Quality Management for Community Health Centers · 2016. 7. 17. · Patient Satisfaction Outcomes...

Quality Management for Quality Management for Community Health CentersCommunity Health Centers

sponsored by sponsored by

The National Association ofThe National Association of

Community Health CentersCommunity Health Centers

presented bypresented by

Jay M.Hughes MD, FACPJay M.Hughes MD, FACP

Ambulatory Innovations, Inc.Ambulatory Innovations, Inc.

11

The Plan

The Plan

••First Session

First Session: Overview of quality in

: Overview of quality in

Health Centers

Health Centers

••Second Session

Second Session: Teaching Quality

: Teaching Quality

management

management

••Third Session

Third Session: Practicing quality

: Practicing quality

management training

management training

22

CQI

Pers

onal

Appro

pri

ate

Eff

icie

nt

Reliable

Unre

liable

Appro

pri

ate

, Eff

icie

nt,

R

eliable

,

INTEG

RA

TED

!

Process Swamp Process Utopia

QU

ALIT

Y

Today T

om

orr

ow

33

THE SOUL OF

THE SOUL OF

QUALITY IS THE

QUALITY IS THE

NEVER ENDING

NEVER ENDING

EFFORT TO

EFFORT TO

IMPROVE

IMPROVE

44

ALL W

ORK IS A PROCESS

ALL W

ORK IS A PROCESS

R E Q U I R E M E N T

(SA

TIS

FA

CTIO

N)

OU

TPU

T

(OU

TCO

MES)

PR

OCESS

(EFFIC

IEN

CY)

SUPPLIER CUSTOMER

R E Q U I R E M E N T S


INPU

TS

55

MEASUREMENT

MEASUREMENT


SA

TIS

FA

CTIO

N

OU

TPU

T

OU

TCO

MES

PR

OCESS

EFFIC

IEN

CY

SUPPLIER CUSTOMER



INPU

TS

66

LEADERSHIP!

LEADERSHIP!

MEASUREMENT


SA

TIS

FA

CTIO

N

OU

TPU

T

OU

TCO

MES

PR

OCESS

(EFFIC

IEN

CY)

SUPPLIER CUSTOMER



INPU

TS

V I S I O N 77

Test

ing

Tre

atm

ent

Pat

ient

P

roce

sses

Ana

lysi

s

H&

P

Ana

lysi

s

Dia

gnos

ticR

esul

ts

Tre

atm

ent

Dec

isio

ns

Dia

gnos

isU

ntre

ated

P

rogn

osis

P A T I E N T

O U T C O M E

TH

E H

EA

LTH

CA

RE

HO

LO

GR

AM

DIA

GN

OS

TIC

CA

RE

TH

ER

AP

EU

TIC

INS

TIT

UT

ION

AL

SU

PP

OR

T

PR

OC

ES

SE

S

CL

INIC

AL

SU

PP

OR

T

Hou

seke

epin

g,

Hum

an R

esou

rces

, P

urch

asin

g,

Cen

tral

Sup

ply,

et

c.

88

Toward a Definition of Quality

Toward a Definition of Quality

••Health Centers have not defined quality

Health Centers have not defined quality

••You m

ust first define quality if you want

You m

ust first define quality if you want

quality

quality

99

The Two

The Two--M

inute Quality Drill

Minute Quality Drill

••The two m

inute proof of quality for my

The two m

inute proof of quality for my

Center:

Center:

1010

Ambulatory Quality

•Patient Satisfaction 23%

•Quality Assurance Program 21%

•Outcomes

13%

•Provider Staff Performance 9%

•Medical Records

8%

11

A F

unct

iona

l Def

initi

on o

f A

Fun

ctio

nal D

efin

ition

of

Qua

lity

Qua

lity

Qua

lity

is th

e de

gree

of e

xcel

lenc

e of

a

Qua

lity

is th

e de

gree

of e

xcel

lenc

e of

a

heal

thca

re o

rgan

izat

ion’

s 1)

pro

cess

es,

heal

thca

re o

rgan

izat

ion’

s 1)

pro

cess

es,

2) p

ract

ition

er a

nd s

uppo

rt s

taff

2) p

ract

ition

er a

nd s

uppo

rt s

taff

perf

orm

ance

, 3 )

deci

sion

s, a

nd 4

) pe

rfor

man

ce, 3

)de

cisi

ons,

and

4)

hum

an in

tera

ctio

ns.

hum

an in

tera

ctio

ns.

––D

ale

Ben

son,

MD

Dal

e B

enso

n, M

D

1212

A Q

ualit

y M

anag

emen

t A

Qua

lity

Man

agem

ent

Def

initi

on o

f Qua

lity

Def

initi

on o

f Qua

lity

Qua

lity

is d

oing

the

Qua

lity

is d

oing

the

right

thin

grig

ht th

ing,,

right

right

,,th

e fir

st ti

me

and

ever

y tim

e.th

e fir

st ti

me

and

ever

y tim

e.

--P

hilip

B. C

rosb

yP

hilip

B. C

rosb

y__

____

____

____

____

__

1313

The

Thr

ee S

trat

egic

Res

ults

of

The

Thr

ee S

trat

egic

Res

ults

of

Qua

lity

Qua

lity

1) P

atie

nt (

cust

omer

) S

atis

fact

ion

1) P

atie

nt (

cust

omer

) S

atis

fact

ion

2) P

roce

ss O

utco

mes

2) P

roce

ss O

utco

mes

3) P

roce

ss E

ffici

ency

3) P

roce

ss E

ffici

ency

Vis

ion:

“W

orld

Cla

ss”

Vis

ion:

“W

orld

Cla

ss”

1414

Pat

ient

Sat

isfa

ctio

nP

atie

nt S

atis

fact

ion

��W

hat i

s it?

Wha

t is

it?

“The

deg

ree

to w

hich

the

“T

he d

egre

e to

whi

ch t

he h

ealth

he

alth

ca

re s

ervi

ces

care

ser

vice

san

d th

e re

sulti

ng

and

the

resu

lting

he

alth

sta

tus

heal

th s

tatu

spl

ease

or

mee

t the

pl

ease

or

mee

t the

ex

pect

atio

ns

expe

ctat

ions

(re

quire

men

ts?)

(req

uire

men

ts?)

of

of

the

patie

nt.”

the

patie

nt.”

1515

How

to L

ook

at S

atis

fact

ion

How

to L

ook

at S

atis

fact

ion

1) A

men

ities

of C

are

(S

truc

ture

)1)

Am

eniti

es o

f Car

e (

Str

uctu

re)

2) A

rt o

f Car

e (

Pro

cess

)2)

Art

of C

are

(P

roce

ss)

3) R

esul

ts o

f Car

e (O

utco

me)

3)

Res

ults

of C

are

(Out

com

e)

1616

Structure, Process, Outcome


Approach to Patient Satisfaction

Approach to Patient Satisfaction

••Amenities of Care: Appointm

ent availability,

Amenities of Care: Appointm

ent availability,

privacy, comfort, waiting time.

privacy, comfort, waiting time.

••Art of Care: Listening carefully, giving

Art of Care: Listening carefully, giving

thorough explanations, treating with respect.

thorough explanations, treating with respect.

••Results of Care: Decreased symptoms,

Results of Care: Decreased symptoms,

increased ability to function.

increased ability to function.

1717

World Class Quality:


Patient Satisfaction


••Patient compliance

Patient compliance

••Curing

Curing vsvs. healing

. healing (of Human Hurts)

(of Human Hurts)

••“Satisfied, Delighted, Dazzled”

“Satisfied, Delighted, Dazzled”

1818

Satisfied: W

e m

eetour patients’ expectations.

Delighted: W

e exceed our patients’

expectations.

Dazzled: W

e so greatly exceedour patients’

expectations that what we do actually contains

an element of surprise.

WORLD

CLASS:PATIENT

SATISFACTION

1919

Our World Class Vision:




Our world class vision should be that

Our world class vision should be that

our patients are

our patients are always satisfied

always satisfied, often

, often

delighted,

delighted,and sometimes even

and sometimes even dazzled.

dazzled.

2121

Outcomes

Outcomes

What are they?

What are they?

––Measures of effectiveness

Measures of effectiveness

––What patients want

What patients want (and need)

(and need)

––The essence of quality

The essence of quality

2222

How to Look at Outcomes

How to Look at Outcomes

••Disease

Disease--Specific vs. General Health

Specific vs. General Health

••Measure one outcome indicator at a time

Measure one outcome indicator at a time

i.e. Classical health m

easures,

i.e. Classical health m

easures,

Functionality,

Functionality,

Cost, in addition to Satisfaction)

Cost, in addition to Satisfaction)

2323



Outcomes

Outcomes

••Focus on outcomes

Focus on outcomes

••Meeting the “needs” of our patients

Meeting the “needs” of our patients

••“Defined, Measurable, Spectacular”

“Defined, Measurable, Spectacular”

2424



Outcomes

Outcomes

Our world class vision should be that the

Our world class vision should be that the

health outcomes for our patients are

health outcomes for our patients are

defined, measurable and spectacular.

defined, measurable and spectacular.

2525

Efficiency

Efficiency

What is it?

What is it?

––Making the best use of available

Making the best use of available

resources

resources

––Doing the appropriate

Doing the appropriate

(right)

(right)thing right

thing right

2626

How to Look at Efficiency

How to Look at Efficiency

••Clinical

Clinicalefficiency

efficiency (the right thing,)

(the right thing,)

“If care is not necessary, it is bad care.”

“If care is not necessary, it is bad care.”

––A

lan K

orn

, M

DA

lan K

orn

, M

D

••Production

Productionefficiency

efficiency (right,)

(right,)

“Elim

inate the 30

“Elim

inate the 30--40% of waste, duplication and

40% of waste, duplication and

rework

rework””

2727



Efficiency

Efficiency

••Creates customer satisfaction

Creates customer satisfaction

••Creates cost savings

Creates cost savings

••Creates healthier patients

Creates healthier patients

••“Breathtaking”

“Breathtaking”

2828



Efficiency

Efficiency

Our world class vision is that we provide

Our world class vision is that we provide

health care services with

health care services with breathtaking

breathtaking

efficiency.

efficiency.

2929

The Impact of Quality

The Impact of Quality

••Patient satisfaction

Patient satisfaction

••Recruitment and

Recruitment and

retention

retention

••Staff m

orale

Staff m

orale

••Productivity

Productivity

••Healthier patients

Healthier patients

••Healthier

Healthier

communities

communities

••Bottom line

Bottom line

3030

Quality as a Marketing Edge

Quality as a Marketing Edge

••Measurements

Measurements

••Accreditation

Accreditation

••HEDIS

HEDIS

••The Three Strategic Results***

The Three Strategic Results***

3131

Leadership & Quality

Leadership & Quality

••Must

Must understand

understandquality

quality

••Must “

Must “talk and walk

talk and walk” quality

” quality

(Empowerm

ent)

(Empowerm

ent)

••The role of the Governing Board

The role of the Governing Board

3232

Quality Assessment /

Quality Assessment /

Quality Improvement

Quality Improvement

••Quality assessment: a carefully planned

Quality assessment: a carefully planned

and structured system to

and structured system to m

onitor

monitorthe level

the level

of quality in the organization.

of quality in the organization.

••Quality improvement: a carefully planned

Quality improvement: a carefully planned

and structured approach to

and structured approach to improve

improve

the

the

level of quality in the organization.

level of quality in the organization.

3333

The Role of

The Role of

Quality Assessment

Quality Assessment

••The changing language of quality

The changing language of quality

••The need to continuously m

onitor

The need to continuously m

onitor

perform

ance, outcomes, satisfaction

perform

ance, outcomes, satisfaction

(entropy vs improvement)

(entropy vs improvement)

••The need for structure and

The need for structure and

comprehensiveness

comprehensiveness

3434

The Ambulatory Care

The Ambulatory Care

Parameters

Parameters

••Provider Staff

Provider Staff

Perform

ance

Perform

ance

••Support Staff

Support Staff

Perform

ance

Perform

ance

••Continuity of Care

Continuity of Care

••Medical Record System

Medical Record System

••Patient Risk Minimization

Patient Risk Minimization

••Patient Satisfaction


••Patient Compliance

Patient Compliance

••Access to Care

Access to Care

••Appropriateness of

Appropriateness of

Service

Service

••Organizational

Organizational

Perform

ance

Perform

ance

3535

Indicator Development Guide

Indicator Development Guide

••Parameter:

Parameter:

••Aspect of Care:

Aspect of Care:

••Indicator:

Indicator:

••Perform

ance or Effectiveness Goal:

Perform

ance or Effectiveness Goal:

••Quality Action Point:

Quality Action Point:

••Data Source:

Data Source:

••Frequency of Review:

Frequency of Review:

••Management Responsibility:

Management Responsibility:

3636

Approaches to

Approaches to

Quality Assessment

Quality Assessment

••Internal

Internalprogram development

program development

••External

Externalprogram availability

program availability

((HCFA, HEDIS, JCAHO)

HCFA, HEDIS, JCAHO)

3737

Quality Improvement (QI)

Quality Improvement (QI)

••Measurement is key

Measurement is key Identifies

Identifies

“Opportunities for Im

provement”

“Opportunities for Im

provement”

••QI as a result of a quality assessment

QI as a result of a quality assessment

program

program

••Understand!

Understand! ––then act

then act

3838

Total Quality Management


(TQM)

(TQM)

••A redirected m

anagement and quality

A redirected m

anagement and quality

philosophy

philosophy

••A patient (customer) focused culture

A patient (customer) focused culture

••The scientific method applied to

The scientific method applied to

improving health care processes

improving health care processes

3939

The Components of TQM

The Components of TQM

••Aim

Aim (Vision)

(Vision)

••A Customer Focus

A Customer Focus

••A Quality Foundation

A Quality Foundation

••Leadership &

Leadership &

Management

Management

••Empowerm

ent

Empowerm

ent

••Training &

Training &

Retraining

Retraining

••Psychology

Psychology

••Benchmarking

Benchmarking

••Quality Assessment

Quality Assessment

& Accreditation

& Accreditation

••Communication

Communication

••Continuous Quality

Continuous Quality

Improvement

Improvement

(CQI)

(CQI)

4040

Role of Leadership in the

Role of Leadership in the

TQM Organization

TQM Organization

••Talk the talk

Talk the talk

••Walk the walk

Walk the walk

••Persevere

Persevere

4141

LEADERSHIP COMMENTS

LEADERSHIP COMMENTS

“ The single greatest predictor of which

organizations will have successful quality

processes and which ones will fail is

whether or not the CEO participates. One

must be fully behind it. One m

ust be out

there participating and visibly involved.”

Peter H. Levine, MD

President and CEO

The Medical Center of Central Mass.

4242

LEADERSHIP COMMENTS

LEADERSHIP COMMENTS

“People take quality just as seriously as

management takes it ---no m

ore.”

Philip B. Crosby,

“Quality is Free”

“All employees are boss watchers”

Tom Peters

“Thriving on Chaos”

4343

What is Reengineering?

What is Reengineering?

••A m

ethod of revamping work processes

A m

ethod of revamping work processes

for dramatic improvements in productivity

for dramatic improvements in productivity

and quality.

and quality.

••Redesigning the patient experience to

Redesigning the patient experience to

achieve competitive advantage.

achieve competitive advantage.

(i.e. Patient Visit Redesign Collaborative)

(i.e. Patient Visit Redesign Collaborative)

4444

Why Reengineering?

Why Reengineering?

••Response to transform

ational change

Response to transform

ational change

vsvs. response to incremental change

. response to incremental change

••The

The“BPHC imperative”:

“BPHC imperative”:

Cente

rs “

need t

o d

iscover

new

ways

to

Cente

rs “

need t

o d

iscover

new

ways

to

opera

te e

ffic

ientl

y a

nd e

ffecti

vely

.”opera

te e

ffic

ientl

y a

nd e

ffecti

vely

.”

(i.e. IHI breakthrough collaboratives)

(i.e. IHI breakthrough collaboratives)

4545

When to do Reengineering

When to do Reengineering

••Global understanding of TQM within the

Global understanding of TQM within the

organization

organization

(Entropy > CQI > Reengineering)

(Entropy > CQI > Reengineering)

••People become impatient=passion

People become impatient=passion

(The Apollo Project)

(The Apollo Project)

4646

Characteristics of Reengineering

Characteristics of Reengineering

••Dramatic Im

provements

Dramatic Im

provements

••Minimized Handoffs

Minimized Handoffs

••Empowered Front

Empowered Front--liners

liners

••Organization W

ithout “W

alls”

Organization W

ithout “W

alls”

4747

The Reengineering How

The Reengineering How

••Vision/Purpose

Vision/Purpose

••Empowerm

ent

Empowerm

ent

••Commitment

Commitment

4848

Outcomes in Ambulatory Care

Outcomes in Ambulatory Care

“Outcomes are those

“Outcomes are those changes

changes, either

, either

favorable or adverse, in the actual or

favorable or adverse, in the actual or

potential

potential health status

health statusof of persons, groups,

persons, groups,

or communities

or communitiesthat can be

that can be attributed to

attributed to

prior or concurrent care.”

prior or concurrent care.”

––D

onabedia

nD

onabedia

n

4949



••Structure

Structure: The “component parts” of

: The “component parts” of

the settings in which care is provided.

the settings in which care is provided.

••Process

Process: W

hat practitioners and other

: W

hat practitioners and other

staff m

embers do in order to provide

staff m

embers do in order to provide

care for patients.

care for patients.

••Outcome

Outcome: A change in health status

: A change in health status

(for better or for worse) that can be

(for better or for worse) that can be

attributed to the care being assessed.

attributed to the care being assessed.

5050

Pat

ien

tO

utc

om

e

Team

Inte

ract

ion

O

ther

Car

egiv

ers

Nur

se C

are

Pro

toco

ls -

Gui

delin

es

Phy

sici

an C

are

Gov

erna

nce

P

harm

aceu

tical

sM

edic

al E

quip

men

t

Acc

ess

Man

agem

ent

S

uppo

rt S

ervi

ces

(App

oint

men

tsy

stem

)S

ocia

l Pol

icy Pat

ien

tC

omm

unity

JCA

HO

. QI i

n A

mb

ula

tory

Car

e 1

994

Ou

tco

me

-A P

rod

uct

of

M

any

Cau

ses

j

j5151

The Quality Interface

The Quality Interface

••Outcomes are

Outcomes are indirect

indirectmeasures of quality.

measures of quality.

••“Outcomes are not direct m

easures of quality.

“Outcomes are not direct m

easures of quality.

They only provide screens and flags that are

They only provide screens and flags that are

warning signals.”

warning signals.”

––JC

AH

OJC

AH

O

(This

refe

rs t

o

(This

refe

rs t

o P

ati

ent

Pati

ent

Outc

om

es

Outc

om

es--

JH)

JH)

5252

PROCESS OUTCOMES /

PROCESS OUTCOMES /

PATIENT OUTCOMES

PATIENT OUTCOMES

PAT

IEN

T

OU

TC

OM

ES

Dis

ease

S

pec

ific

Gen

eral

Per

form

ance

Sat

isfa

ctio

n

Output

Input

Patient

Process

Healthcare

Process

Psycho

Socio

Physio

logic

al

5353

Four Types of Outcomes

Four Types of Outcomes

••Disease

Disease--Specific Outcomes

Specific Outcomes

••General Health Outcomes

General Health Outcomes

••Patient Perform

ance Outcomes

Patient Perform

ance Outcomes

••Patient Satisfaction Outcomes

Patient Satisfaction Outcomes

••(Cost?)

(Cost?)

5454

Disease


Specific Outcomes

••Relate to a particular disease or physical,

Relate to a particular disease or physical,

mental, or social pathology.

mental, or social pathology.

••Can pertain to physiologic, microbiologic,

Can pertain to physiologic, microbiologic,

biochemical, or physical findings.

biochemical, or physical findings.

••Also include reported symptoms or

Also include reported symptoms or

feelings that have clinical significance.

feelings that have clinical significance.

5555

Types of

Types of

Disease


Specific Outcomes

••Level One

Level One: Biochemical, m

icrobiologic,

: Biochemical, m

icrobiologic,

or physiologic change.

or physiologic change.

••Level Two

Level Two: Change in symptoms or

: Change in symptoms or

signs.

signs.

5656



••Relate to quality of life, well being, ability

Relate to quality of life, well being, ability

to function, ability to engage in usual

to function, ability to engage in usual

activities, independence.

activities, independence.

••A global health status measure.

A global health status measure.

5757

Types of

Types of



••Level Three

Level Three: Ability to Function

: Ability to Function

••Level Four

Level Four: Sense of Well Being

: Sense of Well Being

5858

Patient Perform

ance Outcomes

Patient Perform

ance Outcomes

What the patient understands or does

What the patient understands or does

as a result of interaction with the health

as a result of interaction with the health

care system.

care system.

5959

Types of

Types of

Patient Perform

ance Outcomes

Patient Perform

ance Outcomes

••Patient Understanding

Patient Understanding

The degree of knowledge relevant to illness or

The degree of knowledge relevant to illness or

healthful living.

healthful living.

••Patient Compliance

Patient Compliance

Adherence to health care regimens. Changes in

Adherence to health care regimens. Changes in

health related habits.

health related habits.

6060



““Patient satisfaction occupies a special position

Patient satisfaction occupies a special position

in the array of outcomes because it is 1) partly a

in the array of outcomes because it is 1) partly a

factor in improving future care, and 2) partly a

factor in improving future care, and 2) partly a

legitimate objective of current care, and 3)

legitimate objective of current care, and 3)

partly a judgment by the patient on the quality

partly a judgment by the patient on the quality

of care, with particular reference to its outcomes

of care, with particular reference to its outcomes

and amenities as well as the nature of the

and amenities as well as the nature of the

client’s relationship with the practitioner.”

client’s relationship with the practitioner.”

––D

onabedia

nD

onabedia

n

6161

Types of Patient Satisfaction

Types of Patient Satisfaction

Outcomes

Outcomes

••Amenities of Care (Structure)

Amenities of Care (Structure)

••Art of Care (Process)

Art of Care (Process)

••Result of Care (Outcome)

Result of Care (Outcome)

6262

Process Results

Process Results

The result

The result (“output”)

(“output”) of a process.

of a process.

Examples of process results:

Examples of process results:

* Patient education documented

* Patient education documented

* Return appointm

ent given

* Return appointm

ent given

* Correct m

edication prescribed

* Correct m

edication prescribed

* Therapeutic blood level of medication

* Therapeutic blood level of medication

Name some non

Name some non--clinical process results

clinical process results

6363

Ambulatory Outcome Classification System

Ambulatory Outcome Classification System

Biochemical, Microbiologic, Physiologic

Biochemical, Microbiologic, Physiologic

Symptoms or Signs

Symptoms or Signs

Genera

l H

ealt

h O

utc

om

es

Genera

l H

ealt

h O

utc

om

es

Ability to Function

Ability to Function

Sense of Well Being

Sense of Well Being

Pati

ent

Perf

orm

ance O

utc

om

es

Pati

ent

Perf

orm

ance O

utc

om

es



Patient Compliance

Patient Compliance

Pati

ent

Sati

sfacti

on O

utc

om

es

Pati

ent

Sati

sfacti

on O

utc

om

es

Amenities of Care

Amenities of Care

Art of Care

Art of Care

Results of Care

Results of Care

Dis

ease

-Specific

Outc

om

es

6464

The Dynamics of Change

The Dynamics of Change

••The

The W

ork

Work

of Change

of Change

••The

The Threat

Threatof Change

of Change

••The

The Pain

Painof Change

of Change

6565

Part One

Part One: Overview of

: Overview of

Quality in Health Centers

Quality in Health Centers

••Toward an understanding of quality

Toward an understanding of quality

••Building a quality vision: The three strategic

Building a quality vision: The three strategic

results of quality

results of quality

••Im

pact of quality in Health Centers

Impact of quality in Health Centers

••Quality assessment; quality improvement

Quality assessment; quality improvement

••Total Quality Management


••Reengineering

Reengineering

••Outcomes in ambulatory care

Outcomes in ambulatory care

••The dynamics of change

The dynamics of change

6666

Agenda for tomorrow

Agenda for tomorrow

••Session One

Session One

8:00

8:00--8:50

8:50

••Session Two

Session Two

9:00

9:00--9:50

9:50

••Session Three

Session Three

10:10

10:10--11:00

11:00

••Session Four

Session Four

11:10

11:10--12:30

12:30

6767

The Eight Essential Concepts

The Eight Essential Concepts

••A working definition of quality

A working definition of quality

••Customer orientation; the “expectations gap”

Customer orientation; the “expectations gap”

••Cost of quality

Cost of quality --PONC

PONC

••Understanding process

Understanding process

••Measurement

Measurement

••Understanding variation

Understanding variation

••The 10

The 10--Step Process Improvement Method

Step Process Improvement Method

••Teamwork

Teamwork

6868

A W

orking Definition of Quality

A W

orking Definition of Quality

••“Quality is doing the

“Quality is doing the right thing

right thingright

right, the

, the

first time and every time.”

first time and every time.”

••“Quality m

eans

“Quality m

eans always

always

doing the

doing the

appropriate

appropriate

thing

thing efficiently

efficiently.”.”

6969

QUALITY

QUALITY

IS

CONFORMANCE TO

REQUIREMENTS

Philip B. Crosby

7070

ALL W

ORK IS A PROCESS

ALL W

ORK IS A PROCESS


SA

TIS

FA

CTIO

N

OU

TPU

T

OU

TCO

MES

PR

OCESS

(EFFIC

IEN

CY)

SUPPLIER CUSTOMER



INPU

TS

7171

Value

Value

“Doing the

“Doing the right thing

right thing

right

right, ,

the first time and every time

the first time and every time

--at the

at the

--least possible cost

least possible cost.”.”

7272

VALUE

VALUE

Value equals

Outcome + Service

Cost

(Do you agree?)

7373

Customer Orientation

Customer Orientation

and the

and the

“Expectations Gap”

“Expectations Gap”

••Internal and external customers

Internal and external customers

••Determ

ine customer requirements

Determ


••The supplier/customer “expectations

The supplier/customer “expectations

gap”

gap”

7474

Cost of Quality

Cost of Quality --PONC

PONC

••PONC: Price Of Non

PONC: Price Of Non--Conform

ance

Conform

ance

(What it costs to do things wrong)

(What it costs to do things wrong)

••Why PONC?

Why PONC?

••Calculating PONC

Calculating PONC

“As q

uality

goes u

p, cost

com

es d

ow

n”

“As q

uality

goes u

p, cost

com

es d

ow

n”

--Jay Hughes, MD

Jay Hughes, MD

7575

Understanding Process

Understanding Process

••“A process is an activity or a series of

“A process is an activity or a series of

activities that changes something.”

activities that changes something.”

••Elements of a process

Elements of a process

••Process thinking

Process thinking

7878

ALL

WO

RK

IS A

PR

OC

ES

S

HE

ALT

HC

AR

E

PR

OC

ES

S

O U T C O M E S

SU

PP

LIE

RC

US

TO

ME

R

INP

UT

S

TO

PR

OC

ES

S

(owner)

7979

“A process will produce exactly

“A process will produce exactly

what it is designed to produce;

what it is designed to produce;

no m

ore and no less.”

no m

ore and no less.”

Donald Berwick MD

Donald Berwick MD

8181

Medical Transcription

Medical Transcription

Charts by Day

Charts by Day

0510

15

20

25

30

35

40

45

50

55

60

M

W

F

T

T

M

W

F

T

T

M

W

F

Charts P

er D

ay

Goa

l

8282

Elements of a Process

Elements of a Process

••Something passed along

Something passed along

••A series of steps

A series of steps

••Inputs and outputs

Inputs and outputs

••Customers and suppliers

Customers and suppliers

••The owner

The owner

8383

Process Thinking (1)


••Every process can be understood and

Every process can be understood and

improved.

improved.

••Every problem has a cause, and it is

Every problem has a cause, and it is

usually related to the process.

usually related to the process.

••Every process can be m

apped out.

Every process can be m

apped out.

••Every process contains critical points

Every process contains critical points

which can be m

easured.

which can be m

easured.

8484

Flow Charting

Flow Charting

owner owner owner owner

EXERCISE:

“Regis

teri

ng a

pati

ent”

“Turn

ing o

n a

TV”

8585

Process Scoping

Process Scoping

owner owner owner owner owner

For the purpose of analysis

Initial Final

8787



••Every process will contain variation.

Every process will contain variation.

••“Tampering” results from improvement

“Tampering” results from improvement

attempts prior to real understanding.

attempts prior to real understanding.

••Those closest to the process are best

Those closest to the process are best

suited to understand and improve the

suited to understand and improve the

process.

process.

••Every process will have predefined

Every process will have predefined

process requirements.

process requirements.

8888

Measurement

Measurement

••“M

easurement is the voice of the process.”

“Measurement is the voice of the process.”

--W

illiam

Scherk

enbach

William

Scherk

enbach

••“All processes generate data that can be

“All processes generate data that can be

measured and m

onitored.”

measured and m

onitored.”

--D

onald

Berw

ick, M

DD

onald

Berw

ick, M

D

8989

Measurement Steps

Measurement Steps

••Identify the process

Identify the process

••Prioritize

Prioritize

••Choose an indicator

Choose an indicator

••Count

Count

••Communicate

Communicate

9090

Understanding Variation

Understanding Variation

••Variation happens. All processes have

Variation happens. All processes have

variation.

variation.

••Expect and understand variation.

Expect and understand variation.

••Common cause

Common cause vsvs. special cause variation.

. special cause variation.

••Avoid tampering.

Avoid tampering.

••Reduce variation as much as possible.

Reduce variation as much as possible.

9191

The Control Chart

The Control Chart

••Plot points.

Plot points.

••Should be at least 20 points.

Should be at least 20 points.

••Within 3 standard deviations

Within 3 standard deviations——

common

common

cause variation.

cause variation.

••Outside 3 standard deviations

Outside 3 standard deviations——

special

special

cause variation.

cause variation.

••Good and inexpensive software is

Good and inexpensive software is

available.

available.

9292

Common Cause Variation

Common Cause Variation

••Controlled variation.

Controlled variation.

••Causes of variation are built into the

Causes of variation are built into the

process.

process.

••Need to redesign the process in order to

Need to redesign the process in order to

reduce common cause variation.

reduce common cause variation.

9393

Special Cause Variation

Special Cause Variation

••Uncontrolled variation.

Uncontrolled variation.

••Variation is the result of forces from

Variation is the result of forces from

outside the process.

outside the process.

••Investigate special cause variation

Investigate special cause variation

immediately.

immediately.

9595

What is Tampering

What is Tampering

••Treating everything as a special cause.

Treating everything as a special cause.

••Trying to improve something without

Trying to improve something without

understanding it.

understanding it.

••Continual adjustment of a stable process

Continual adjustment of a stable process

(tampering) will increase process

(tampering) will increase process

variability and do m

ore harm

than good.

variability and do m

ore harm

than good.

••Most American m

anagers are adept at

Most American m

anagers are adept at

tampering.

tampering.

9797

The 10

The 10--Step

Step

Process Improvement Method

Process Improvement Method

1) Identify the problem

1) Identify the problem

2) Identify the process

2) Identify the process

3) Measure the problem

3) Measure the problem

4) Identify the

4) Identify the

customer(s)

customer(s)

of the process

of the process

5) Determ

ine customer

5) Determ

ine customer

requirements

requirements

6) Determ

ine possible

6) Determ

ine possible

causes of the

causes of the

problem

problem

7) Determ

ine possible

7) Determ

ine possible

solutions

solutions

8) Prioritize and choose

8) Prioritize and choose

one possible solution

one possible solution

9) Test and m

easure

9) Test and m

easure

the solution

the solution

10) Continue to m

onitor

10) Continue to m

onitor

the

theprocess

process

9898

The 10

The 10--Step

Step

Process Improvement Method (1)


••Identify the problem

Identify the problem

••Identify the process

Identify the process

••Measure the problem

Measure the problem

••Identify the customer(s) of the process

Identify the customer(s) of the process

••Determ


Determ


9999

The 10

The 10--Step

Step



••Determ

ine possible causes of the

Determ

ine possible causes of the

problem

problem

••Determ

ine possible solutions

Determ

ine possible solutions

••Prioritize and choose one possible

Prioritize and choose one possible

solution

solution

••Test and m

easure the solution

Test and m

easure the solution

••Continue to m

onitor the process

Continue to m

onitor the process

100

100

Cause and Effect Diagram


Patient

Provider

Inform

ation

Procedures

Materials

EFFECT

Inform

ation

Policies

101

101

102

102

103

103



Perform

ance

Standards

Training and

Knowledge

Facilities &

Equipment

Inform

ation

Procedures

Protocols

Protocols

Materials

EFFECT 10

410

4

CELEBRATE!!

CELEBRATE!!

105

105

If you haven’t got the time to

If you haven’t got the time to

do it right, when will you find

do it right, when will you find

the time to do it over?

the time to do it over?

106

106

Teamwork

Teamwork

••The secret for improving processes

The secret for improving processes

••Better mapping; better measuring; better

Better mapping; better measuring; better

ideas

ideas

••Stronger buy

Stronger buy--inin

••Balanced team representation

Balanced team representation**

107

107

The Quality Improvement

The Quality Improvement

Culture

Culture

••Visualize the new culture

Visualize the new culture

••Ensure absolute leadership commitment

Ensure absolute leadership commitment

••Practice constant reinforcement

Practice constant reinforcement

••“Plot points”

“Plot points”

••Involve everyone in the transform

ation

Involve everyone in the transform

ation

••Create heroes

Create heroes

108

108

Guidelines for Presentations

Guidelines for Presentations

••Determ

ine points to be m

ade

Determ

ine points to be m

ade

••Develop an outline of essential factors

Develop an outline of essential factors

relating to each point

relating to each point

••Practice m

aking the point

Practice m

aking the point

••Provide visual reinforcement for each

Provide visual reinforcement for each

point (handout)

point (handout)

••Involve the audience (questions,

Involve the audience (questions,

interactive discussion, etc.)

interactive discussion, etc.)

109

109

Our Health Center

Our Health Center

Culture of Quality (1)


••When something goes wrong, we ask

When something goes wrong, we ask

“why” rather than “who.”

“why” rather than “who.”

••We believe that every individual on our

We believe that every individual on our

staff is a worthwhile human being who will

staff is a worthwhile human being who will

always do his/her best.

always do his/her best.

••We build self respect and pride in a job

We build self respect and pride in a job

well done.

well done.

110

110

Our Health Center

Our Health Center



••We are continuously and relentlessly

We are continuously and relentlessly

improving.

improving.

••Our employees are empowered,

Our employees are empowered,

enthusiastic and proud.

enthusiastic and proud.

••Our patients are always satisfied, often

Our patients are always satisfied, often

delighted, and sometimes dazzled.

delighted, and sometimes dazzled.

111

111

Our Health Center

Our Health Center



••We know how to improve processes

We know how to improve processes

without tampering.

without tampering.

••Our walls are adorned with flow charts,

Our walls are adorned with flow charts,

data charts, and bold statements of our

data charts, and bold statements of our

Mission, Vision, and Values.

Mission, Vision, and Values.

••Achieving our goals is not good

Achieving our goals is not good

enough... W

e are not satisfied until we

enough... W

e are not satisfied until we

have achieved our full potential.

have achieved our full potential.

112

112

“A journey of a thousand

“A journey of a thousand

miles begins with a single

miles begins with a single

step.”

step.”

113

113

Process Model Worksheet*

Process Model Worksheet*

Quality Perform

ance Procedures

Standards

Protocols

INPU

TS

OU

TPU

T

(Custo

mer

Requir

em

ents

)

Equipment/ Training/

Facilities Knowledge

PROCESS

*Philip Crosby Associates

114

114

Quality Management for Community Health Centers · 2016. 7. 17. · Patient Satisfaction Outcomes...

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Transcript of Quality Management for Community Health Centers · 2016. 7. 17. · Patient Satisfaction Outcomes...