Quality Improvement in Behavioral Health Care:

1
Quality Improvement in Behavioral Health
Care Concepts and Tools
In preparation for the New Jersey Statewide
Behavioral Health Care Quality Improvement Fair
Shula Minsky, Director, Quality Improvement, UBHC
minsky_at_umdnj.edu
2
Training Objectives

• Review quality improvement (QI) principles
• Describe, and walk through the quality
  improvement process
• Examine QI tools and how when to use them
• Practice the development and presentation of a QI
  project for the inaugural QI Fair of 2010

3
WHAT IS QUALITY IMPROVEMENT ?
What should BE
What IS

• AND
• designing, testing and monitoring interventions
  that bridge the gap

4
A FEW IMPORTANT PRINCIPLES

• Continuous improvement must be high priority for
  all
• Quality improvement is a team effort
• Focus of improvement is on process, not
  individuals
• Quality improvement must be data-driven
• The QI Process is best when based on an
  established, accepted model.
• The QI Process information must be communicable
  (documentation is essential).

5
A GENERAL MODEL FOR QUALITY IMPROVEMENT
6
Data Collection

• Collecting data is much like collecting
  garbage..
• You must know in advance what you are gonna do
  with the stuff.
• Mark Twain

7
Collecting Data
Consider

• What really needs to be measured?
• Whats the best way to measure it?
• How much data needs to be collected, for how
  long, and how often?
• How will the data be used?
• if you cannot answer this question, dont collect
  this information

8
Collecting Data
Practical suggestions

• Use (if possible) currently collected data, it
  will
• help pinpoint your problem and the purpose of
  your QI team
• provide ready-made baseline and outcome measures
• If you have to use other measures, choose a
  tested and proven instrument
• If you cant find what you need, develop your own
  measure (very carefully)
• Look for simple, concrete counts of things and
  events

9
QI Tools
10
Overview of useful QI tools
What they are. When and How to do them.

• Process tools
• Brainstorming
• Multi-voting
• Pareto Charts
• Cause Effect Diagrams (Fishbone)
• Flow Charts
• Data display tools
• Run Charts and Control Charts
• Work Plans and project tracking

11
Process Tools
12
Brainstorming Select a problem
WHAT A formalized way to generate ideas
efficiently and creatively and get all team
members involved in the process.
UTILITY/PURPOSE
Used to identify topic/problem for improvement at
the planning stage, generate ideas about
possible/probable causes of problems, or ideas
for interventions.
13
Brainstorming (cont.)
HOW

• Structured each team member gives an idea in
  turn
• A variant members write ideas on cards
• Unstructured team members give ideas as they
  come to mind
• Use flipchart/large paper, write all ideas
• Do not discuss. Do not agree/disagree. Do not
  criticize (only allow clarification questions)
• When new ideas are exhausted, stop

14
Multi-Voting Prioritize
WHAT A way to build team consensus by
incorporating individual preferences/ratings into
the overall team decision
WHEN When you need to reach consensus, but team
members seem torn between competing options. Can
be done to finalize priority issues after
brainstorming (topics/problems, causes,
interventions, etc.)
15
Multi-Voting Prioritize
HOW

• List all the options on a flipchart
• Eliminate duplicates, or group similar items,
  clarify meanings where/if necessary
• Give each statement an identifier (a, b, c,
  etc.)
• Decide how many votes each member would have (3-5
  is usual)
• Each team member (independently) places his/her
  votes on an index card
• Cards are collected, votes tallied on
  flipchart/large paper

16
Pareto Chart Display Priorities
WHAT A way to display the magnitude/importance
of some problems/issues or to prioritize
potential causes of identified problems

• WHEN When you wish to
• focus efforts on tasks that have the greatest
  potential impact
• shift focus away from someones pet peeve to
  the real issues
• provide a simple picture, easy to understand and
  communicate, regarding the relative importance
  of specific issues/solutions
• display the results of multi-voting ( on your
  poster)

17
Pareto Chart (cont.)
HOW

• Determine the categories related to your issue
  (e.g., different QI topics, probable causes)
• Determine your unit of measurement (e.g., number
  of votes, percent of votes, etc.)
• Collect the data (if you dont already have it)
• Count the units of measurement per category, and
  plot the highest one first, the second highest
  second, etc. (use PPT)

18
Use the Process Tools to Identify Probable
Causes of Your Problem

• Brainstorm the probable causes of the problem you
  identified
• Prioritize the causes using multi-voting
• Display your results in a Pareto chart

(you have 10 minutes to do it)
19
Cause Effect AnalysisFishbone Diagram

• WHEN When you need
• a simple, graphical way to explore and
  communicate possible causes for an identified
  problem
• to facilitate focusing on the main issues that
  need corrective action

20
Cause Effect AnalysisFishbone Diagram

• HOW
• Work as a team
• Use a skeleton of a fishbone diagram (see
  handout)
• Place the identified problem in the box on the
  right
• Decide on the major cause categories, and place
  them at the top of the main bones (dont plan
  on more than six)
• Brainstorm possible causes and place them all on
  the draft

21
A Fishbone Diagram
Environment
Staff
Process
The problem
High no-show rates
Equipment
Training
Patient
22
Flow Charts
What A formalized way to describe a process or
an event

• WHEN When you need to
• understand what happened
• streamline a process
• design an intervention (in the right place)
• show change from past to the present
• share understanding about a specific event or
  process

23
Flow Chart Symbols
Alert possible breakpoint
24
Flow Chart
Start you want to cook special dinner
An example
Look for recipe book
Scream in frustration
Have all ingredients?
Yes
Is it on the shelf?
No
Yes
No
Scream in frustration
Find the book!
Yes
Get your spouse to buy what you need
Are stores open?
No
Yes
Did he get all?
Cook dinner
Smile, The End
No
Scream in frustration
Cry, The End
25
Flow Chart Guidelines

• Dont be concerned about defining the
  process/event completely in the first draft
• Involve people who are familiar with the
  process/event
• Review the flow chart for accuracy and
  completeness (several times)
• It is useful to create the as is before you
  attempt to do the as it should be

26
Improvement Planning Milestones

• Before implementing the intervention, the team
  should have

• Clarified/specified the problem in need of
  improvement
• Established a baseline measurement
• Identified at least one probable significant
  cause
• Considered several possible interventions that
  address the identified cause
• Selected a small set of interventions to start
  with

27
Implementing Improvement

• Your interventions do not have to address ALL
  problems everywhere to be effective
• Implement in small doses
• Monitor, measure and share even small performance
  improvements with peers, build acceptance and
  alliances
• Sustainable improvement takes time

28
Data Display Tools
29
Displaying Outcomes Run Chart
WHAT Charting a specific measure over time.
For example, number of no-shows or restraints
by quarter, number of falls by month, number of
phone calls per day, number of BMI (BP)
documented by month.

• WHEN When you want to
• monitor performance to detect trends or shifts,
  over time
• compare a measure before and after an
  intervention
• focus attention on changes in the process under
  scrutiny

30
Displaying Outcomes Run Chart

• HOW
• Select a performance measure
• Gather enough data points (at least 20-30)
• Create a graph with timeline on the horizontal
  axis (x axis) and the measure on the vertical (y
  axis)
• Plot the data points and connect them with a line
  (or use PowerPoint to do it for you)
• Calculate the mean for the measure and draw the
  line in your graph

31
Run Chart Example
Seclusion rates in Adolescent Inpatient settings
July 98-December 02
32
Control Chart
WHAT A way to look at run charts and facilitate
recognition of meaningful variation.
WHEN When you monitor ongoing performance
measures and need to have a quick way to
recognize trends or shifts that are meaningful or
significant.
33
Control Chart
Seclusion rates in Adolescent Inpatient settings
July 98-December 02
High upper control limit (2SD)
Upper control limit (1SD)
Mean
Lower control limit (1SD)
34
Work Plans and Project Tracking
35
Document your QI team Process
( if it was not documented, it was not done)

• Have a clear and consensual definition of your
  purpose (write it down)
• Develop a work plan, with specific tasks,
  responsibilities, and timeline (modify and revise
  as you go along)
• Have designated minutes-taker (you can rotate the
  honor) and facilitator (should be two different
  people)

36
Document your QI team process (cont.)

• Circulate minutes to members within a day or two
  (keep it fresh)
• Keep all drafts used in your deliberations
  (brainstorming lists, fishbone diagrams, flow
  charts, Pareto charts, multi-voting results,
  baseline data, etc.)

37
WORK PLANS Two Examples
38
(No Transcript)
39
Guidelines for Your Poster Presentation

• Use fewer words, more pictures if you use words,
  use large print
• Make the presentation colorful, vivid,
  interesting (but dont go overboard...)
• Include enough detail to tell the story, but not
  too much (you will have a handout with details
  for those who are interested)
• Plan your space well

40
Guidelines for Poster Presentation (cont.)

• Include in your poster

• The purpose of your project
• Team members and their affiliation
• Steps of the QI model you have used
• Methods used to select topic, and achieve
  consensus on causes and interventions
• A (short) description of your interventions
• Baseline and outcome data
• Conclusion/status/plans for the future

41
Guidelines for your Oral Presentation

• Do not read from your summary page (everyone
  knows how to read)
• Keep it short, and stick to the main points
• Keep eye contact with the audience, dont
  hesitate to express your enthusiasm
• Consider your presentation an infomercial, a
  marketing tool to whet audience appetite for more

42
Now is your chance To critique someone elses QI
process
Each table will receive one actual case,
presented in past QI Fairs
Your task

• First, review the poster presentation and summary
  page according to the criteria we discussed (10
  minutes)
• Second, have one member provide a 2-minute
  oral presentation of your groups findings.

43
The Third Statewide QI Fair of 2013
June 20, 2013

• Letter-of-intent due on March 30, 2013 (fax to
  QI Department, 732.235.3922)
• If you have questions or need consultation
  regarding general issues or statistics, please
  e-mail qiquestions_at_umdnj.edu
• Final project Poster and one-page summary due
  to QI at UBHC on May 28, 2013
• Guidelines for the one-page summary and the
  project judging criteria on the next slide.

44
The Third Statewide QI Fair of 2013
June 20, 2013
45
Questions? Comments?