This document outlines steps for designing and implementing a quality improvement program at a health care organization. It discusses creating infrastructure for quality improvement, selecting performance measures, collecting and analyzing data, planning and implementing changes, and monitoring performance over time. The document provides guidance on developing a quality improvement plan, identifying improvement opportunities, testing changes, and sustaining improvements. It emphasizes establishing a quality improvement culture and integrating these efforts into existing processes.

1. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
How To Design a Health Care
Quality Improvement
Program

2. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Learning series on quality improvement
planning
Focus on implementation
Roadmap for getting there
Create a QI infrastructure
Seek resources and technical
assistance
Third-party quality recognition
Build on partnerships with the
national cooperative agreements

3. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
% entered prenatal care in the first trimester
% of children received all recommended
immunizations by 2nd birthday
Hypertensive Patients with Blood Pressure<=
140/90
% Diabetic Patients with HbA1c <= 8
Total Cost per Patient
Cost per Medical Visit

4. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Improve Access to Quality Health Care and
Services
Community/new site development
Expansion planning
Patient-centered medical/health home
development
Strengthen the Health Workforce
recruitment and retention
Build Healthy Communities and Improve
Health Equity

5. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Develop and enhance access points
Transform care delivery system
Recruit, develop, retain skilled workforce
Integrate Health Center into local health
systems - Specialists, ER
Public Health
Align policies and programs where possible

6. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Performance Profile (National/State) -- Number & Percent
of Health Centers
Meet Meaningful Use Standards
Achieve National Quality Recognition
Exceed Healthy People Goals (Core Clinical Measures)
Increase in Cost/Patient Less than National
Increase in Patients
Going Concern Issues
Claims/Visit
60 or 30 Day Progressive Actions
1 year Project Periods

7. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Ongoing QI/QA Plan encompassing
management and clinical services
maintaining.
Confidentiality of patient records.
Focused responsibility for QI.
Periodic assessments of
appropriate service use and quality.

8. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Roadmap for HC organization
(1)Leadership, focus, & prioritization.
(2)Efficient coordination of staff &
resources.
(3)Better outcomes.
(4)Satisfy external requirements.
(5)CBAHI, State.
(6)Third-party quality.
(7)accreditation and recognition.

9. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
OK Great!!
So how do we actually do this when we are:
Short staffed.
Busy with lots of complicated patients.
Short on resources (shouldn’t all our money
go for patient care?).
Lacking QI skills (not covered well in medical
school, nursing school, business school).

10. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Depends on where you are, who you are,
when you began, how big you are…
One site 3 providers rural-Urban 2,000 users
12 sites Khobar providers 100,000 users
history of organization,
fully implemented EHR for 4 years
New start 2010 paper medical records

11. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
The Steps
(1)Design the Basic Structures.
(2)Evaluate & Determine Priorities.
(3)Select Performance Measures.
(4)Collect Data/Determine a
Baseline.
(5)Analyze Data/Evaluate
Performance.
(6)Plan & Implement Changes for
Improvement.
(7)Monitor Performance Over Time.

12. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Quality as an integral part of the
organization’s “culture”
Buy-in at all levels.
Board, management, staff and
patients.
Resources—staff time, meetings,
information systems.
Provide education.

13. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
QI Committee
QI Plan & Health care plan
QI calendar
Clinical practice guidelines
Policies & procedures
Peer review
Chart audits
Patient satisfaction surveys
Tracking systems
Credentialing and privileging
Data sources

14. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Set goals for measures
A SMART goal is a goal that is
Specific,
Measurable,
Attainable,
Relevant and
Time based.
In other wor ds,a goal that is ver y
clear& easily under stood.

15. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Define measurement population and
delineate eligibility criteria.
Create a data collection plan to
include:
Sampling strategy.
Determine method of data collection,
i.e. chart abstraction, interviews.

16. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Create data collection tools
Design instructions for data collection
tools.
Train personnel who will collect data.
Conduct pilot test of tool.
Establish process of communicating with
staff about measurement process.
Collect data.

17. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
i.Analyze data and review the results.
ii.Identify areas where additional data is
required.
iii.If historical data are available,
compare for trends.
iv.Display and distribute data to
communicate findings and results.
v.Identify areas for improvement and
select a quality improvement project.

18. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A

19. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
i.Develop a time line or calendar
of activities for the year.
ii.Select a QI approach,
iii. such as the Chronic Care Model.
iv.Clarify QI responsibilities of
staff.

20. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Identify potential solutions to make
improvement to the systems of care.
Recognize quick fixes and longer term
solutions.
Try a small test of change and analyze results.
Refine improvement plan.
Develop timeline for implementation of plan.
Delineate team responsibilities.
Implement changes.
Track changes and improvement actions

21. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
i.Determine interval for re-measurement.
ii.Remeasure indicator after change has
been implemented.
iii.Look for incremental improvement.
iv.Communicate results to team, staff and
leadership.
v.Develop a plan for sustained
improvement.

22. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Processes
(1)Chronic Diseases Care being
implemented
(2)Staff training.
(3)Patient education.
(4)Plan to institute new consent form
(5) specific for women’s health and policy
to ensure its use.

23. S ilv e r C r e s c e n t D is p e n s a r y – K h o b a r - K S A
Implementing your QI plan
(1) How to choose specific strategies.
(2) How to evaluate.
(3) Connection to risk management, peer
review accreditation.
(4) How to use the collected data,
to fuel your QI process.
(5) Setting goals and performance metrics.
(6) Increasing data reliability.