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How can one tell whether or not a healthcare organization is really serious about improving its quality, instead of simply engaging in defensive measurement to protect itself against the demands of outsiders for information?
Don Berwick, The Basic Concepts of Quality Improvement , unpublished paper, 1987
Performance management is “the use of performance measurement information to help set agreed-upon performance goals, allocate and prioritize resources, inform managers to either confirm or change current policy or program directions to meet those goals, and report on the success in meeting those goals”
In the ACMHA project, five national accreditation entities reached consensus on a set of performance measures (CARF [The Rehabilitation Commission], the Council on Accreditation, the Council on Quality and Leadership in Support of Persons with Disabilities, JCAHO and NCQA) but not on the specifications for measurement
They concluded that it was “important to recognize that selecting appropriate measures depends on the purpose of assessing performance”
They designated measures as either a comparison measure or a quality improvement measure to clarify the intended use of each measure and its data set
For comparison purposes, the standards and measures should provide sufficiently valid and reliable quantification such that comparison across the system’s programs and departments can be made. By identifying the highest level of performance or outcome (the benchmark), an organization can duplicate those work processes to achieve higher performance overall.
For improving quality , some standards and measures lend themselves more to internal monitoring of performance and local accountability and are most suitable for supporting the improvement of the organization rather than for comparability among organizations.
Balanced Budget Act (BBA) of 1997 was a substantial rewrite of the Medicaid and Medicare program rules. Final rules were passed on 6/14/02; protocols and checklists then rolled out. Details in the protocols and checklists are critical for an understanding of BBA impact.
External Quality Review Organization (EQRO) is an independent entity that meets competence criteria for conducting Medicaid EQR activities; EQROs are being selected through state procurement processes to review the operations of risk bearing organizations contracting with state Medicaid agencies.
Crossing the Quality Chasm: a New Health System for the 21 st Century, Institute of Medicine (IOM) 2001
Redesign of the health care system based on 10 new rules
Build organizational supports for change, including the incorporation of care process and outcome measures into daily work and revising financial methods to support quality work
Priority Areas for National Action: Transforming Health Care Quality , IOM 2003—20 priority areas selected including major depression (screening and treatment) and severe and persistent mental illness (focus on treatment in the public sector)
Currently an IOM Committee is studying how to adapt the Quality Chasm recommendations to Mental Health and Addictive Disorders
In December 2004, a meeting was co-hosted by the National Council for Community Behavioral Healthcare (NCCBH), RWJ Center for Health Care Strategies and SAMHSA to frame a National Initiative for Behavioral Health Care Quality Improvement (CMS participated in this effort, an opportunity to generate their support as well as to foster relationships)
The Institute for Healthcare Improvement (IHI) and Don Berwick, MD, have led the healthcare dialogue from its early beginnings
IHI is a healthcare industry focal point through National Forums, trainings, and Breakthrough Series that target reducing adverse drug events, medical errors or reducing delays and waiting times throughout the system
IHI partnered with Health Resources and Services Administration (HRSA) in developing and staffing the Health Disparities Collaboratives for Federally Qualified Health Centers (asthma, diabetes, depression)
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation process has shifted from “survey preparation and scores to continuous operational improvement in support of safe, high-quality care”
ORYX ® core measure data are used to continually assess key performance areas, and eventually will be incorporated into the organization’s performance report as core measures are adopted for programs
JCAHO prepared the CMS protocols for BBA EQROs to use in review of Medicaid MCOs and PIHPs
So we have a QAPI and PIPs—it’s all about the bureaucracy, right?—wrong, the work must have relevance to the organizational vision, mission and goals—it’s about achieving your purpose and serving your consumers
Requires leadership commitment and a deep understanding of the vision and mission of the system and/or organization
If you cannot tell 1) how a project specifically relates to your agency’s vision and mission, or 2) (worse) if you cannot tell how your agency’s mission and vision relate to quality, the project should be sidelined until you can…
Hayes and Nelson, A Handbook Of Quality Change Implementation For Behavioral Health
The quality organization does not wait to be told (via regulations or requirements) what processes, procedures, or programs to implement. Instead the quality organization proactively implements a program that it recognizes it may have to alter as standards or regulations are developed…
Consider the ACMHA list of indicators as a starting place—it includes measures of what quality service means to consumers
From Hayes and Nelson, A Handbook Of Quality Change Implementation For Behavioral Health
85% of poor quality is a result of poor work processes, not of staff doing a bad job
When things go wrong, it is often at the point of the “handoff” in the process
Attend to improving the overall design, not just one part—some of the most complex and poor quality processes are the result of “improving” and creating “work arounds” at some steps instead of redesigning the entire process
DMAI Forty or more paired measurements Scatter diagrams Correlations Forty or more measurements Histograms Distributions Time-ordered measurements (At least 12 sets of data points) Line graphs Trend Simple tallies by category (At least 30 cases) Bar charts, pie charts or summary statistics Simple percentage or magnitude comparisons Data Needed Use To Show
Sources of variation include: machines, materials, methods, measurements, people, environment
Control charts are pictures of trend data with an extra feature—the range of variation built into the system
Common cause variation occurs if the process is stable— variation in data points will be random and obey a mathematical law—it is said to be in statistical control, with a large number of small sources of variation
If an organization reacts to random variation in a process that is stable/in statistical control, it is called tampering and leads to further complexity, increasing variation and mistakes
Special cause variation arises because of specific circumstances which are not part of the process all the time and may or may not ever recur—if the recurrence is periodic, clues to the root cause may emerge
Not in statistical control is:
One data point above or below the upper/lower control limits (three standard deviations)
Two out of three consecutive data points beyond two standard deviations
Of five consecutive data point, four are on the same side of the mean and beyond one standard deviation
Eight consecutive data points are on the same side of mean
Need to investigate special cause variation before making any conclusions about performance level