Creating a Quality Culture

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Creating a Quality Culture

• Pacing our Way to Healthcare Quality
• Setting, Managing Maintaining the PACE of our
  Organizations Future

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Cultural Continuum Where Are We?
HOSTILE Blocks activities of change at all costs
UNCOOPERATIVE Needs constant encouragement and
explanation to get cooperation
RESISTANT Openly verbalizes and acts on
opposition to a point
INDIFFERENT Wont Help, Wont Hurt, will follow
the crowd
COMPLIANT Does the minimum required and
subversively erodes standard
HESITANT Holds reservations, wont volunteer but
can be encouraged
CONTRIBUTORY Provides appropriate support but
wont lead or act independently
ENTHUSIASTIC Works hard to make it happen and
will lead and act independently
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Cultural Continuum Where Are We?
Cultures that Get By
HOSTILE Blocks activities of change at all costs
UNCOOPERATIVE Needs constant encouragement and
explanation to get cooperation
RESISTANT Openly verbalizes and acts on
opposition to a point
INDIFFERENT Wont Help, Wont Hurt, will follow
the crowd
COMPLIANT Does the minimum required and
subversively erodes standard
HESITANT Holds reservations, wont volunteer but
can be encouraged
CONTRIBUTORY Provides appropriate support but
wont lead or act independently
ENTHUSIASTIC Works hard to make it happen and
will lead and act independently
New Employees what happens to them? Promotes us
to lose our good employees
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How Many of You.

• Surveyor
• Same Way
• Dont Do

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All do it. What?

• Quality!

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Purpose of Quality

• Not for
• Surveyors
• Inspectors
• More paperwork
• But Rather
• Good of the people we serve

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What has healthcare become?

• A product
• Why should they CHOOSE us?
• Intolerant of excuses

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Its not just about getting there!

• Its about hanging on to it
• Can we sustain our outcomes
• Today
• Tomorrow
• Next Year?

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Quality Continuum

• Difference between
• QA
• QI
• PI

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Let me help ?

• Point out your Q
• Give yourself CMH credit

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PACE Cycle

• Structured model for quality and performance
  improvement
• Focuses on methodically working through a series
  of steps to create or improve a process until the
  desired outcome is achieved

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• P Plan to create improvement
• A Act to carry out the plan
• C Check to see if we are achieving the desired
  results
• E Enhance the plan and approach to hold the
  improvement and strive for continuous improvement

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Working to Plan, Act, Check Enhance

• 1st plan may not be the best plan
• All initial plans viewed as a draft that will be
  completed as it is tested and refined
• Once a plan is in motion, it will generally go
  through a series of revisions to make it the BEST
  plan possible

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Will we be Successful?

• Largely dependent on how comprehensive and
  effective the activities are that led up to the
  plan
• When Finding start _at_ root
• Dont treat symptoms
• The resulting corrective action plan simply
  becomes an activity to control the symptom rather
  than an activity to improve the process

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Success continued

• When symptom control becomes the focus, the
  corrective plan frequently adds complexity to the
  process
• AND
• Requires a higher level of resources over time to
  sustain the outcome

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Success continued

• How well critical ingredients come together to
  turn the plan into a reality
• Besides root treating symptom
• Developed using a multidisciplinary approach
  not the result of functional silo thinking?

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Success continued

• Does topic and plan address something that
  supports the department or CMHs mission/vision
  avoid topics that have superficial value to
  strengthening pt care or operations?
• Does the plan include all the right people
  support necessary to make the plan happen?

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Give Radiology Medical Record Example Victims
Villains Heroes All must own plan in order
for it to work. If quality plan, neither will
like it but will be able to talk to each other
about how plan will/will NOT work My Purpose
not resident problem solver of CMH nor negotiator
of deals between conflicting departments. TANGENTS
Just b/c Med-Rec collects data should be
timeliness of dictation, mis-filed records,
etc Occurrence reporting, not Med-Rec
responsibility
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• In Organizing, Clarifying and Identifying, the
  steps of effective process improvement activities
  are important to understand.
• The goals are to have a clear understanding of
  where the activity is at the current moment in
  time and the performance that will yield the
  desired outcomes.

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Organize, Clarify Identify

• The goal is NOT to cosmetically dress a process
  up to make it look the best it can.
• The goal is to drive a meaningful level of actual
  improvement into the process to create meaningful
  and sustainable improvement.

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Now, about these Calendars

• Greatest challenge we face
• Easy tool
• Organizes