NCST QI Training presentation and TB clinics using MUAC or BMI within 3 months • At Nyungwe health...

NCST QI Training July 2014

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NCST TRAINING MODULE 6

Managing Quality of NCST Services

July 2014

USAID Applying Science to Strengthen and Improve Systems

Module Objectives

• Explain the concept of quality improvement in NCST

• Describe the quality improvement approach in NCST

• Discuss the process of integration using the improvement model; ‘Plan, Do, Study, Act (PDSA) approach

• Develop an action plan for implementation for the first three steps

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What is meant by Quality?

What do you understand by quality?

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Quality - Simply Stated

• Quality is the measure of how well a product or service matches a need, Langley et. al

– Making sure we are doing the right things at the right time for every client, every time

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Quality improvement and Quality Assurance

• Quality improvement: is an approach that tests promising changes in health care processes with the goal of improving health outcomes and systems performance.

• Quality Assurance: refers to the oversight process, including the adherence to standards and guidelines

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Difference between QA and QI

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Quality AssuranceFull cycle of activities and systems for

maintaining the quality of patient care.Generally associated with the monitoring of

compliance with standards.Quality Improvement

The combined and unceasing efforts of everyone—healthcare professionals, patients

and their families, researchers, payers, planners and educators—to make the changes that will

lead to better patient outcomes (health), better system performance (care), and better

professional development

Batalden, Paul B., and Frank Davidoff. "What is "Quality Improvement" and How Can It Transform

Healthcare?" Quality and Safety in Health Care 16.1 (2007): 2-3


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What is the problem?

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“The reality is straightforward. The power of existing interventions is not matched by the power of health systems to deliver them to those in greatest need, in a comprehensive way, and at an adequate scale.”

—Margaret ChanDirector General

World Health Organization


Principles of Quality Improvement

1. Client focus

2. Understanding work as processes and systems

3. Testing changes to know what works and emphasizing the use of data for making decisions

4. Teamwork

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Client Focus

• Services should be designed to meet the needs and expectations of clients and community.

• Dimensions of clients focused care

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Dimensions of Quality improvement

• Safety

• Effectiveness

• Patient Centeredness

• Timeliness and continuous

• Efficiency

• Equity

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Understanding Work as Processes and Systems

• Providers must understand the service system and its key service processes in order to improve them.

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Understanding Work as Processes and Systems

• A process is defined as a sequence of steps through which inputs are converted into outputs.

• A system is defined as the total of all the elements (including processes) that interact together to produce a common goal or outcome

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Model of a system

Resources necessary to carry out a process

Inputs

A series or sequence through which inputs are transformed into outputs

Process

The sum of all elements (including processes) that interact together to produce a common goal

Quality Improvement

The outputs (services/products) and outcomes (health outcomes) result from the inputs & processes

Outcomes

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Inputs(Resources)

• People• Equipment• Supplies• Infrastructure• Information• Technology

Processes (Activities)

• What is done?

• How it is done?

Outcomes (Results)

• Health services delivered

• Change in health behavior

• Change in health status

• Client satisfaction

Quality from a systems view

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Source: Donabedian (1980)


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Steps to standard NCST care

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Linkage with community EC/L/FS support

Linkages are established between

Assessment

All HIV and TB patients

are assessed at each clinic

Classification

Nutrition status is

recorded on the care card for each HIV-

infected patient

Counselling

All HIV-infected patients receive

counselling

Nutrition care plans and support

All malnourished patients are

provided with supplementary

food and therapeutic

foods

Follow up and referral

All patients on care plans

receive follow up and

referral within services

Linkage with community

EC/L/FS support

Linkages are established

between

Health Education

All HIV patients receive health

education on nutrition and hygiene


Testing Changes and Emphasizing the Use of Data

• Solutions are tested in order to determine whether they yield the required improvement.

• Data are used to analyze processes, identify problems, and to determine whether the changes have resulted in improvement.

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Teamwork

• Improvement is achieved through the team approach to problem solving and quality improvement.

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Why is teamwork important for improvement?

• Healthcare processes consist of inter-dependent steps that are executed by different people

• Quality faults often occur in the hand-overbetween people

• Given the opportunity, staff can often identify problems and generate ideas to resolve them.

• Participation improves ideas, increases buy-in, and reduces resistance to change.

• Accomplishing things together increases the confidence of each team member, which empowers organizations

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Quality Improvement Methodology

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Adapted from:T. Nolan et. al.

The QualityImprovement Guide



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STEP 1. Identify the problem• Identifying the area to improve• Clearly define the aim for improvement• Decide who should be on the team that will

solve the problem• Achieve a consensus on the problem by the

team

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Identify areas for improvement

• Patient complaints

• Routine patient treatment data, program monitoring indicators, direct observation

• Use of problem identification index

Prioritize critical problems

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Patient Receptionist Nurse Physician Lab technician Specialist Patient

Patient arrives

Patient leaves

Registration Take temperature

Doctor’s Exam

Collect Tests

Specialist’s Exam

Patient Arrives

Registration Take Temperature

Doctor’s Exam

Collect Tests Specialists Exam

Patient Leaves

Form a Team

Who would be on your team?

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Creating good QI teams

• Keep the team to a reasonable size - not too big (7-9 members)

• Team members who want to contribute –take really motivated people

• Helpful to involve reluctant persons too

• Look to involve a champion

• Remember leaders and managers


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Developing an Aim Statement

• An aim statement guide teams to define their focus areas and what they want to achieve over s specific period

A good aim statement must have:• A defined boundary that specifies the scope of

the improvement goal • Specific numerical goals for outcomes that

are ambitious but achievable• A timeframe (how much improvement by

when?)• Guidance on how the aim will be achieved

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Examples of Aim Statements

• We will improve the delivery of nutritional services for HIV clients

• At Phimbi Health Centre , we will assess and categorize every client who visits the ART, PMTCT and TB clinics using MUAC or BMI within 3 months

• At Nyungwe health Centre, we will reduce the default rate from 12% to 0% from January 2014 to June 2014, by following up patients who miss appointments

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STEP 2. Analyze the problem• Understand the process(es)/ system that yield

this goal for improvement• Conduct cause and effect analysis• Determine the indicators which enable us to

know that we have made the improvement we are seeking

• Analyze the available data and information• Collect additional data (as needed)

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How could process

mapping be useful for improving services?

• Make the process clear and understandable

• Reduce complexity

• Eliminate unnecessary steps

• Avoid extra work and re-work

• Rationalize the steps of the process

• Reduce waste

Why?

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Process mapping: Flow diagram

Process mapping used to help teams understand how their work relates to others


How to create & use a Flowchart in understanding a system/process

1. Decide on the beginning and end points of the process to be flowcharted

2. Identify the steps of the process

3. Link the steps with arrows showing direction

4. Review the draft to see whether the steps are in their logical order

Follow instructions on appendix 6 to develop a flow chart

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Begin or End

Step

Decision

Delay

Cloud (unclear step)

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Document

Storage

Flow lines

Connectora

How to Create a Process Flowchart:Symbols of a flow chart


NO

YESDecision

One flow line

out of a step

Two flow lines out of a

decision

Must ask a yes / no

question

How to Create a Process Flowchart:Flow lines

Step

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Cause and effect analysis

• Conducted to understand possible cause of the problem.

• The cause and effect analysis is done by asking ‘five whys? or by drawing a fishbone diagram

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Fishbone diagram

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Effect

p p p g pstaff/providers, resources/equipment, process/procedure, patients, guidelines/policies


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Measuring Improvement

• If you don’t measure what you are doing, how will you know if it an improvement, or what led to improvement?

• Indicators are used to measure improvement

• Should be linked to aims, be used to guide improvement and test changes and be integrated into the team’s daily routine

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Types of Indicators

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Patient moves through systemPatient arrives

Short-Term Result

Long-Term Result

Input Indicators

Process Indicators

OutputIndicators

OutcomeIndicators

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# of staff trained in nutritional

assessments

# of HIV positive

clients that received

nutritional assessments

% compliance with assessment guidelines

Proportion of HIV positive clients with nutritional assessment

Proportion of HIV positive clients that received NACS

Reduction in mortality due to malnutrition


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Qualities of a good indicator

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• Clear and unambiguous (teams should not confuse what is meant by the indicator

• Quantifiable

• Identifies the source of the data and the person responsible for collecting it

• Identifies a clear numerator and denominator

• Identifies the frequency with which the data should be collected


Example of an indicator

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• Indicator: proportion of clients assessed and categorized

• Numerator: Number of clients assessed

• Denominator: Total number of clients visiting the PMTCT, ART and TB clinic

• Source: Assessment registers

• Person responsible: Data clerk at ART, nutrition focal persons at TB and ART

• Frequency: Monthly


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Exercise: Developing an indicator

Select/ develop the indicator for the aim statement you developed

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Analyzing data Variation

• Data is used continuously to – To identify gaps in service,

– To test changes to see whether they lead to improvement

– For decision making

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0%

20%

40%

60%

80%

100%

Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Proportion of patietns assessed and categorised at Kaporo Rural Hospital, Jan13- Mar14


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Plotting a time series chart

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• Clear and well defined title on top of the graph that includes when and what we are measuring

• X and Y axis have clear scale and include indicator label

• Numerator and denominator values shown for each month

• Numerator should ne defined including data source and sampling strategy

• Denominator should be defined including data source and sampling strategy


Elements of a time series chart

Jan FebMar

AprMay

Jun Jul Aug Sep OctNov

Dec14‐Jan

14‐Feb

14‐Mar

# seen 606 641 448 390 627 935 12171309114515721047112112031134 900

# assessed 4 0 208 177 525 758 951 1309114515721047112112031134 900

% assessed 1% 0% 46% 45% 84% 81% 78% 100 100 100 100 100 100 100 100

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of clients

Results of assessment and categorization at Kalembo H/C, Jan13‐Mar 14

HSAs at TB and maids at PMTCT not always available

Re allocate ART counsellor toPMTCT and assigned TB officer to assess

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X and Y axes have clear scale and

include indicator label

Numerator defined, including data

source and sampling strategy

Numerator and denominator

values shown for each month

Denominator defined, including data source and

sampling strategy

Tested changes are annotated

Clear defined title that includes what, where and when


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The QI model

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Step 3: Developing Changes • Develop possible changes (interventions) we

believe may yield improvement• Organize changes according to importance and

practicality • What change can you make?• How will it work?• What improvement will we expect to see as a result

of this change• What do you think the result will be?

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Testing and implementing changes

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Testing changes- Plan

• How will change be done?

• Who will do it?

• Where will it happen?

• When will it happen?

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Testing Changes - Do

Implement the plan/solution

• Test BIG changes on an initially small scale, then ramp up

– Focus on learning rather than planning and thinking

• Test individual changes separately when possible

• Document any changes

• Negative results are an opportunity to learn47


Testing Changes - Study

• Review the data and plot on a chart

• Review other qualitative evidence surrounding the qualitative data

• What do the results tell us?

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Testing Changes - Act

Analysis

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Did the change lead to an improvement?

ABANDONDevelop and testother changes

No

Yes

Is the change significant?

MODIFYthe changeand conductanother test

ADOPTKeep the changeDevelop newchanges

No Yes


Monitoring QI activities

• Data collection tools– NCST Assessment Register

– NCST treatment register

• Reporting tools– NCST Monthly Report form

• QI documentation Journal

• QI team Building – SOW for QI teams

– Guide to achieving high performance QI teams

– QI team maturity index

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NCST QI Training presentation and TB clinics using MUAC or BMI within 3 months • At Nyungwe health...

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