in different sectors of their service area. Staff: 2 family physicians, 1 physician s assistant, 1 part-time certified nurse-midwife Problem: Center noticed number of patients were arriving for prenatal care in their second or third trimester Initiated a process that included: developing an aims statement, creating infrastructure for improvement, and gaining commitment from leadership Developed a model of a critical pathway for access to care

34 Critical Pathway for First Trimester Prenatal Care Access Potential Factors that Have an Impact on Access 1. Woman of reproductive age presents for care Patient Care Team Health System 2. Preventative care needs are assessed as part of intake-family planning, pregnancy plans Patient Care Team Health System 3. Education provided related to contraception, preconception, preventative health services available Patient Care Team Health System 4. Patient presents for pregnancy test with positive results Patient Care Team Health System 5. Patient is scheduled for initial prenatal visit with provider Patient Care Team Health System 6. The pregnant woman is seen in the first trimester Patient Care Team Health System Source:

35 Example of factors impacting access 1. Woman of reproductive age presents for care Patient Care Team Health System 2. Preventative care needs are assessed as part of intake-family planning, pregnancy plans Factor Category Factors Pertinent to our Organization - Steps 1 and 2 Patient Care Team Health System Hispanic population - cultural norms impede understanding need for early prenatal care; large teen population presents challenges to engage patients in planning No staff, workflows, or prompts dedicated to assessment of family planning needs; available educational materials are not culturally appropriate for the population Additional co-pay for preconception visit and appointments for routine gynecological care are backed up eight weeks Source:

36 Changes That Work Area of Critical Pathway Patient Changes Care Team Changes Health System Changes A woman of reproductive age presents for care Patient educational resources regarding importance of early prenatal care routinely given Create expectation that patient must take responsibility to assure early prenatal care Care team members knowledgeable about importance of early prenatal care and can reinforce with messaging and materials during well-woman exams Health system understands importance of early prenatal care Preventive care needs are assessed as part of intake family planning, pregnancy plans Education provided related to contraception, pre-conception, and preventative health service Patient presents for pregnancy test with positive result Patient is scheduled for initial prenatal visit with provider Educational materials are available regarding signs of pregnancy Education materials regarding the importance of good health before pregnancy Education provided regarding contraception, preconception, and preventative care Patient educated on signs of pregnancy and the importance of early prenatal care Patient understands importance of early prenatal care Care team knowledgeable regarding clinical guidelines for preventive care Care team knowledgeable regarding clinical guidelines and understanding of latest contraceptive methods, including risk assessments for contraception, etc. Care team members knowledgeable about importance of early prenatal care Care team members knowledgeable about importance of early prenatal care The pregnant woman is seen during her first trimester Source: Clinical guidelines for preventive care embedded in health system Education is provided related to contraception, preconception, and preventative health Health System understands the need for early prenatal care

37 Question 3 What kind of approach does this plan take? What are the advantages of this approach?

38 Lessons Learned Organizations that achieved improvement shared 3 characteristics 1. Clear Direction Developed an appropriate aim statement (essentially a SMART Objective) Additional resources: Readiness Assessment & Developing Project AIMS 2. Functional infrastructure for quality improvement Need a systematic approach to measuring performance, testing small changes, and tracking the impact of those changes over time Essential infrastructure components: a) Quality improvement teams b) Tools and resources c) Organizing improvements d) Building on the efforts of others by using changes that worked 3. Commitment from Leadership Source:

39 Functional Infrastructure for Quality Improvement Multi-disciplinary Quality improvement team members bring expertise knowledge about what they do, need willingness to improve and ability to think from a systems perspective Tools and resources Organize meetings efficiently Tips for Effective Meetings Manage data for performance improvement e.g. a data dashboard Managing data from performance improvement Planning an approach to change is essential, adopt a model (e.g., Link to PDSA worksheet) to guide the actual change process and managing how changes are made Build on the Efforts of Others by Using Changes that Worked - steal shamelessly Source:

40 How organization can make changes: Organizing for Improvement 1. Model for Improvement The Model for Improvement identifies aims, measure, and change strategies w/ 3 questions: 1. What are we trying to accomplish? 2. How do we know that change is an improvement? 3. What changes can we make that will result in improvement? Questions are followed by use of learning cycles (e.g. Plan-Do-Study-Act cycles) to plan and test changes in systems and processes Source:

41 Model for Improvement Source:

42 Keep the changes small Involve care teams Tips for Testing Changes Study results after each change Involve others who do the work Make sure that overall aims are improving; changes in one part of a complex system sometimes have an adverse effect in another Source:

43 How organization can make changes: Organizing for Improvement (cont.) 2. Process Mapping Provides a visual diagram of a sequence of events that result in a particular outcome Purpose is to use diagramming to understand current process (i.e., how a process currently works within the organization) and identify opportunities for improvement Can be used before or in conjunction with PDSA cycle Mapping out the current process often uncovers unwanted variation (different staff/practices, time day/week) Additional Resources for Process Mapping: Redesigning a System of Care to Promote QI Source:

44 Holding gains and spreading improvements Ongoing monitoring QI data ensures that an organization holds the gains over time Can reduce the frequency of monitoring the process, BUT some ongoing assessment of the measure is necessary Processes that work well now may need to change as environment shifts e.g. Population mix change Successful QI effort that were started out small or impacted only a particular population can be spread organization-wide Source:

45 References Gorenflo, G; Moran, J. The ABCs of PDCA. Public Health Foundation Health Information Technology Research Center; The National Learning Consortium. Continuous Quality Improvement (CQI) Strategies to Optimize your Practice. April 30, Hunter, S; Kilburn, R; Mattox, T; Wiseman, S. Getting to Outcomes for Home Visiting: How to Plan, Implement, and Evaluate a Program in Your Community to Support Parents and their Young Children. RAND Corporation Murray, M. Lessons for Youth Program Quality Improvement Initiatives: A Summary of the YMCA of Greater Seattle s Initiative. MEMconsultants. January U. S. Department of Health and Human Services Health Resources and Services Administration. Developing and Implementing a QI Plan. ntingaqiplan/part4.html