Continuous Quality Improvement1

Introduction

Continuous Quality Improvement (CQI) is an approach to quality management that uses data to analyze and improve service processes and outcomes. CQI uses the root causes of a problem to identify areas of improvement. In order to be successful, CQI should be integrated into the everyday flow of the program.

BMHS’ goal is to provide the framework for CQI. Once implemented, CQI will promote a culture where programs continuously seek to improve the quality of services for members. We hope programs incorporate a recovery-oriented, strengths-focused approach to this process, and engage staff, members and families in identifying opportunities for change.

Continuous Quality Improvement versus Quality Assurance

Quality Assurance (QA) and CQI are two points along the quality management continuum. QA assures that basic tenets of accountability and safety are followed and that negative outcomes are corrected, whereas CQI is aimed at improving processes and achieving better outcomes.

CQI QAFocus is on systems first and individual performers second. CQI aims to seek root causes in a process that can be improved rather than attribute blame.

Focus is on human error and identifying and eliminating outliers (poor performers).

Strives to ensure that policies, procedures, and protocols make sense and meet the current and evolving needs of members.

Strives to ensure that individuals are following their policies, procedures, and protocols.

Relies on teamwork between different stakeholders of the organization, as those closest to the problem usually have the best ideas about the solution. Incorporates evidenced-based care.

Relies on following the rules and policies of the organization to meet the standards required by regulatory and accrediting bodies.

Monitors improvement in quality of care through continuous review.

Monitors compliance through periodic audits and inspections.

1 Some of the content of this document was extracted, with permission, from New York City Department of Health and Mental Hygiene, Division of Mental Hygiene, Bureau of Planning, Evaluation & Quality Improvement. (2008). Quality IMPACT Basic CQI Course. New York, NY.

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Implementing a Continuous Quality Improvement Project

Step 1: Establish a Structure to Implement your Project

Your program should create an internal team to implement CQI projects. It is essential that program staff and management are all on board with the idea of implementing a CQI project. Ideally, this team will include representatives of all stakeholder groups close to the problem/opportunity. It is often helpful to include members and family members as well.

Step 2: PLAN – Develop your CQI Project

A. Identify the Aim of the Project

An aim statement is a measurable and time-sensitive statement that captures the expected results of an improvement process. A good statement describes the quality area you are hoping to improve and defines the measure for recognizing improvement. Make sure the improvements you are striving for will really make a significant difference to your program.

Identifying an Aim Statement1. Identify an area for improvement2. Consider the evidence3. Consider your workflow and business processes4. Incorporate member feedback

(example on next page)

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PlanDoCheckAct

Example: Aim Statement

The CQI team plans to increase the number of consumers who are gainfully employed or work in volunteer positions. Consumers consistently state that employment is an important goal for them, and evidence shows that employment and volunteering increases consumers’ quality of life. We will achieve this by providing vocational assessments as part of consumers’ treatment plans. The project duration will be six months.

B. Identify Root Causes

A CQI project is aimed to improve a certain area or aspect of services. Before initiating efforts to improve services, it is necessary to assess the current state of service delivery. The team should meet with wider program staff to brainstorm possible reasons for the identified area needing improvement. Then the team should categorize and prioritize the list, including distinguishing which root causes are actionable and which are not.

Example: Root Causes

Program Causes Program doesn’t engage in treatment planning until 6 months after consumer enrolls Program doesn’t have the capacity to support employment activities

Consumer Causes Consumers don’t say they want employment during treatment planning Consumers aren’t motivated to work because they’re afraid they’ll lose benefits

Staff Causes Some staff don’t believe consumers are capable of working Staff doesn’t know how to do vocational assessments

Environmental Causes The economy is bad; everyone is having a hard time finding jobs There are no jobs available in the area

C. Develop Project Indicators

An indicator measures an improved outcome or a process associated with an improved outcome. Indicators clarify the aim of your project, and they allow you to monitor your overall progress as you initiate small interventions. Most indicators are rates; however, they can also be counts or means (averages).

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Developing Project Indicators1. Find out what is already known about the topic you selected2. Select indictors3. Define indicators

Example: Process Indicators

Numerator: Number of vocational assessments integrated into treatment plans Denominator: Number of consumers with treatment plans

Numerator: Number of treatment plans with documented discussions about employmentDenominator: Number of consumers with treatment plans

A rate-based measure has a denominator (made up of the population that the measure will be applied to) and a numerator (made up of that portion of the population who meet the specific circumstance you are measuring). Although both the denominator and the numerator will vary over the course of your project, implementation of quality improvement efforts should result in an overall increase of your numerator relative to your denominator.

D. Develop a Data Plan

Once you have developed indicators to track your progress towards your aim, you will need to develop a starting point (baseline) and a target for desired improvement. Baseline data can be found through sources such as agency-wide billing systems, electronic medical records, consumer satisfaction surveys and chart reviews. Your target should be challenging, but realistic. Targets can be established by reviewing literature and past program performance. In cases where there is no information available, the target can be a noted increase or decrease (percent change).

Developing a Data Plan1. Determine the Indicator Baseline2. Establish an Indicator Target3. Develop a Plan for Measurement

Example: Data Plan

Baseline: 25% of consumers currently have vocational assessments in their treatment plansTarget: 75% of consumers will have vocational assessments in their treatment plans after 6 months

1. Do a random sampling of charts to estimate the number of treatment plans with vocational assessments to establish the indicator baseline.

2. Do a literature review to determine the most reasonable target.3. Check the number of vocational assessments in treatment plans each month.

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Step 3: DO – Carry Out the Intervention and Collect Data

Carry out the plan, collect data on progress, and document problems and unexpected observations.

Example: CQI Project Implementation

Staff was instructed to ask all consumers about employment during treatment planning and to document consumer responses.

Training was provided to staff to increase their skills in facilitating discussions with consumers about their vocational interests and conducting comprehensive vocational assessments.

When consumers were interested in employment, staff completed a vocational assessment. Program staff met after the first two months of implementation to discuss progress.

Step 4: CHECK/ACT – Measuring and Evaluating Your Project

Track your overall project measures by measuring your indicators at predetermined time intervals (weeks, months, quarters, etc.). You can plot the relevant numbers on a line graph (also called a “run chart”). This can be helpful to show your progress visually. Project success is gauged by how well the program was able to meet or approach the established aim. When considering your successes, look both at quantitative and qualitative evidence of change. Keep in mind that results may not always be immediate.

Example: Measuring and Evaluation

Baseline 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-Dec0%

10%

20%

30%

40%

50%

60%

Percentage of Consumers with Vocational Assessments in their Treatment Plans

Date

Perc

ent

A review of the treatment plans revealed that 50% of consumers now have vocational assessments in their treatment plans. Additionally, 60% of treatment plans noted a discussion about employment.

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Step 5: PLAN – Re-Evaluate Project

Continuous is the operative word here. The outcome of this year’s project can become the baseline for next year’s. If enough improvement is achieved, then you can move on to a different project.

Example: Re-Evaluation

The CQI team determined that this project has significantly increased the number of vocational assessments being done and would like to continue with this same project for another six months to try to meet the target of 75% of consumers with vocational assessments.

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