Quality Improvement in Arizona CAHs System and Practice

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Quality Improvement in Arizona CAHsSystem and
PracticeRefining and Measuring Your Process

• Andrea B. Silvey, PhD, MSN
• Chief Quality Improvement Officer
• Health Services Advisory Group

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Objectives

• Refine Aim statements.
• Refine process flow charts.
• Identify key leverage point(s) for monitoring
  process performance.
• Identify potential process measures.

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Overview of Kansas Hospital Association Quality
Health Indicators Project

• Joyce A. Hospodar, MBA, MPA
• Senior Program Coordinator
• The University of Arizona
• Mel and Enid Zuckerman College of Public Health
• Rural Health Office

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Demonstration ofProject Web Page

• http//www.hsag.com/services/special/cahs.aspx

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Review of Homework

• Aim Statements
• Process Flow Charts

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Effective Aim Statements

• Answer the question, What are we trying to
  accomplish?
• Communicate the expectations
• Are time specific
• Are measureable
• Define the specific population or populations
  affected
• Are clear and unambiguous
• Can be used in your elevator speech
• They aim BIG

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Example Aim Statement for Infection Monitoring
and Reporting

• By August 31, 2010, the infection control
  officers log of infections and communicable
  diseases will document 100 of the reportable
  incidents related to all hospital staff and
  patients, including infections up to 30 days
  post-operative for all inpatient and outpatient
  surgeries.

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Targeting the Aim Statement

• Our hospital would like to improve infection
  surveillance through more consistent analysis,
  interpretation, and recording of infection
  control data (such as laboratory and other
  clinical reports) to identify and act on emerging
  trends.
• Identify all specific lab and clinical reports
  included in the term infection control data
• Clarify what is meant by analysis?
  interpretation?
• Specify where data should be recorded
• What are the processes that might need to be
  improved?

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Homework Aim Statement

• By August 31, 2010, the infection control
  officers log of infections and communicable
  diseases will document 100 of the reportable
  incidents related to all patients.

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The Difference Between a Team Charter and an Aim
Statement

• An AIM statement is part of a team charter and
  addresses what the team intends to accomplish and
  how it will know if its effective in its work.
• In addition to the Aim statement, a charter also
  includes information to structure and organize
  what the team is going to do, how it will go
  about its work, and how it will communicate its
  barriers, needs, activities, and results.

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Refining the Process Flow Chart

• Name of process.
• Process owner.
• Process output/product.
• Who is involved in delivering the process.
• Who cares about the process (stakeholders).
• Extent of the process to be mapped (level of
  detail).
• Activities that define the process.
• Start point.
• End point.

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Homework Aim Statement

• The process this hospital has chosen to improve
  is the reporting of healthcare acquired
  infections (HAI). The individuals involved in
  this process will include the Infection Control
  Nurse, Director of Professional and Support
  Services, CEO, lab personnel, and the
  Hospitalist. The process that is currently in
  use is to receive the lab reports and to verify
  whether the infection was acquired in the
  hospital or if the patient arrived with the
  infection. In addition to the staff currently
  involved, nursing staff will be trained to look
  for indications of infection and to report this
  to the Infection Control Nurse. This process
  change will improve the timeliness and accuracy
  of the reporting of HAIs.

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Exercise Refining AIMs

• Utilizing the Criteria for Effective Aim
  Statements, come up with a list of questions that
  will get the information necessary to clarify the
  Aim. Develop suggestions that will make the
  statement more specific and actionable.

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Understanding and Refining the Process

• Name of process
• Start point
• Extent of the process to be mapped (level of
  detail)
• Who cares about the process (stakeholders)
• Who is involved in delivering the process
• Activities that define the process
• End point
• Process output/product

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Aim Statement By August 31, 2010, the infection
control officers log of infections and
communicable diseases will document 100 of the
reportable incidents related to all patients.  
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Key Leverage Point(s)

• Intermediate points in the process at which
  monitoring will be easiest to accomplish and will
  give you most pertinent information as to whether
  your Aim is being accomplished.
• The key focal point(s) for designing
  interventions that will have maximum impact on
  improving the process.

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Exercise Identifying KeyLeverage Points

• In your group, discuss what you think are the key
  leverage points in the process and explain why.
  Select a spokesperson who will report back to the
  larger group.

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By August 31, 2010, the Infection Control
Preventionist will achieve 100 compliance with
the initiation of timely and appropriate
Isolation Precautions for all admitted patients.
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Aim Statement Reduce the number of patients to
zero who are treated inappropriately for
infections in both the Emergency Department and
the Hospital Inpatient Unit, with a target date
of October 1, 2010.
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Just for FUN!!

• http//www.youtube.com/watch?vZhoos1oY404

• How do you think he went about perfecting his
  process???
• What kind of measures do you think he used?
• Where were his leverage points?

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About Measures

• Measures can be used for learning.
• Measures can be used for judging.
• All measures have limitations, but the
  limitations do not negate their value.
• Measures are one voice of the system. Hearing the
  voice of the system gives us information on how
  to act within the system.
• Measures tell a story goals give a reference
  point.

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Measurement Guidelines

• Types of measures
• Tips for developing measures
• Measure specifications

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Types of Measures

• Outcome
• Process
• Relative
• Absolute
• Rates
• Percentages
• Counts

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Tips for Developing and Using QI Measures

• The key measures should clarify the Aim and make
  it tangible.
• Keep it simple be careful about overdoing
  process measures.
• Seek usefulness, not perfection.
• Small samples over time should be used to
  determine if the process is improving.
• Collect data in segments at key leverage points
  in the process.

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How does our process perform?

• Measure Variation
• Is it stable?
• Is it predictable?
• Process Performance
• Does it meet our performance expectations?

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Measure Specifications

• Denominator
• What aspects of the process are you going to
  measure? What will you look at?
• Numerator
• What are the criteria for successful completion
  of that aspect of the process?

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Exercise Identify Potential Process Measures

• Utilizing the Tips for Developing and Using
  Measures, develop a measure to monitor how well
  your process is performing.

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Take-Home Messages

• An AIM statement is part of a team charter and
  addresses what the team intends to accomplish and
  how it will know if it is effective in its work.
• In addition to the Aim statement, a charter also
  includes information to structure and organize
  what the team is going to do, how it will go
  about its work, and how it will communicate its
  barriers, needs, activities and results.
• Clear Aims and detailed process flow charts are
  essential for developing effective measures.
• Effective measures should focus on monitoring key
  intervention point(s) that have maximum leverage
  for improving the process.

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Homework for WebEx2 (2/23/10)

• Refine Aim statement and draft a team charter.
• Refine process flow chart and identify key
  leverage points.
• Draft measure(s) to monitor the process.

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Next StepsWho Does What by When
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Contact Information

• Andrea B. Silvey, PhD, MSN
• Chief Quality Improvement Officer
• Health Services Advisory Group
• [phone] direct line
• asilvey_at_hsag.com

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year in health care settings. The Institute of
Medicine estimates that at least a quarter of
these injuries are preventable. To find out how
to prevent medication errors, go to
http//www.hsag.com/drugsafety/.
www.hsag.com
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