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  • 1. PERFORMANCE IMPROVEMENT BRIDGING THE GAP BETWEEN “WHAT IS” AND “WHAT SHOULD BE” A Step-by-Step Workbook and Reference Guide By Lisa DeBilio, Ph.D. QI Coordinator, UCHC, UBHC and Shula Minsky, Ed.D. QI Director, UBHC All rights reserved ©
  • 2. CONTENTS Introduction……………………………………………………………………………………..…. 3 CHAPTER 1. A Few Basic Questions What is Performance Improvement? …………………………......................................................... 4 How is QI/PI Set Up at UBHC and UCHC?.....……………….......................................................... 4 The QI Mission and Principles..........................................................................................................7 The QI Model…................................................................................................................................8 CHAPTER 2. The Performance Improvement Process How Does this Workbook Work? …………………………………………………………………10 STEP 1: PLAN/DESIGN Activity #1: Develop Your PI Team & Define Your Roles…..…………………………………..11 Activity #2: Generate Ideas for a QI Project through Brainstorming & Decide on project using Multi-Voting or Selection Matrix. Submit PI Activity Notification Form……….12 Activity #3: Develop & Categorize Probable Causes using Brainstorming & Multi-Vote …….. 21 Activity #4: Display Probable Causes on a Fishbone Diagram…………………………………. 24 Activity #5: Display the Causes in a Pareto Diagram… …………………………………..….. 28 Activity #6: Use the Flow Chart if There is a Need to Create or Change an Existing Process ……. 31 Activity #7: Brainstorm Potential Interventions & Multi-Vote ………………………................ 36 STEP 2: MEASURE Activity #8:Review Existing Data or Collect New Data, Develop a Plan, Implement Interventions, and Collect Post Data……………………………………………….………………. 38 STEP 3: ASSESS Activity #9:Analyze Data and Compare Results……………………………….…………………47 STEP 4: IMPROVE Activity #10: Implement, Educate and Monitor Improvements…………………………………. 51 CHAPTER 3. The Performance Improvement Fair What is a PI Fair? ……………………………………………………………………………..…… 54 The Judges Criteria ........................................................................................................................... 54 The Judges’ Scale………………………………………………………………………………....55 Activity #11: PI Poster Boards…………………………………………………………………. 56 PI Board Examples……………………………………………………………………………..... 57 Registration Form..……………………………………………………………………………… 61 Activity #12: Meeting Minutes…………………………………………………..……………... 62 QI Help Line……………………………………………………………………………………....64 2
  • 3. INTRODUCTION If you are saying “I wasn’t hired into the Quality Improvement Department, so why do I need to know about the PI process?” then this booklet is for you. In the ever-changing health care environment, continuous quality improvement (CQI) programs have become essential; not only because of the need to monitor and improve services, but also to ensure that programs adhere to the standards set by accrediting organizations like the Joint Commission on Health Care Organizations (for UBHC), and the National Commission on Correctional Health Care (for UCHC). CQI helps fulfill the mission of providing the best possible treatment and services to those under our care. Better services can make a difference and can help clients achieve their goals, overcome difficulties, and live better lives. We can achieve excellence through the collaboration of multidisciplinary Performance Improvement (PI) teams who identify areas of care in need of improvement, discover the root causes of problems, and take action by generating and implementing interventions, and monitoring improvement over time. This workbook is designed to help staff follow step-by-step guidelines for carrying out PI projects from selecting and prioritizing issues for improvement all the way to presenting the final product at a Performance Improvement Fair. The workbook can also be used as a tool to document and track the progress of individual projects. We hope that this workbook will make your job easier; however, please view it as a work-in-progress. If you have any feedback, suggestions or questions please send them to Lisa DeBilio at or Shula Minsky at CHANGE CHANGE CHANGE CHANGE 3
  • 4. CHAPTER 1 A FEW BASIC QUESTIONS What is Performance Improvement? You have heard the terms QA, CQI, QI, PI, etc.; rest assured that these terms are more or less interchangeable and they all refer to a systematic approach to analyzing current performance and designing, testing, implementing and monitoring interventions that bridge the gap between “what is” and “what should be”. The concept was derived from a set of management theories (Total Quality Management) first developed and applied in the manufacturing industry. Since then, the concept and strategies have been applied to the service industry with impressive results. Performance Improvement (PI) focuses on processes, not individuals. Teamwork and measurement are a few of the core principles that drive performance improvement in health and behavioral healthcare environments like ours. In UBHC and UCHC we have adopted a four-step model to guide performance improvement activities throughout the organization. How is QI/PI set up at UBHC and UCHC? The QI program at UBHC is overseen by the Quality Improvement and Patient Safety Committee (QIPSC). The committee is co-chaired by the director of the Quality Improvement Department and the Medical Director/VP for medical Affairs. The QIPSC has six subcommittees: Clinical Case Review, Clinical Documentation, Performance Measures/Outcome Assessment, Physical Health, Behavior Management, and Patient Safety Workgroup (see figure I). UCHC, a subsidiary of UBHC, is one of two service providers working under the New Jersey Department of Corrections (DOC). The other service provider, Correctional Medical Services (CMS) provides medical services to the inmate population. The QI organizational structure at UCHC consists of a combined statewide and two provider- specific QI committees. In addition there is a QI committee on each of the DOC sites and numerous PI teams that report to the above committees (see figure 2). 4
  • 5. Figure I UNIVERSITY BEHAVIORAL HEALTHCARE QI Organizational Structure President & CEO Executive Committee QIPSC Performance Measures/ Clinical Clinical Physical Behavior Patient Outcome Case Documentation Health Management Safety Assessment Review Work- group 5
  • 6. Figure II UNIVERSITY CORRECTIONAL HEALTHCARE QI Organizational Structure Legend: Direction/Guidance Summary reporting Statewide QI Detail reporting/ Committee minutes UCHC CMS Regional QI Committee QI Committee Site QI Committees DOC UCHC Combined CMS PI Teams PI Teams PI Teams PI Teams 6
  • 7. THE QI MISSION & PRINCIPLES What is the QI Mission at UBHC/UCHC? The QI Mission statements at UBHC and UCHC are similar with one exception, while UBHC is a stand-alone organization, the UCHC team works in collaboration with NJDOC and CMS. QI strives to… 1. Continually seek opportunities to improve performance of all aspects of services and care. 2. Promote data-driven improvement efforts. 3. Achieve the above through collection, interpretation and the effective dissemination of relevant, accurate & timely information to management and staff. What are the Principles of PI/CQI? 1. Performance improvement (PI) must be a high priority for all levels of staff in the organization. 2. PI is data-driven and requires the use of some data collection methods and appropriate statistical tools. 3. The focus of PI is on processes not individuals. 4. To be effective, PI must follow a coherent model. 5. PI is best when involving a collaboration between all relevant functions within the organizational structure. 6. The PI process information must be “communicable” (i.e., documentation is crucial). 7
  • 8. THE QI MODEL What QI Model is used at UBHC/UCHC? The quality improvement model used at our organization is circular, and has four steps/phases (see figure 3. on page 9). Sometimes you may need to take a step back and work through previous steps before moving forward through the steps. Step 1: Plan/Design This is where you outline your plan or “road map.” All activities are thought about and planned during this step. Some questions to think about, clarify and document include: 1. What is the purpose of this project, how is it related to the mission and values of the organization? 2. Who should be involved? (A team is more then 1 or 2 people…) 3. What resources will be needed (staff, time, and materials)? 4. What possibly could cause the problem you are seeking to improve? 5. How can the problem(s) be remedied? Which interventions are possible/feasible/likely to succeed? 6. What are the success indicators going to be (how will you know the interventions worked?) 7. How and when to measure effectiveness (baseline and outcome)? 8. What data collection methods will be used? 9. What will the project timelines be? Step 2: Measure This step involves implementing interventions and collecting data to measure the effectiveness of such interventions. 1. Review existing data or collect (baseline) pre-data; use organizationally available data whenever possible. 2. Implement interventions. 3. Collect post-data. 4. Analyze the data. Step 3: Assess This step involves review of data analyses, assessing the effects of the interventions, and comparing to baseline and other data. Compare the outcome to information from other sources (i.e., the literature, Mental Health Corporation of America, National Commission on Correctional Health Care (NCCHC), etc.), other sites in your organization, and your own past performance). The final product of this step is a decision to declare the project fully successful, continue to test it, or abandon the intervention. Step 4: Improve If the previous step indicates that the initiative was successful, implement the new or revised processes, educate staff or clients, share the improvements and continue to monitor the improvement to ensure gains are maintained. 8
  • 9. Figure 3. GENERAL MODEL FOR QUALITY IMPROVEMENT Why do this? What are the objectives? Does it fit overall mission, values, plans? What are the expected results? PLAN Who must be involved? What exactly will we do? For how long will we engage in this activity? How will we If it works, implement, measure baseline performance? How disseminate, publicize, do will we measure outcome? training and in-service, and maintain gains. DESIGN IMPROVE MEASURE Collect relevant baseline and ASSESS outcome data, analyze, compare Evaluate the results, interpret, discuss, with past performance and with is the new process/ external resources. strategy/improvement useful? Practical? Cost-effective? 9
  • 10. Chapter 2 THE PERFORMANCE IMPROVEMENT PROCESS How Does This Workbook Work? This workbook will take you through the four steps of the PI model and beyond; from the time you begin thinking about a project to the time you present your final results at the PI fair. Although there are a host of PI tools available, we selected only a few to be used in the 12 optional activities presented here. For each activity, we provide an overview, directions, examples, and blank worksheets. It is important to keep track of your work and document meeting minutes. Having all documentation in one workbook can help keep all the information organized and will make preparing for a PI Fair a snap. (You might want to punch holes and keep the workbook and any additional, relevant papers in a 3-ring binder.) After completion of the project, you may put a title on the front cover and file it for future reference. Information documented in the workbook can be easily transferred to charts and tables for a poster boards you could prepare for a PI Fair, along with your team’s other creative touches. Pictures of two poster boards and project summaries are provided at the end of this workbook. The tools offered here are optional and could aid the teams to clarify their thinking about areas of care in need of improvement and interventions that could achieve such improvement. Performance Improvement in a Nutshell: Four Milestones 1. Identify a problem that needs improvement 2. Consider the most probable cause for the identified problem 3. Consider appropriate interventions and implement them 4. Use data to demonstrate your effectiveness, i.e., the baseline and the post-intervention status Situation Tools you may use Activity You have to have a PI project, but you do Brainstorming; multi-voting 2 not know what to select… You have a topic already, but you are not Brainstorming; multi-voting; sure about the causes of the identified fishbone analysis; Pareto diagram 2, 3, 4, 5 problem (and different people think different things…) You know/are sure about what causes the Brainstorming; multi-voting; identified problem, but you have no idea Pareto diagram 2, 3, 8, 9 how to correct it (and/or different people have different ideas) You know all the above, so what now? Collect/present/review pre-data; develop pareto diagram, run/bar 5, 8, 9 charts; timetable for specific tasks; minutes 10
  • 11. ACTIVITY #1 Step 1: Plan/Design DEVELOP THE PI TEAM & DEFINE MEMBERS’ ROLES How Do PI Projects Get Assigned? Often you will be asked by your supervisor, by the quality improvement committee at your site, or by the statewide/organizational QI committee to lead or participate in a PI effort to address a specific problem. Other times, you may be asked to put a team together and come up with ideas for a PI project on your own. Sometimes a group of staff members realize they could/should correct a problem that is impacting their effectiveness or efficiency. How Many Staff Should Be On A PI Team? A PI team should consist of 4 to 8 staff. You must include staff who are directly involved in the day-to-day operations. You also need at least one person who has decision-making responsibility, to help facilitate the implementation of the proposed interventions. Sometimes the team grows over time, depending on the need for additional resources to meet the goals of the PI initiative. THE FIRST MEETING What Should be Accomplished During the First Meeting? 1. Decide how often to meet and where. 2. Decide on a few necessary roles: (a) A team leader/facilitator, (b) a record-keeper, (c) someone to document and distribute minutes and other documents 3. Begin the work of defining the problem. 11
  • 12. ACTIVITY #2 Step 1: Plan/Design SELECTING A PI PROJECT: GENERATE IDEAS THROUGH BRAINSTORMING If you were not assigned a PI project, selecting the project or process in need of improvement should be data-driven and prioritized based on one or more of the following criteria: The process to be improved should be… 1. Related to your organization’s mission and values 2. A high-risk process (e.g., rates of restraint, suicide watch) 3. A high-volume process (e.g., medication variances, medication errors, group attendance) 4. Based on client needs (e.g., results from the client satisfaction surveys, clinical outcomes- basis-24) 5. Based on staff views (e.g., results from a staff satisfaction survey) 6. Provide opportunity for savings How are ideas for a PI project generated? Ideas for PI projects can be generated with a Brainstorming activity, a method to generate ideas efficiently and creatively. It is also a way to get all team members involved in the process and avoid the process being taken over by one vocal member. How to Conduct a Brainstorming session? 1. Gather supplies: blank worksheet, flipchart, pens, markers, tape, etc. 2. Select one person to be the recorder, i.e., write ideas on a flipchart or on paper (on the wall). 3. Go around the table and ask each person to offer one idea at a time. 4. All ideas are accepted and written on the flipchart, no discussion, no debate, no critique is allowed at this time. State ideas in action terms reflecting your goal. (See example on page 13.) 5. When one round is done, start over. Individuals are allowed to “pass.” When no more new ideas come up or everyone “passes,” begin the next step (categorizing and multi-voting). 12
  • 13. EXAMPLE BRAINSTORM IDEAS IDEAS FOR A PI PROJECT 1 Increase compliance with outcome measures 2 Reduce readmissions 3 Reduce medication variances and errors 4 Increase inmate/client satisfaction with services 5 Improve the timeliness of completing treatment plan updates 6 Increase inmate/client satisfaction with staff-client interaction 7 Reduce no-shows for treatment 8 Improve tracking system of paper charts 9 Increase the number of groups offered to inmates/clients 10 Reduce time between appointments 11 Reduce the number of write-offs 12 Improve inmate attendance at community meetings 13 Increase correction officers’ attendance at treatment team meetings 14 Reduce number of times clinician supervisors are paged 15 Improve chart tracking system for inmate transfers 16 Reduce inmate PPD refusals 17 Improve documentation in progress notes for abnormal labs 18 Improve diagnosis/medication consistency in treatment plans 13
  • 14. WORKSHEET BRAINSTORM IDEAS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 What’s Next? Multi-Vote or use a Selection Matrix to Vote decide on a PI project. See directions on page 16 &17 14
  • 15. SELECT A PI PROJECT WITH MULTI-VOTING OR A SELECTION MATRIX MUTLI-VOTING What Is Multi-voting? Multi-voting is a tool used to build team consensus by incorporating individual preferences/ratings into the overall team decision. You can use this PI tool when you need to arrive at consensus but team members are torn between competing options or when there are many ideas/options and your team needs to focus on a few feasible ones. How Do You Multi-vote? 1. Obtain supplies: paper, marker, and tape. 2. Use the list of ideas from the brainstorming (on flipchart or worksheet); put it on the wall where all can see it. 3. sometimes you need to categorize the list first, if there is a lot of overlap and duplication 4. Give each of the brainstormed ideas a number or letter. 5. Distribute 3x5 index cards or 3x3 pieces of paper to members (see page 65 for paper). 6. Members should be instructed to write the number or letter representing their choices on the card/paper. Usually each member is allowed three choices. 7. Collect the cards and tally them on the brainstorming worksheet or on the flipchart. 8. If this was your project selection activity, complete and submit a copy of the PI registration/ Notification Form to QI Department or committee. See pages 21 & 11 15
  • 16. WORKSHEET SELECT A PI PROJECT WITH MULTI-VOTING Tally Decision Ideas/options 1 2 3 4 5 6 7 PI 16
  • 17. SELECT A PI PROJECT USING A SELECTION MATRIX What is a Selection Decision Matrix? An alternative to the multi-voting tool, used to evaluate and prioritize a list of options against specific criteria. When should this PI tool be used? 1. When you need to narrow your choices down to 1 or 2 from a list of possibilities. 2. When you want the decision to be based on specific criteria. How to use a selection decision matrix? 1. Give each member a blank process improvement selection decision matrix grid. 2. Have group members individually and independently review each possibility/topic and rate them based on the decision matrix scoring guide. 3. Total the individual “sum of ratings”; the highest scoring option is selected. 17
  • 18. Process Improve ment Sele ction Matrix-EXAMP LE Potential Areas For P rocess Improvement th ps wi ou gr on gr t i sf se sa cre a ps t i se ou ac ea In Selection Criteria cr In 1. Alignment with organizational mission, 1 9 priorities and goals 2. Customer needs and 1 9 expectations 3. High-volume services, 3 3 functions or activities 4. High-risk services, functions or activities 1 1 5. Problem-prone services, functions, or activities 1 1 6. Staff’s view of importance of the process 9 3 7. Organizational support 9 9 for improvement 8. Opportunity for savings 9 1 9. Size and scope of the process 3 3 10. Stability of the process 3 SUM O F RAT IN GS 37 42 Use the following r ating scale: 1= low 3= mediu m 9= high Note: This PI member selected a project to increase client satisfaction with groups 18
  • 19. WORKSHEET Process Improvement Selection Matrix Potential Areas For Process Improvement Selection Criteria 1. Alignment with organizational mission, priorities and goals 2. Customer needs and expectations 3. High-volume services, functions or activities 4. High-risk services, functions or activities 5. Problem-prone services, functions, or activities 6. Staff’s view of importance of the process 7. Organizational support for improvement 8. Opportunity for savings 9. Size and scope of the process 10. Stability of the process SUM OF RATINGS Use the following rating scale: 1= low 3= medium 9= high 19
  • 20. UNIVERSITY BEHAVIORAL HEALTHCARE Notification of Local PI Activity (PI registration) Unit/Department: ________________________________ Unit Code: ______________________________________ Date:_____/_____/_____ Contact Person: ___________________________ Phone: _____________________ Topic/Goal: ___________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 20
  • 21. New Jersey Department of Corrections Correctional Medical Services University Correctional HealthCare PI Registry Notification of Local PI Activity Date: ___/____/____ Site: Topic/Goal: Project Title: Contact Person: Phone #: Membership Title Team Leader: Team Facilitator: Team Members: 21
  • 22. ACTIVITY #3 Step 1: Plan/Design IDENTIFY PROBABLE CAUSES OF A PROBLEM USING BRAINSTORMING & CATEGORIZATION How Is Brainstorming And Categorization Done? 1. Obtain supplies, make extra copies of worksheet. 2. Brainstorm probable causes to problem by asking the question “why is this problem happening? Use same directions for brainstorming as in activity # 2 on page 12. 3. Decide on what categories apply to your list of probable causes. 4. You may use the table below to record the category for each cause. 5. Select the most probable cause using multi-voting. Use same directions for Multi-Voting used in Activity #2 on page 5. Why is this happening to me? 22
  • 23. EXAMPLE PROBABLE CAUSES (BRAINSTORMING, CATEGORIZATION & MULTI-VOTING) Identified Problem: Psychologist preliminary treatment plans are not being completed within specified time frames Probable Causes Category 1: Category 2: Category 3: Category 4: Category 5: Administrative Tally Client Resources Staff Training /work process Votes Decision 1.Inmate X X 1111 ☺ transferred to 1 another unit 2. Inmate arrives X 1111 ☺ Friday evening 1 3.Computers were X 11 down 4. Computer not X 11 available 5. Staff was X 1 covering another unit and not aware of inmate arrival 6. Inmate was not X 1 assigned to MH staff 7. Staff out sick X 1 8. Officer did not let X 1111 clinician talk to inmate due to a custody issue 23
  • 24. WORKSHEET PROBABLE CAUSES: BRAINSTORM & CATEGORIZE Identified Problem:__________________ Category 1 Category 2 Category 3 Category 4 Category 5 Probable causes Client Resources Staff Training Work Process Cat eg orie s Vote s 24
  • 25. ACTIVITY #4 Step 1: Plan/Design DISPLAY PROBABLE CAUSES OF THE IDENTIFIED PROBLEM: USING A FISHBONE DIAGRAM What Is A Fishbone Diagram? A Fishbone Diagram is a formalized way to display potential causes to an identified problem: A fishbone diagram 1. Focuses on a specific problem to be fixed 2. Creates a snapshot of collective knowledge around the problem 3. Allows differentiating between proximate and root causes 4. Focuses on potential causes, not symptoms When To Use It? When you need a simple graphical way to explore and communicate possible causes for an identified problem and to facilitate focusing on the main issues that need corrective actions. How To Do A Fishbone Diagram? 1. Place the problem statement on the Fishbone Diagram in the box labeled “problem statement.” 2. Using the brainstorming & categorizing activity, write the grouping categories in the boxes above the “bones.” 3. Write the causes on the lines under/over each of the categories then multi-vote. Note: you can also choose to display your data in a Pareto Diagram 25
  • 26. FISHBONE EXAMPLE 1 The important issues are around how we respond to these patient factors. Work Patient Equipment processes Code beeper and Code response Refusal of medical workup Green emergency bag/ Public safety response Crash Cart On-site medical services/APN Pre-existing medical conditions Resident’s code beeper Identification of medical issues Health Habits Protective barriers (Tx plan) Response to abnormal labs Noncompliance with health care AED (defibrillator) (Refused Thyroid medication) Pt ed. Heart attack of Hereditary factors Patient while on Adult IP unit. Key access to IP ACLS The Problem Construction /Move-temporary changes Code response (& beeper) Medical clearance Treatment planning for medical issues Symptom recognition Staff Environment Training Door width had nothing to Staffing pattern do with the outcome, but is was excellent as a root issue in future was staff emergencies and in the response, staffing use of restraint stretchers issues did not contribute to the outcome 26
  • 27. FISHBONE EXAMPLE II CLIENT RESOURCES STAFF Staff out sick Inmate transferred to another unit Computers were down FISHBONE EXAMPLE 2 Inmate not available, went to clinic Computer not available The problem Psychologists initial treatment plan not completed in expected Officers will not let you talk to Inmate referred to another time frame on IP unit inmate due to a custody issue Inmate Arrives Friday Evening Lock Down Staff was covering another unit and not aware Inmate was not assigned to MH staff CUSTODY ADMIN/WORK PROCESS 27
  • 28. A Fishbone Diagram WORKSHEET Staff Process Environment The problem Training Equipment 28 Note: Put the root causes closest to the central fishbone, other causes (proximate) further away.
  • 30. ACTIVITY #5 Step 1: Plan/Design PROBABLE CAUSES OF THE IDENTIFIED PROBLEM: USING A PARETO DIAGRAM What Is A Pareto Diagram? A Pareto Diagram is a sorted bar chart used to display the magnitude/importance of some problems/issues or to prioritize potential causes of identified problems When To Use It: When you want to: 1. Focus efforts on tasks that may have the greatest potential impact on the identified problem. 2. Provide a simple picture, easy to understand and communicate regarding the relative importance of specific issues/solutions. How To Use It? The Pareto diagram can be used with counts or percentages and is used to display magnitude or order and to prioritize issues (it can be used with the results of multi-voting following brainstorming or fishbone analysis). 1. Determine the categories related to your issue (e.g., wrong dose, wrong route, etc). 2. Determine your unit of measurement (number of events of different types of variances). 3. Collect/assemble the data. 4. Plot the highest one first, then second highest, etc. 30
  • 31. O Percent ri en ta 0 10 20 30 40 50 60 70 tio n/ Tr ai ni ng 62 C om m un ic at io n 56 Pt .a ss es sm en t Source: JCAHO publication Ph ys 50 ic al en vi ro ne m en In t fo 43 rm at io n av ai la C bi om lit pe y 35 te nc y/ c re Figure 4 de nt ia lin g 28 E A Pareto Chart: qu ip m en tf ac to r s 26 St Root Causes of Sentinel Events af fin g le ve ls 24 St or ag e /a cc es s 19 31
  • 32. WORKSHEET PARETO DIAGRAM Title: _____________________ 0 Fill in the range ________ ________ ________ ________ ________ of occurences: 0, 20, 40, 60, 80, 100 or 0, 2, 4, 6, 8, 10, etc Fill in variable names 32
  • 33. ACTIVITY #6 Step 1: Plan/Design DESCRIBE A PROCESS & HOW IT NEEDS TO BE CHANGED USING A FLOW CHART What Is A Flow Chart? The Flow Chart is a formalized way to describe a process or an event. When using this PI tool, involve staff who are familiar with the process/event, and focus on creating an “as is” flowchart before you work on the “as it should be”. When To Use A Flow Chart: You should use the Flow Chart when you need to: 1. Understand what happened in a process; 2. Streamline a process; 3. Design a new process, and 4. Visualize a process change. How To Do Flow Chart? 1. Obtain supplies: markers, flipchart/paper. 2. Get staff working closely with the problem to participate. 3. Write each activity that is part of the process/event, be careful to recognize concurrent activities and decision points, where actions diverge. 4. Do several drafts as needed until there is consensus among participants. 5. Identify the areas that need to be changed in order to improve the process Another Option When flipcharts are not available, try using sticky notes. Find workspace near a blank wall, write each activity on a sticky note and attempt to place them in order. (Someone would be responsible to copy all the work once you are done.) 33
  • 34. FLOW CHART – EXAMPLE Scheduling Meetings The Process ‘As Is’ Identified need for meeting E-mail to all participants with dates No No Yes Date/time Yes Schedule Got responses? acceptable? meeting, End Problem: if recipients do not respond, the process has no end point and can go on forever.... 34
  • 35. FLOW CHART – EXAMPLE Scheduling Meetings The Process ‘As it should be’ Identified need for meeting E-mail to all participants with dates Set time limit for responding No No No Yes Date/time Yes Schedule Time limit expired? Got responses? acceptable? meeting, End Yes Notify supervisor Schedule meeting, End 35
  • 36. WORKSHEET FLOW CHART “AS IS” SHAPES Action Decision Start/end Connection point 36
  • 37. WORKSHEET FLOW CHART “AS IT SHOULD BE” SHAPES Action Decision Start/end Connection point 37
  • 38. ACTIVITY #7 Step 1: Plan/Design SELECTING INTERVENTIONS USING: BRAINSTORMING & MULTI-VOTING EXAMPLE Problem: Initial treatment plans are not being completed in specified time frame Probable Cause: (#1) Inmate transferred to another unit Votes Decision IDEAS FOR INTERVENTIONS 1. Communicate with the receiving unit responsible for initial treatment plan 2. Receiving unit to check record for current treatment plan 3. Assigned clinician to check time to ensure time frame was not exceeded Problem: Initial treatment plans are not being completed in specified time frame Probable Cause: (#2) Inmate Arrives on Friday Evening IDEAS FOR INTERVENTIONS Votes Decision 4. Supervisor to inform staff that 48 hour standard must be adhered to even on weekends 5. Revise the standard since clinicians do not work on weekends 6. Revise clinician schedule 7. Have supervisor cover weekend 38
  • 39. WORKSHEET SELECTING INTERVENTIONS USING MULTI-VOTING Problem Statement: ______________________________________ Probable Cause:_________________________________________ BRAINSTORM INTERVENTIONS Tally Decision & MULTI-VOTING 1 2 3 4 5 6 39
  • 40. ACTIVITY #8 Step 2: Measure IMPLEMENT AND TEST INTERVENTINS What Is Involved In This Step? This step involves implementing interventions and testing to see whether or not they were effective. How? 1. Review existing data or collect (baseline) pre-data; use existing data when you can 2. Implement interventions: Use Activity Tracking Log a. Involve the administration, clinical staff, support staff and get “buy in”. b. Adjust work flows c. Monitor adherence to new process d. Identify problems and correct them 3. Collect post data. 40
  • 41. INTERVENTION ACTIVITY LOG (WORK PLAN) EXAMPLE Intervention Log (WORK PLAN) Anticipated Completion Activity/task Responsibility Start Date Date Status Develop data Shula 12/01/2006 12/25/06 collection worksheet Meet with unit Lisa 01/30/2007 2/30/06 staff Develop a Jeff 02/07/07 02/07/07 consensus work flow Define client Lisa & Jeff 02/07/07 02/07/07 selection criteria Select sample Lisa & staff 02/14/07 02/14/07 Implement Staff 03/01/07 intervention Develop Lisa 03/01/07 03/03/07 database Data entry Unit secretary 03/07/07 12/31/07 Data analysis Lisa & Shula 01/01/08 02/01/08 Final report Lisa 02/01/08 02/28/08 41
  • 42. WORKSHEET INTERVENTION LOG (WORK PLAN) Intervention Log Anticipated Completion Activity/task Responsibility Start Date Date Status 42
  • 43. ACTIVITY #9 Step 3: Assess ANALYZE DATA AND COMPARE RESULTS What Is This Phase About? The final product of this step is a decision to: 1. Declare the intervention fully successful 2. Continue to test the intervention, or 3. Declare the intervention a failure and start working on a different one. How To Assess/Evaluate The Results Of A PI Project? 1. Review data analyses, assess the effects of the interventions and compare to baseline and other data. 2. Compare your outcome to information from other sources. 3. Use a Bar Chart or an Excel table to present/display comparisons between your pre- and post data or between different groups. 43
  • 44. BAR CHART What Is A Bar Chart? Bar Charts are used to show the differences between related measurements. When To Use It? When you want to show change (pre- and post data) or display data in several categories How To Do A Bar Chart? 1. Decide on the data that must be displayed in the chart. 2. Decide how the individual bars will be set up (e.g., by month? by quarter? by type of respondents? by gender?). 3. Plot the data. (You may use PowerPoint, Excel or any other graphing software). 44
  • 45. BAR CHART EXAMPLE FROM UBHC Pre- and Post- Intervention Weight in Two Client Groups* 220 220 215 214 210 W eight in Pounds 205 200 200 195 190 192 185 180 175 INTERVENTION NON-INTERVENTION pre-weight post-weight * From the healthy living study, Vreeland et al. 2003 45 Note: See page 45 for Bar Chart Directions
  • 46. BAR CHART EXAMPLE FROM UCHC Inpatient Medication Variances and Errors Quarter 4, 2005 to Quarter 3, 2006 50 45 40 35 30 33 34 25 29 20 15 18 15 16 10 12 5 10 0 Q4/05 Q1/06 Q2/06 Q3/06 Variances Errors 46
  • 47. WORKSHEET BAR CHART Title: ___________________________ Number of _____________________ Fill in the range of occurences: 0, 20, 40, 60, 80, 100 or 0, 2, 4, 6, 8, 10, etc Fill in the names of the month 47
  • 48. EXAMPLE DISPLAYING COMPARISON DATA USING EXCEL University Correctional HealthCare Results from the Statewide Inmate Satisfaction Survey August, 2006 UCHC Georgia DOC UBHC MHCA Me ntal He alth Se rvice s Q 1 (N=709) Q 4 (N=870) Q 2 (N=1112) N=47 N=1,000 N=59,725 Scale:1=Poor 2=Fair 3=Good 4= Very Good 5=Excellent N Me an N Me an N Me an N Mean N Mean N Mean 1. Overall, how would you evaluate the quality of mental health services you received 654 3.6 767 3.6 983 3.6 47 3.2 947 4.0 58,101 3.9 2. T he helpfulness of the mental health staff 694 3.7 864 3.7 1108 3.7 47 3.5 994 4.0 58,593 3.9 3. Courtesy shown you by the mental health staff 688 3.9 853 3.9 1103 3.8 --- --- 993 4.0 58,338 4.0 4. Attention to privacy during treatment sessions 694 3.8 860 3.8 1098 3.8 --- --- 981 4.0 57,747 4.0 5. Professionalism of the mental health staff 695 3.9 860 3.9 1102 3.8 --- --- 992 4.1 57,517 4.0 6. T he extent to which your individual mental health needs were addressed 692 3.6 864 3.6 1104 3.7 47 3.8 974 3.9 57,016 3.8 7. Availability of mental health staff to talk with you 701 3.6 862 3.7 1098 3.6 47 3.3 975 4.0 56,934 3.9 8. T he frequency of appointments with mental health staff 692 3.5 851 3.6 1095 3.6 --- --- 930 3.6 51,365 3.7 9. T he length of time you had to wait for your first mental health appointment 688 3.5 859 3.6 1085 3.6 --- --- 923 3.7 49,185 3.7 10. T he helpfulness of medication and/or other treatment that you received 692 3.5 849 3.6 1091 3.7 47 3.2 903 3.8 54,521 3.8 11. T he degree to which mental health staff respect your confidentiality 694 4.0 856 4.0 1091 3.8 --- --- 986 4.1 57,640 4.1 12. T he opportunity to participate in decisions about your mental health treatment 693 3.6 861 3.7 1079 3.6 47 2.9 966 3.9 56,516 3.8 Me an: 3.68 3.69 3.69 3.32 3.93 3.88 13. The availability of mental health groups (Mean 3.4) 14. The helpfulness of mental health groups you participated in (Mean 3.4) 48
  • 49. ACTIVITY #10 Step 4: Improve IMPLEMENT IMPROVEMENTS, EDUCATE STAFF, AND MONITOR RESULTS How To Improve? If the previous step indicates your initiative was successful: 1. Implement the new or revised processes in your unit and/or in your organization; 2. Educate staff or clients, as necessary; 3. Share the project and results with others (by preparing and presenting it at the PI Fair), and 4. Continue to monitor the improvement to ensure gains are maintained by using a Run Chart. 49
  • 50. RUN CHART What Is A Run Chart? A run chart is used to present data over time, so that you can observe trends, changes and patterns. When To Use A Run Chart: 1. When monitoring performance to detect trends over time. 2. When comparing a measure before and after an intervention . How? 1. Select a performance measure. 2. Gather at least 20—30 data points. 3. Create a graph with time line on the horizontal axis and the measure on the vertical axis. 4. Plot the data points and connect them with a line (use PowerPoint, Excel or any other software for best looking results). 50
  • 51. Events 0 10 20 30 40 50 60 70 80 90 Q1 91 Q3 91 Q1 92 Q3 92 Q1 93 Q3 93 Q1 94 Q3 94 Q1 95 Q3 95 Q1 96 RESTRAINTS Q3 96 Q1 97 Q3 97 Q1 98 Q3 98 Q1 99 Q3 99 Q1 00 1991 - 2006 (BY QUARTER) RESTRAINT USE AT UBHC’S Q3 00 RUN CHART EXAMPLE Q1 01 q3_01 q1-02 Poly. (RESTRAINTS) CHILD AND ADOLESCENT INPATIENT SERVICES q3-02 q1-03 q3-03 q1-04 q3-04 q1-05 q3-05 q1-06 q3-06 51
  • 52. Percent 0 10 20 30 40 50 60 70 qrt3-98 qrt4-98 qrt1-99 qrt2-99 qrt3-99 qrt4-99 qrt1-00 qrt2-00 qrt3-00 qrt4-00 qrt1-01 July 98-December 02 RUN CHART EXAMPLE II qrt2-01 qrt3-01 qrt4-01 qrt1-02 Seclusion Rates in Adolescent Inpatient settings qrt2-02 qrt3-02 qrt4-02 52
  • 53. WORKSHEET RUN CHART TITLE:____________________ Number of _____________________ ____ ____ ____ ____ ____ ____ ____ ____ Fill in the range of occurences: Jan Feb Mar Apr May 0, 20, 40, 60, 80, 100 or T1 T2 T3 T4 T5 0, 2, 4, 6, 8, 10, etc Fill in the names of the months, times, etc. 53
  • 54. CHAPTER 3 THE PERFORMANCE IMPROVEMENT FAIR What Is A PI Fair? A PI Fair is a forum for staff to share information about their PI initiatives and achievements. It is an opportunity to network and exchange ideas with staff from other sites. All staff including the teams who present projects must register prior to the PI Fair in order for the PI Fair Committee to make appropriate preparations for the event. So, keep your eyes open for notices, they will be distributed about two months prior to the event. Projects submitted by the deadline will be judged by three judges selected by the PI Fair Committee. The winners will be announced at the Fair. How To Prepare For The PI Fair Each team will assemble a poster board and write a one-page summary. The posters and summary page are submitted to the QI Department responsible for organizing the Fair by a specified deadline. This is necessary to allow the judges sufficient time to review the posters and render their decisions. What Criteria Do The Judges Use In Evaluating PI Projects? 1. A clear planning process 2. Sound/explicit data-gathering design 3. Evidence of the use of the QI model 4. Appropriate use/analysis of data 5. Evidence of plan for follow up 6. Visual appeal of poster 7. Reflects value of the organization 8. A clearly written summary 54
  • 55. PI FAIR PROJECT JUDGING TOOL 1. A clear planning process, including choice of appropriate team members, including staff close to the processes) under study. 1 2 3 4 5 6 7 2. Sound/explicit data gathering design. 1 2 3 4 5 6 7 3. Evidence of the use of QI model. 1 2 3 4 5 6 7 4. Appropriate use/analysis of data. 1 2 3 4 5 6 7 5. Evidence of plan, for follow-up (if team was successful) or for further process improvements. 1 2 3 4 5 6 7 6. Visual appeal of poster as a whole.* 1 2 3 4 5 6 7 7. Reflects the agencies Mission 1 2 3 4 5 6 7 8. Clearly written description (summary page) of what was done by PI team, results, conclusions, and future plan. 1 2 3 4 5 6 7 *Starting 2007, UBHC will no longer judge posters on visual appeal. 55
  • 56. PI POSTER BOARDS What are PI Poster Boards? PI poster boards provide an organized and creative way to present the work and the results of a PI project. Presentations should be colorful, vivid, interesting, use few words in large fonts and present data in graphs and pictures. The boards are available from the QI Department or can be purchased by the team. What Needs To Be Included On Your Poster Board? 1. The purpose of the project. 2. Team members (a picture of the team may be added). 3. Steps of the QI Model and where the project is/was on that model. 4. Methods used to arrive at identifying the problem, and its probable causes (fishbone chart, Pareto diagram, etc.). 5. A description of your interventions and how you selected and prioritized them. 6. Baseline data (or plans for it). 7. Outcome data (or plans for it) . 8. Conclusion, status of the project, plans for the future, etc. How To Use Powerpoint To Create A Presentable Poster? 1. Use separate pages to stick on the board to show the content that needs to be included: bar charts, PowerPoints, Excel tables, the QI model. 2. Create one large poster using Microsoft PowerPoint, and have it printed at a print shop (Kinkos, Staples, etc, or for UBHC at RWJMS internal computing services) and attach to poster board. post See examples on staff data the next 2 pages QI model step re s pre ul ts da t a 56
  • 57. BUILDING COMMUNICATIONS Team Members: Judi D’Agostino; Sandra Iwasawa; Irene Szaloczi Purpose: Effective communication is a foundation that compassionate care is built on. Our PI team’s goal was to create a new Handbook of Helpful Information for our clients, families and friends that use the AIPU/AADH/IOP units. The focus of the handbook was to provide clear and concise information about the units and a “picture” for what clients can expect when participating in our programs. It is our belief that clients who know what is expected of both staff and themselves can have anxiety about receiving treatment decreased. Our team also designed the Handbooks so that providers outside of acute services can better describe our programs to clients they hope to refer to our facility, thus reducing anxiety about attending a new program with new providers. We also plan to have these handbooks used as a manual for effective communication from shift to shift, unit to unit and also as a reference for staff training about our units. Methodology Used: Our team met weekly to openly discuss what each person felt was important information to provide our clients. Our team membership consisted of professionals from disciplines that are most involved in daily patient care and have different experiences in our roles on the treatment team to best provide our clients with well-rounded information. Once we determined what we felt as staff for the pts to know we then presented our clients on both the units with a sample of the proposed handbooks and sought direct feedback from pts, this was done in a group format. The pt suggestions were compiled and the handbook re-edited for distribution. We then designed pre-tests for both staff and patients, using different questions with each population. Once we created a “sample” population, we then distributed the handbooks for use on the units. After a period of three months where the handbooks had become part of the unit milieu we implemented post tests to test the overall effectiveness of the handbooks. Baseline and Outcome Data: Based on the data collected from each population of Staff: AIPU/AADH and Clients AIPU/AADH, there was an overall gain in knowledge of unit rules and expectations by all of the tested populations as seen in the increase of correct answers. Interventions: Created two booklets, Adult Inpatient and Adult Partial, based on staff and patient input. Utilized pre- and post questionnaires with 30 random volunteers in each group, to test the knowledge of unit rules and expectations, before and after booklet distribution. Current Status: The new handbooks are distributed to pts in the AIPU/AADH/IOP programs as they are admitted. The handbooks are utilized in community meetings of each program during discussions of unit rules and expectations. Clients are also encouraged to share the information with their family. Staff from the PI team did visit one extended outpatient site to distribute and present the handbooks so that referral sources have a better understanding of the overall program and services provided. 58
  • 58. 59
  • 59. POSTER SUMMARY EXAMPLE-UCHC DISCHARGE PLANNING AND AFTERCARE UCHC - RIVERFRONT STATE PRISON Team Members: Wayne Blodgett, Ph.D.; John Blasé, Ed.Spec, LPC; Tamara Thompson, MSW, LCSW; Patricia Cummings, MSW; Cassaundra Gordon, A.A. Project Purpose: The Discharge Planning and Aftercare PI Project will improve the Mental Health Special Needs Inmate’s opportunities for successful community re-entry through coordinated services for the individuals being released from a Department of Corrections facility. Project Scope: Riverfront State Prison will be the pilot site for the project. RFSP has approximately 160 Special Needs Inmates living with a Severe and Persistent Mental Illness. Approximately 5-10 Special Needs Inmates are discharged from Riverfront State Prison on a monthly basis to the community. Problem: The problem was examined via the NJ Department of Corrections Electronic Medical Records system, interdepartmental/interagency meetings with UCHS and NJ DOC Social Services Staff, and bi-weekly Mental Health Special Needs Meetings at Riverfront State Prison. Team members met to discuss factors that contribute to the high recidivism rate among the Severe and Persistently Mentally Ill Inmate related from prison within the state of NJ. Factors included: no discharge planning groups to assist in the transition from incarceration to community release, limited resources available to the inmates upon release, no follow up for scheduled appointments. Statistical review of the Electronic Medical Records revealed there was a 21% recidivism rate for MH Special Needs inmates from April 1, 2003 through April 11, 2005. Plan: A Program design was developed that would place a MH Special Needs Inmate in a Discharge Planning Group, called Transitions. The group will run in 8-week intervals. Format: Group Treatment including process time and psycho-education. Size: 8-15 inmates Length of Session: 1.5 hours every week THE UCHS Discharge Planning Social Worker will develop an aftercare plan for the inmate that includes a 2-week supply of medication from the treating psychiatrist. If the inmate is maxing out on his sentence, appropriate releases of information will be signed, and a mental health appointment will be scheduled at a Community Mental Health Center in his discharge county. Outcome Measures: The total number of inmates released will be calculated by completing a query on the Electronic Medical Record using the following criteria: Search Documents from Riverfront State Prison AND beginning date on and after March 1, 2005 through March 1, 2006 AND Document Summary containing “MH Discharge Summary”. Goal: Statistical review of the Electronic Medical Records will produce at least a 5% reduction in the recidivism rate for MH Special Needs inmates from March 1, 2005 through March 1, 2006. This will occur through increased discharge preparation and coordination of care between the Department of Corrections, University Correctional Health Services and the NJ State Parole Board and community social services and mental health services 60
  • 60. UNIVERSITY CORRECTIONAL HEALTHCARE CORRECTIONAL MEDICAL SERVICES NEW JERSEY DEPARTMENT OF CORRECTIONS PI FAIR REGISTRATION FORM Facility: ______________________________ Unit: _________________________________ Date: ____/____/____ Contact person:_______________ Phone: __________ Topic/goal: ___________________________________ Project Title: _______________________________ Facilitator: ___________________________________ Team Leader: _________________________________ Team Members: _______________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ 61
  • 61. UNIVERSITY BEHAVIORAL HEALTHCARE Date: ____/____/____ Participants: Excused: Topic Discussion Action/Recommendations Responsibility Target Date 62
  • 62. UNIVERSITY CO RRECTIONAL H LTHC EA ARE CORREC NALMED L SER CES TI ICA VI NEW JERSEYDEP TME OFCOR AR NT RECTIONS Continuous Quality Im ove en P pr m t rogram __/ _/ _ Start Date: __ ___ ___ PerformanceImprove nt Proj ct F s/G l: me e ocu oa Mem bers: Note: Sub acti itysh 1 w k pri r to mit v eet ee o C I meetng o theH Q i t SM. U e 1she p PIproje s et er ct Date Me be Pre nt m rs se Issue isc /D ussion Re om ene A ti n c m d co Re o ilit s nsib y p Ta t D te rge a 1. 1. 1. 2. 2. 2. 3. 3. 3. 1. 1. 1. 2. 2. 2. 3. 3. 3. 1. 1. 1. 2. 2. 2. 3. 3. 3. DOCUMENTING MEETING MINUTES 1. 1. 1. 2. 2. 2. 3. 3. 3. 1. 1. 1. 2. 2. 2. 3. 3. 3. 63 ACTIVITY #12
  • 63. Copy page, fold on lines and cut. 64
  • 64. QI HELP LINE UBHC Shula Minsky Director of QI 732-235-5003 Mike Gara Professor of Psychiatry 732-235-3921 Dorothy Hutty Administrative 732-235-4253 Coordinator Sheila Jackson Secretary II 732-235-3921 Kim Wilson Data Control Clerk 732-235-7587 UCHC Lisa DeBilio QI Coordinator 609-341-3093 Shirley Lee Secretary I 609-341-3093 Rich Cevasco Administrator 609-984-6474 Marci Masker Administrator 856-225-5753 Mitch Abrams Administrator 973-465-0068 Magie Conrad Administrator 609-341-3178 Mechele Morris FMHC Trainer 609-341-9383 DOC Debbie Raab HSM Supervisor 609-984-4188 Linda Adler Psychiatric Nurse 609-943-4373 Practitioner CMS Carl Ausfahl QI Director 609-771-8014 ext. 24 65