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Taney cqi plan docx

  2. 2. Table of ContentsIntroduction 3Terms 9Vision 13Quality Improvement Program Structure 14 QI TrainingProject Identification Process 15Goals, objectives and measures with time-framed targets 16Quality Assurance and the Monitoring QI Plan 17QI Program Evaluation Process 19Communication of QI activities 19Appendix A: PDCA Checklist 21 2
  3. 3. IntroductionOne of the opportunities for improvement that the Taney County Health Department (TCHD)identified through the Missouri Institute of Community Health’s Accreditation Process in 2005was a need for a Continuous Quality Improvement (CQI) program. The department was slatedfor MICH reaccreditation in early 2008 and Quality Improvement was an arena that needed tobe addressed. The field of quality improvement is an extensive one. Information pertaining to itis exceedingly vast with a plethora of options tailored to suit the needs of various businessstructures. Therefore, it was important to identify and employ the most appropriate CQIstrategy for the department.What is Continuous Quality Improvement?Continuous Quality Improvement is the complete process of identifying, describing andanalyzing strengths and weaknesses and then testing, implementing, learning from and revisingsolutionsi. It relies on an organizational culture that is proactive and that supports continuouslearning. CQI is firmly grounded in the overall, mission, vision and values of the agency. Mostimportantly, it is dependent upon the active inclusion and participation of staff at all levels ofthe agency, and stakeholders throughout the processii.Which CQI strategy?As was just mentioned, the topic of quality improvement was an extensive one. Therefore, oneof the first challenges was to find a process that would suit the needs of the agency. After anexhaustive CQI literature review, it was felt that the Plan, Do, Check, Act (PDCA) or theDeming/Shewhart Cycle would be the most conducive to meet the needs of TCHD. Moreaccurately, the process is referred to as the FOCUS-PDCA approach. Having originated in thebusiness industry, the FOCUS-PDCA approach has been tweaked for effective application in avariety of healthcare institutions – including a public health department.FOCUS: Find a process to improve Organize to improve a process Clarify what is known Understand variation Select a process improvement.After FOCUS has been achieved, a process improvement plan needs to be implemented. Onesuch plan is the PDCA cycle – or the Plan Do Check Act cycle.Planning: Involves creating a timeline of resources, activities, training and target dates. Duringthis stage a data collection plan needs to be developed, tools for measuring outcomes need tobe identified, and thresholds for identifying when targets have been met need to be stipulated. 3
  4. 4. Do: This involves the actual implementation of the various interventions as well as datacollection.Check: This step includes an analysis of the results of the data and an explanation for thereasons of variations – if any.Act: Means that one can act on what was learned and then determine what was learned. If theintervention was successful, then steps to make it a part of standard operating procedure needto be implemented. If the intervention was not successful, then the various sources of failureneed to be identified. Once these are determined new solutions need to be designed and thePDCA cycle needs to be repeatediii.A studyiv showed that repetitive cycles of measuring outcomes followed by implementation ofinterventions to improve outcomes could be effectively used to improve quality of care in ruralhealth clinics.Why Continuous Quality Improvement?In addition to increased productivity, improved service quality, enhanced customerresponsiveness and enhanced employee satisfaction, there are several other benefits ofincorporating CQI into the daily workings of the health department. Some of these are v: Ownership of Process/Program Objectives CQI can bring about changes in attitudes towards a process/program. Employees can see how a set of objectives helps to identify a process’s success or indications that a program is moving in the right direction. Inclusiveness/Consistency Implementation of a program on an organizational-wide level promotes a feeling of inclusiveness in the organization. Employees feel part of a team, have similar experiences, use the same CQI tools, as well as participate in organizational wide training. Improved Communication/Teamwork Regular management meetings involve sharing of information among programs and services. Staff can offer suggestions on interventions for opportunities in other areas to assist in needed improvement. This further fosters teamwork. 4
  5. 5. Stakeholder Perception Reporting of trended information allows stakeholders to see performance levels on a routine basis. They can see that the organization sets goals, evaluates data collected and reviews the impact on organizational programs. Proactive vs. Reactive CQI initiatives place the organization in a proactive mode. Under a CQI philosophy, programs and services are aggressively monitored which assists with detecting problems in a timely fashion. Analysis of data also helps to distinguish between acceptable and unacceptable performance levels.What is required?The six Key Success Factors (KSFs) for CQI are as followsvi: Key Success Factor 1: Visionary Leadership. Key Success Factor 2: Commitment to Customers / Clients. Key Success Factor 3: Trained Teams. Key Success Factor 4: Employee Participation. Key Success Factor 5: Total Quality Management Process (detailed below). Key Success Factor 6: Alignment of Management Systems. 5
  6. 6. The CQI Framework: Fig. 1 VALUES Adopt Apply outcomes Learnings indicators and standards M V I Train and S I support leaders, S S staff and I I O stakeholders O N N Review, analyze and Collect data interpret and data information ORG. CULTURE 6
  7. 7. The Crux of Continuous Quality ImprovementThe central idea of CQI lies in the philosophies of scientific method which include hypothesisgeneration, experimentation, observation and hypothesis testing. CQI is all about improvementwhich can only be brought about by change. The PDCA cycle mentioned earlier is a proven toolused to help agencies develop tests and implement changes. In other words, the PDCA is aframework for efficient trial-and-error methodology. The cycle begins with a plan and ends withan action based on the learning gained from the cycle. Improvement comes from theapplication of the knowledge gained and generally, the more complete the appropriateknowledge, the better the improvements will be when the knowledge is applied to makingchanges. Any approach to improvement must be based on building and applyingknowledge.This view leads to a set of fundamental questions, the answers to which form thebasis of improvement: 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in improvement?These questions provide the framework for a “trial and learning” approach. The word “trial”implies that the change is going to be tested.The term “learning” imples that the criteria thatare intended to be studied from the trial have been identified. This approach stresses learningby testing changes on a small scalevii.Plan of Action Proposal Identify a process that needs improvement that is common to all departments The literature emphasizes that CQI be adopted using a team based approach. This allows for synergistic problem solving, assumed empowerment and can aid in consensus building. This approach also forces participants to view how the agency operates as a unified system as opposed to separate entities that just happen to be a part of the larger “whole.” A team- based approach infuses a sense of purpose to the issue at hand and can also serve as a platform for future problem solving initiatives. Document current operating procedures. This allows us to understand where we stand at the moment. This information will act as the basis for formulating future improvement strategies. Collect Data. This step calls for data collection using existing standard operating procedures. Once collected, this data will help us to analyze the effectiveness of the current methods of operation. 7
  8. 8. Brainstorm for improvement strategies.This phase calls for taking a second look at the way things are currently done and to thenquestion whether any improvements can be made. If this is the case, then an exhaustive listof how the various processes can be improved needs to be generated. Meet to hammer out consensus for all proposed strategies.Since this is a team-based and collaborative effort, buy-in by all employees and stakeholdersis a mandatory precursor for any measure of success. All parties need to cross evaluate eachother’s proposed solutions to ensure that no inter-departmental glitches come about oncethe actual trial is rolled out. Implement the new process / processesThis is where the ‘rubber meets the road’ or where the newly conceptualized process is firstput in action. The data collection structures or templates may also need to be fine-tuned toreflect any procedural changes and related data collection points. Collect dataData collected here needs to be consistent with the type and format of data collected in theinitial data collection phase. This will allow for valid comparisons to be made of the ‘before’and ‘after’ procedures. Meet for feedback and see if the stipulated objectives were met.This is the ‘learning’ phase. Participants need to meet and analyze what worked and whatdidn’t. What did work needs to be documented and suggestions for further improvementneeds to be sought. Similarly, strategies that did not result in any significant improvementalso need to be documented for future reference. 8
  9. 9. Key quality terms: CQI – Continuous Quality Improvement The ongoing improvement of products, services or processes through incremental and breakthrough improvements. A philosophy and attitude for analyzing capabilities and processes and improving them repeatedly to achieve customer satisfaction PDCA – Plan Do Check Act FOCUS 1.) F – Find a process to improve 2.) O– Organize to improve a process 3.) C – Clarify what is known 4.) U – Understand variation 5.) S - Select a process improvement. Brainstorming: A technique teams use to generate ideas on a particular subject. Each person on the team is asked to think creatively and write down as many ideas as possible. The ideas are not discussed or reviewed until after the brainstorming sessionviii. Baseline measurement: The beginning point, based on an evaluation of output over a period of time, used to determine the process parameters prior to any improvement effort; the basis against which change is measuredix. Benchmarking: A technique in which a company measures its performance against that of best in class companies, determines how those companies achieved their performance levels and uses the information to improve its own performance. Subjects that can be benchmarked include strategies, operations and processes. Best practice: A superior method or innovative practice that contributes to the improved performance of an organization, usually recognized as best by other peer organizations Big QI: This is where top organizational leaders address the quality of the system at a macro level. Capability: The total range of inherent variation in a stable process determined by using data from control charts. Chart: A tool for organizing, summarizing and depicting data in graphic form Check sheet: A simple data recording device. The check sheet is custom designed by the user, which allows him or her to readily interpret the results. The check sheet is one of the “seven tools of quality” (see listing). Check sheets are often confused with checklists (see listing). Checklist: A tool for ensuring all important steps or actions in an operation have been taken. Checklists contain items important or relevant to an issue or situation. Checklists are often confused with check sheets (see listing). Common-Cause Variation: Any normal variation inherent in a work process. Complexity: Unnecessary work; any activity that makes a work process more complicated without adding value to the resulting product or service. Compliance: The state of an organization that meets prescribed specifications, contract terms, regulations or standards. Consensus: A state in which all the members of a group support an action or decision, even if some of them don’t fully agree with it. 9
  10. 10. Constraint: Anything that limits a system from achieving higher performance or throughput;also, the bottleneck that most severely limits the organization’s ability to achieve higherperformance relative to its purpose or goal.Cross functional: A term used to describe a process or an activity that crosses the boundarybetween functions. A cross functional team consists of individuals from more than oneorganizational unit or function.Employee involvement (EI): An organizational practice whereby employees regularly participatein making decisions on how their work areas operate, including suggestions for improvement,planning, goal setting and monitoring performance.Empowerment: A condition in which employees have the authority to make decisions and takeaction in their work areas without prior approval. For example, an operator can stop aproduction process if he or she detects a problem, or a customer service representative cansend out a replacement product if a customer calls with a problem.Facilitator: A specifically trained person who functions as a teacher, coach and moderator for agroup, team or organization.Failure: The inability of an item, product or service to perform required functions on demanddue to one or more defects.Feedback: Communication from customers about how delivered products or services comparewith customer expectations.Five whys: A technique for discovering the root causes of a problem and showing therelationship of causes by repeatedly asking the question, “Why?”Focus group: A group, usually of eight to 10 people, that is invited to discuss an existing orplanned product, service or process.Gap analysis: The comparison of a current condition to the desired state.Group dynamic: The interaction (behavior) of individuals within a team meeting.Groupthink: A situation in which critical information is withheld from the team becauseindividual members censor or restrain themselves, either because they believe their concernsare not worth discussing or because they are afraid of confrontationHistogram: A graphic summary of variation in a set of data. The pictorial nature of a histogramlets people see patterns that are difficult to detect in a simple table of numbersImprovement: The positive effect of a process change effort.Individual qi: When staff members seek ways to improve their own behaviors and environmentsit is referred to as individual qi.Internal Customer: Anyone in the organization who relies on you for a product or service.Key performance indicator (KPI): A statistical measure of how well an organization is doing in aparticular area. A KPI could measure a company’s financial performance or how it is holding upagainst customer requirements.Leadership: An essential part of a quality improvement effort. Organization leaders mustestablish a vision, communicate that vision to those in the organization and provide the toolsand knowledge necessary to accomplish the vision. 10
  11. 11. Little qi: When professional staff attack problems in programs or service areas by improvingparticular processes, it is termed as (Little qi).Mean: A measure of central tendency; the arithmetic average of all measurements in a data set.Mission: An organization’s purposeObjective: A specific statement of a desired short-term condition or achievement; includesmeasurable end results to be accomplished by specific teams or individuals within time limits.Outputs: Products, materials, services or information provided to customers (internal orexternal), from a process.Pareto chart: A graphical tool for ranking causes from most significant to least significant. It isbased on the Pareto principle, which was first defined by Joseph M. Juran in 1950. The principle,named after 19th century economist Vilfredo Pareto, suggests most effects come from relativelyfew causes; that is, 80% of the effects come from 20% of the possible causes. One of the “seventools of quality”.Problem solving: The act of defining a problem; determining the cause of the problem;identifying, prioritizing and selecting alternatives for a solution; and implementing a solution.Process improvement: The application of the plan-do-check-act cycle to processes to producepositive improvement and better meet the needs and expectations of customers.Process improvement team: A structured group often made up of cross functional memberswho work together to improve a process or processes.Process map: A type of flowchart depicting the steps in a process and identifying responsibilityfor each step and key measures.Quality assurance/quality control (QA/QC): Two terms that have many interpretations becauseof the multiple definitions for the words “assurance” and “control.” For example, “assurance”can mean the act of giving confidence, the state of being certain or the act of making certain;“control” can mean an evaluation to indicate needed corrective responses, the act of guiding orthe state of a process in which the variability is attributable to a constant system of chancecauses. One definition of quality assurance is: all the planned and systematic activitiesimplemented within the quality system that can be demonstrated to provide confidence that aproduct or service will fulfill requirements for quality. One definition for quality control is: theoperational techniques and activities used to fulfill requirements for quality. Often, however,“quality assurance” and “quality control” are used interchangeably, referring to the actionsperformed to ensure the quality of a product, service or process.Quality Circle: A small group of employees organized to solve work-related problems; oftenvoluntarily; usually not chaired by a department manager.Quality: a customers perception of the value of a product or service; organizations, theorists,and dictionaries define it differently. Well-known definitions include: "conformance torequirements" (Crosby) "the efficient production of the quality that the market expects"(Deming) "fitness for use"; "product performance and freedom from deficiencies" (Juran) "thetotal composite product and service characteristics of marketing, engineering, manufacturing,and maintenance through which the product and service in use will meet the expectations ofthe customer" (Felgenbaum) "anything that can be improved" (Imal) "meeting or exceeding 11
  12. 12. customer expectations at a cost that represents value to them" (Harrington) "does not impartloss to society" (Taguchi) "the totality of features and characteristics of a product or service thatbear on its ability to satisfy a given need" (American Society for Quality Control) "degree ofexcellence" (Websters Third New International Dictionary)Root cause: A factor that caused a nonconformance and should be permanently eliminatedthrough process improvement; The prime reason(s) why an incident occurred. Root causes areoften related to deficiencies in management systems.Run chart: A chart showing a line connecting numerous data points collected from a processrunning over time.Scatter diagram: A graphical technique to analyze the relationship between two variables. Twosets of data are plotted on a graph, with the y-axis being used for the variable to be predictedand the x-axis being used for the variable to make the prediction. The graph will show possiblerelationships (although two variables might appear to be related, they might not be; those whoknow most about the variables must make that evaluation). One of the “seven tools of quality”(see listing).Seven tools of quality: Tools that help organizations understand their processes to improvethem. The tools are the cause and effect diagram, check sheet, control chart, flowchart,histogram, Pareto chart and scatter diagram (see individual entries).Six Sigma: A method that provides organizations tools to improve the capability of theirbusiness processes. This increase in performance and decrease in process variation lead todefect reduction and improvement in profits, employee morale and quality of products orservices. Six Sigma quality is a term generally used to indicate a process is well controlled (±6 sfrom the centerline in a control chart).Special-Cause Variation: Any violation arising from circumstances that are not a normal part ofthe work processStakeholder: Any individual, group or organization that will have a significant impact on or willbe significantly impacted by the quality of a specific product or service.Standard deviation (statistical): A computed measure of variability indicating the spread of thedata set around the meanValues: The fundamental beliefs that drive organizational behavior and decision making.Vision: An overarching statement of the way an organization wants to be; an ideal state of beingat a future point. 12
  13. 13. Vision of quality in the organization:The phrase ‘Continuous Quality Improvement’ as well as its abbreviated form – CQI have becomecommon parlance within the Taney County Health Department. Today we can safely say that mostemployees have a fairly good idea of what CQI is and how it applies to their various work areas. Little ‘qi’efforts are almost automatic in some parts of the organization. In fact, some staff members have atendency to say “CQI it” when they feel the need to trouble shoot problems within their work areas.Several work flow process improvements have been initiated and completed without the requirement ofany sort of management intervention. Many of these successes have been presented at thedepartment’s monthly staff meetings.However, the big “QI“projects still need support from the CQI Manager. We feel that these system-wideprojects are best conceptualized and executed at the management level with full support of the topleadership. These larger QI initiatives require the use of some of the more advanced QI concepts andtools and training towards this end will need to be administered or required.The Goal of the CQI program is to continuously improve the systematic use of the CQI process with theprocess becoming more automatic, more sophisticated, and a routine job responsibility of every staffmember at every level of the organization. The program will also focus on more cycles of the CQIprocess in order to facilitate “fine-tuning” of performance and processes. Additionally, the program willfocus on more, larger department-wide systemic Quality Improvement projects that would involve moreof the management team to facilitate organizational improvement. 13
  14. 14. Quality Improvement Program Structure:Organization structure, roles and responsibilitiesThe Taney County Health Department Quality Improvement Manager is responsible for thedevelopment, review and implementation of the CQI program and initiatives for the department withassistance from the CQI team which consists of the management team and Performance ManagementTeam. The CQI Team is made up of members of management, staff, and senior leadership. The CQITeam is then tasked with the implementation of department-wide CQI initiatives or the identification ofprogram specific projects. Management staff also encourages staff members to identify “qi” projects tofocus on process specific issues. These staff driven “qi” projects are communicated to the CQI Managerfor feedback, further input, technical development, and assistance with the final presentation. The CQIManager is also responsible for review of CQI projects, the CQI Program overall, and QI training needs ofmanagement and staff.MembershipThe CQI Team consists of all members of the TCHD Management Team which representseach division of the organizational chart, including: the director, assistant director, clinical servicesdivision manager, finance and HR division manager, dental division manager, environmental healthsupervisor, WIC division manager, community outreach division manager, CQI and IT manager, andanimal control supervisor. Program staff are included in the CQI process through “qi” and “QI” projectsroutinely.Quality improvement Training ProcessQuality improvement training is an ongoing process that reflects the philosophy of the TCHD and the CQIprogram. Training is incorporated into staff meetings, manager meetings and board meetings routinely.Each “qi” or “QI” project is reviewed by the CQI manager who provides guidance to the person(s)involved in the project. This allows for the direct delivery of project specific training to those involved inthe project and helps with the learning process as the CQI project becomes a learning example. Formaltraining is also provided to new employees, existing employees, management and the CQI Manager.Formalized training includes: 1. New employee orientation presentation materials 2. Introductory Presentation for new staff 3. Online courses for all staff through Heartland Centers 4. Advanced training and resources for CQI Team 5. Continuing staff training on QI 6. Other training as needed – position specific training (MCH, Epidemiology, etc.) 14
  15. 15. Project identification process: Improvement areas are identified through several methods. The simplest method involves an intuitive process where employees or managers identify a process, policy, or procedure that is creating difficulties or is thought to be inefficient. This will result in the initiation of the PDCA cycle and is likely to result in a “qi” project or may develop into a more involved problem leading to a “QI” level project. The managers can also initiate a “QI” project after the identification of an issue through the performance management program (PMP) or the “Pressing Need” approach. The “Pressing Need” Approach (PNA) is a process whereby a supervisor or manager identifies priorities in the program area which need to be addressed to further the improvement of their program or area of responsibility. The most involved process involves system-wide projects which includes multiple programs or cross-functional team members in the organization. These projects are long-term and more complicated in their development and completion. The system-wide “QI” projects are identified by the director, management team, or Board members through data captured by specific programs, the PMP, identified priorities, or a possible “crisis” that impacts functioning of the department. The basis of the TCHD CQI plan is based on the Mission and Vision of the health department to provide quality and effective programs to members of the community and visitors to the area. The Mission and Vision are the foundation of the goal of the Strategic Planning process and the CQI projects are developed to ensure that program delivery is meeting the stated goals and objectives formulated in the program planning and strategic planning processes. For instance, if the data collected through the PMP determines that a program area is not functioning at the appropriately level during anytime during the year, a CQI process is initiated to determine the reason behind the decreased performance and to implement corrective actions. The CQI program is therefore, the chosen method which is utilized by management to ensure that the goals and objectives of the strategic plan are achieved. Additionally, CQI projects may be expressly identified as a goal within the strategic plan to review and improve a specific function, program, etc. of the department. This would normally involve a substantial, long-term “QI” project involving multiple program areas or divisions. 15
  16. 16. Goals, objectives and measures with time framed targetsThe performance measures that the CQI program seeks to achieve includes the following: i. Ensure that the PDCA cycle is fully recognized and acknowledged in each project ii. Ensure that the CQI projects become more sophisticated with additional data elements utilized and more advanced quality improvement concepts and methodologies implemented iii. Ensure that additional PDCA cycles are implemented after the initial PDCA iv. Increase training opportunities for management team and staff v. Develop and implement quality improvement process vi. Revise Standard Operating Procedures (SOP) for CQI program at the end of the year to include new standards and methods developed.ResponsibilitiesThe CQI manager is responsible for evaluating the CQI program and ensuring that the objectives of theCQI program are being met through assistance by the TCHD management team. As CQI is a componentof the TCHD culture, the philosophy has always been that management and senior leadershipinvolvement is crucial to the overall success of the program. Employees will be provided guidance by themanagement team, supervisors and CQI manager on specific projects. Training will be provided at staffmeetings periodically through formal training and presentation of ongoing CQI projects.Time frames associated with CQI ObjectivesThe following timeline will be managed by the CQI program manager. These timelines will be the basisfor evaluation of the CQI program as well. Objective Timeframe Ensure that the PDCA cycle is fully recognized and acknowledged in each Quarterly project Ensure that CQI projects become more sophisticated and more advanced QI Annually concepts and methodologies implemented Ensure that additional PDCA cycles are implemented after the initial PDCA Conclusion of each project Increase training opportunities for management team and staff Quarterly Develop and implement quality improvement process Annually Revise Standard Operating Procedures (SOP) for CQI program at the end of the Annually year to include new standards and methods 16
  17. 17. Quality Assurance and Monitoring QI Plan TCHD’s CQI Program is integrated into the Department’s Performance Management Program (PMP) and Strategic Plan. The Performance Management Program has been designed to showcase critical program related quantitative data on a monthly basis. During the development phase of the PMP, managers identified data elements that represented the goals and objectives in programmatic areas. For example, the number of clients seen on any particular day could be construed as the most important performance related program data for the WIC, Immunization and Dental programs. These numbers are provided to the PMP coordinator to be entered into the PMP system which automatically updates associated Dashboard charts and graphs for review by management and the board monthly. The PMP Dashboard evaluation range identifies “poor”, “moderate” and “optimal” performance. The represented “dashboard” of “speedometers” provides a quick visual method of identifying performance within any division. If performance is shown to be suboptimal, CQI cycles are initiated and executed until performance once again falls within the optimal range. An optimal value is one that falls between 85% and 100% of the established range for that data element. Based on the PMP process, the CQI program and initiatives are monitored through the effects that CQI initiatives have on the overall performance management numbers. The more programs the department has running optimally, the fewer CQI projects are triggered under this mechanism. As CQI initiatives are implemented and completed, they are tracked utilizing the CQI monitoring tool. The CQI monitoring tool allows the collection and analysis of data from each CQI project: whether a standardized process has been achieved; how many cycles have been completed or if benchmarks have been achieved to become a Standard Operating Procedure (SOP); what PDCA phase the project is in; the percentage of project complete; and timeframe for next CQI report. Stated goals and objectives within each CQI project are utilized to determine the percentage of project completion. By utilizing this method the CQI Manager is able to quickly monitor progress of each CQI project that is in progress and what has been achieved. Because of the continued development of the TCHD CQI Program, additional components and improvements to the CQI Performance Management Plan are being implemented. Currently, the management team is in the process of becoming more familiar with the fundamental aspects of the PMP and CQI system using quantitative data. The implication is that the department is moving toward a point where quantitative data will be increasingly utilized to measure and reflect program effectiveness. Challenges still exist when it comes to designing apt data collection mechanisms for TCHD programs that do not lend themselves as well to quantification. For instance, “How do you measure communications for the Public Information Division?” is one example among several for the department. These kinds of problems are where the second CQI mechanism is triggered. For these more ambiguous problems, the CQI philosophy is drawn upon extensively to help program managers delve into the most important component of TCHD programs. Once this has been clearly 17
  18. 18. identified, managers are challenged to design a data collection methodology that can be used withinthe Performance Management Program.Monitoring of the effectiveness and efficiency of the CQI program itself is achieved through aQuality Assurance (QA) program that takes into account the goals and objectives of the CQIProgram, as well as the timeframes identified. # Objective Timeframe 1 Ensure that the PDCA cycle is fully recognized and acknowledged in each project Quarterly 2 Ensure that CQI projects become more sophisticated and more advanced QI Annually concepts and methodologies implemented 3 Ensure that additional PDCA cycles are implemented after the initial PDCA Conclusion of each project 4 Increase training opportunities for management team and staff Quarterly 5 Develop and implement quality improvement processes Annually 6 Revise Standard Operating Procedures (SOP) for CQI program at the end of the year Annually to include new standards and methodsThe following QA processes will be utilized to monitor the associated Objectives: # Quality Assurance Tool Utilized By Objective 1 Each project is monitored utilizing the PDCA Checklist (Appendix A). Quarterly the CQI Manager reviews the completion rate of the PDCA cycle to ensure that each project has fully utilized the PDCA Cycle to include the necessary PDCA elements. This is represented by the CQI Monitoring tool percentage complete data element. 2 Annually, the CQI program manager will review the current ongoing and completed CQI initiatives for opportunities to apply more advanced CQI concepts. This report will be forwarded to the management team with recommendations for implementation. Once approved, the CQI manager will provide additional training for the management team and staff on additional CQI methodologies. The goal will be to increase awareness regarding more complex CQI methods and to use these methods when appropriate. However, the implementation or utilization of more complex CQI strategies and concepts on projects will continue to be dependent on the needs of individual projects. 3 The CQI monitoring tool will be used to track the progress of each project. After the project is complete a determination will be used as to whether additional CQI cycles are necessary to improve processes further. The goal will be to ensure that additional cycles are implemented until an optimal Standard Operating Procedure is identified and monitoring is established to ensure optimal performance is maintained. 4 Training will be provided to the management team, staff and board members on a regular basis. For quality assurance purposes, the CQI Manager will work to provide one training each quarter with documentation on the training and outcomes. An annual report will be submitted to the management team. 5 The benchmark standards established by PHAB and the Public Health Foundation will be utilized to measure and critique the CQI Program. A quality improvement review will be implemented annually to identify areas of improvement within the CQI Program and Projects. This QI review will be based on the Quality Assurance data, training program outcomes, CQI Monitoring tool, or other identified priorities by the CQI Manager in coordination with the Management team and Board. These QI Processes will also be in alignment with the TCHD strategic plan and priorities. 6 After completion of the annual reports and QI processes, the CQI Manager will submit recommendations and revisions to the management team for the Continuous Quality Improvement Plan SOPs to include new standards, concepts, and methodologies. 18
  19. 19. CQI Program Evaluation ProcessThe CQI annual report will focus on reporting the accomplishments of the CQI Program, the completedprojects for the year, the lessons learned, training provided, new processes implemented and activitieswhich may need to be implemented during the coming year. The process to assess the effectiveness ofthe quality improvement plan and activities may include: 1. Review of the process and the progress toward achieving goals and objectives 2. Efficiencies and effectiveness obtained and lessons learned 3. Customer/stakeholder satisfaction with services and programs 4. Description of how reports on progress were used to revise and update the quality improvement planCommunication of quality improvement activities Communication of quality improvement activities in the Taney County Health Department will becompleted through presentations provided during monthly staff meetings, management team meetings,and board meetings. In depth CQI Training is conducted on various topics. However, during each staffmeeting, CQI presentations from various programs focusing on accomplishments and lessons learnedare provided. During staff meetings and board meetings, CQI projects that address administrative orsubstantial programmatic outcomes are presented. These presentations allow management and boardmembers to discuss CQI initiatives, ask questions, and learn from the CQI presentations and projects. 19
  20. 20. References:i Casey Family Programs and National Child Welfare Resource Center for Organizational Improvement. “UsingContinuous Quality Improvement to Improve Child Welfare Practice – A Framework for Implementation.” [Online]14 August, 2007 http://muskie.usm.maine.edu/helpkids/rcpdfs/CQIFramework.pdfii Ibidiii Center to Advance Palliative Care. “Continuous Quality Improvement” [Online] 14 August, 2007<>iv Salman, Ghassan F. “Continuous Quality Improvement in Rural Health Clinics.” [Online] 14 August, 2007 <http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1490210>v Crawford, Shirley and Colangelo, Michael. “Methods in Implementing an Effective CQI Program in a SocialServices Setting.” [Online] 11 December, 2007<http://www.cwla.org/programs/trieschman/2003toolsfiles/2003toolswkshopD2slides.ppt>vi Melum, Mara Minerva. “How to Make CQI Work For You – Continuous Quality Improvement of Healthcare.”[Online] 7 December, 2007 < http://findarticles.com/p/articles/mi_m0843/is_n6_v17/ai_11647230>vii Slavin, Lee and Bennett, Leo. “Continuous Quality Improvement: What Every Healthcare Manager Needs toKnow” [Online] 15 September, 2007 < http://www.case.edu/med/epidbio/mphp439/CQI.htm>viii (Quality Improvement Course, 2007)ix Ibid 20
  21. 21. Appendix APDCA Checklist 21