The document outlines steps for designing a quality improvement program for a health care organization. It discusses creating a QI infrastructure, selecting performance measures, collecting baseline data, analyzing data to identify areas for improvement, planning and implementing changes, and monitoring performance over time. The key aspects emphasized are developing a QI plan and committee, setting SMART goals, creating a data collection process, analyzing data to choose improvement projects, implementing test changes, and sustaining improvements through ongoing measurement.

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
Hypertensive Patients with Blood Pressure<=
140/90
Asthmatic patients that were controlled
FVC/FEV%
Diabetic Patients with HbA1c <= 8
Total Cost per Patient
Cost per Medical Visit
Sutured wounds with good healing and no
infection

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
Community/new site development
Expansion planning
Patient-centered medical/health home
development
Strengthen the Health Workforce
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
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
Leadership, focus, & prioritization
Efficient coordination of staff &
resources
Better outcomes
Satisfy external requirements
CBAHI, State
Third-party quality
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:
●Create the Basic Structures
●Evaluate & Determine Priorities
●Select Performance Measures
●Collect Data/Determine a Baseline
●Analyze Data/Evaluate Performance
●Plan & Implement Changes
●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
●Chart audits
●Patient satisfaction
surveys
●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 words,
a goal that is very clear and easily
understood.

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:
Create 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
Analyze data and review the results.
Identify areas where additional data is
required.
If historical data are available, compare
for trends.
Display and distribute data to
communicate findings and results.
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
Develop a time line or
calendar of activities for the year.
Select a QI approach,
such as PDSA or the Chronic
Care Model.
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 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
Determine interval for remeasurement.
Remeasure indicator after change has been
implemented.
Look for incremental improvement.
Communicate results to team, staff and
leadership.
Determine need for and/or level of
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…
Chronic Diseases Care being implemented
Staff training
Patient education
Plan to institute new consent form
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
How to choose specific strategies
How to evaluate
Connection to risk management, peer review,
accreditation and PCMH
How to use data that you are already
collecting to fuel your QI process
Setting goals and performance metrics
Increasing data reliability