QUALITY WHAT IS IT AND HOW IS IT STRUCTURED Transplant Quality Institute Kathy Schwab Integrity and Compliance Coordinator Disclosures No Disclosures Objectives Define what is quality in transplantation Review development of and use of objective measures in the quality process Describe and discuss quality assessment measures in transplant QAPI Review and discuss use of committee/council in the QAPI process. Define comprehensive membership structure for QAPI process. Describe communication process between transplant program and hospital/institutional leadership 1
The Institute of Medicine defines healthcare quality as the extent to which health services provided to individuals and patient populations improve desired health outcomes. The care should be based on the strongest clinical evidence and provided in a technically and culturally competent manner with good communication and shared decision making. Pelletier & Beaudin, PhD, Q Solutions: Essential Resources for the Professional, Second Edition, (Glenview, IL: National Association for Healthcare Quality, 2008); p.3. Patients experiences should be the fundamental source of the definition of quality. (Donald M. Berwick) Six Aims of the Institute of Medicine Efficient Effective Patient Centered Equitable Timely Safety 2
Quality Health Care Quality Are you good at what you do? Data Are you good at what matters? Patient Experience How do you know? Analysis Quality Health Care Four Levels of Impact Level A- The patients experience Level B- Microsystems Level C- Structure where care is provided Level D- Environment that impacts care Transplant QAPI Program- Program Function Implement Plan Establish Scope Reporting Process Monitor Compliance Coordinate Improvements Establish Quality Environment Develop/Document Annual Evaluation Communicate bidirectional Identify Opportunities/Initiat e Initiatives 3
FQAPI Survey Tool 5.3 Do the performance and improvement projects reflect the scope and complexity of the transplant program s services and operations? 5.4 Does the project include multi-disciplinary team members, transplant leadership member and where feasible hospital leadership members? 5.5 Can the program provide evidence showing why each project was selected? Quality Components- Objective Measures Structure Facility/Organization Characteristics Patient Census Organizational structure Process Components of clinical care, actions or functions ABO verification Informed consent Outcome Affect of care delivered, measure that relates to result or end of care Wait list mortality Patient and graft survival PROGRAM OBJECTIVE MEASURES PROCESS MEASURES (measures that reflect sequential steps to complete a task) PATIENT TYPE PRE-TRANSPLANT TRANSPLANT POST TRANSPLANT RECIPIENT Referral to Listing (median days) Multidisciplinary Rounds Involvement Documentation of follow-up visits ABO Verification Cold Ischemic Time Medication Reconciliation Donor Acceptance Rates Informed consent for surgery OUTCOME MEASURES (measures that relate to a result or end of care) PATIENT TYPE PRE-TRANSPLANT TRANSPLANT POST TRANSPLANT RECIPIENT Mortality on the Waiting List (O<E) Transplant Rate (O>E) Readmission Rates within 30 Days Six minute walk Length of Stay (LOS< 5) Patient & Graft survival at 1 year Blood Utilization in OR Acute Rejection Rates Unplanned return to the OR 4
Quality Improvement Plan A QI plan is a detailed, and overarching organizational work plan for a health care organization's clinical and service quality improvement activities. It includes essential information on how your organization will manage, deploy, and review quality throughout the organization. A QI plan is generally developed by executive and clinical leadership and, in many organizations, must be approved by the organizations governing body such as a Board of Directors. It is updated regularly to reflect what your organization is doing to improve quality. A QI plan generally outlines the specific clinical focus areas for the current and subsequent calendar years. Often, it is developed as an outgrowth of the evaluation of the previous year's QI activities, organizational priorities and organizational program requirements. U.S. Department of Health and Human Services HRSA 14 Hospital Quality Structure Hospital Quality Program Transplant Quality General Quality Programs Regulatory Structure and Leadership Formal organizational structure maximizes value by matching mission and vision with over-all quality process. Implement Prioritize Model Promote Advocate Allocate Organizational Design: A Step-by-Step Approach Burton RM, DeSanctis G, Obel B. 5
Components for successful organizational structure to support QAPI identified by HRSA Leadership Role Board of Directors Information Management Defined Organizational Priorities Annual Evaluation and Work Plan Development Resource Allocation - Leadership The Role of Leadership To plan and manage quality improvement Develop links to the quality process Lead by demonstrating engagement FQAPI Survey Tool will evaluate: 3.1-Has the formal Transplant QAPI program been-approved by the Governing Body? 3.2-Is there evidence of hospital leadership s involvement with and knowledge of the transplant QAPI 3.4-Can the transplant leadership provide evidence that the hospital s governing body is involved in QAPI activities? - Leadership Board of Directors/Equivalent Commitment to regular close oversight Communication Delegation Determine structures approach (DAMAIC/PDSA) Lead and support change through words and actions 6
- Executive Level Leadership Information Management Technology Point of Care Dissemination of information through out care system -Leadership Define Organization Priorities Mission, Vision, Scope of Service Performance measures Performance indicators -Leadership Implementation of Operational Goals Operations implement the strategy and planning that supports the organizations growth and development Evaluation of QI process Benchmarking Data collection and analysis Frequency Assign responsibility for analyzing and interpreting Establish system for intervention for improvement For example PDSA Implementation of QI plan Annual evaluation and work plan development Continuous Monitoring Resource Allocation 7
- Structure Goals Process QAPI Indicators Metrics Roles Tasks Committee Council QAPI Structure: Sharing Information Board of Trustees Board of Trustees Quality and Performance Improvement Committee Summary of Annual Report to BOT distributed to Transplant Executive Quality Council Summary of Transplant Executive Quality Council to organ specific QAPI programs Quality and Performance Improvement Committee of the Medical Board Transplant Executive QAPI Committee Organ Specific QAPI Programs Reporting Structure Board of Trustees Medical Executive Committee Adult Hospital Quality Council Transplant Quality Council TQI QAPI Committee Children s Hospital Quality Council Kidney & Pancreas QAPI Living Donor QAPI Intestine QAPI Liver QAPI Thoracic & VAD QAPI Pediatric QAPI 8
Structure - Communication 9
- Organ Specific/Single Program Membership Charge Meeting schedule Committee responsibilities - Six Sigma Communication Tactics Face to Face Town Hall Brown Bag s Face to Face Meetings Electronic Email Intranet posting FAQ s Memo Mass Distribution Newsletter Surveys Posters Video Six Sigma Communication Strategies for Six Sigma Initiatives Leadership level committees Institutional/hospital specific Membership Scope QAPI functions Communication Transplant Center/Institute QAPI Oversight of programs specific groups Scope Membership QAPI functions Communication 10
In 1910 one of the founders of Mayo Clinic is noted for stating. The Needs of the Patient Come First References Ransom, Joshi, Nash;2005-The Health Care Quality Book Ransom, Joshi, Nash; Third Edition 2014-The Health Care Quality Book HRSA; 2013 Progress Report to Congress: National Strategy for Quality Improvement in Health Care CMS Program Analysis Worksheet IOM, 1999 To Err is Human: Building a Safer Health System Berwick, Donald;2002 Health Affairs-At the Intersection of Health, Health Care and Policy HRSA, 2011; Developing and Implementing a QI Plan Catapult Consultants, LLC, 2010; A Resource Guide for Transplant Surveyors Transplant Quality Institute SPONSORED BY AFDT. 11