QUALITY IMPROVEMENT PLAN

Transcription

1 QUALITY IMPROVEMENT PLAN Effective Date: 07/18 Purpse: T prmte a culture f quality within Barren River District Health Department (BRDHD) that includes an rganizatin-wide management and staff philsphy f cntinuus quality imprvement (QI) in prgrams, service delivery and ppulatin health utcmes. BRDHD has an interest in rutinely evaluating and imprving the quality f prgrams, prcesses and services t achieve a high level f efficiency, effectiveness and custmer satisfactin. Failure t Cmply: Emplyee failure t cmply with this plicy culd result in stagnant, nnprductive prgrams. Agency failure t cmply culd result in lss f accreditatin. Definitins and Key Terms ACT Team (Ambassadrs fr Change and Transfrmatin): The ACT Team is cmprised f members chsen, representing a crss-sectin f each level f the rganizatinal chart, including Administratin, prgram managers and prgram staff. Additinal ad-hc members (representing HIPAA cmpliance, Human Resurces, Strategic Planning, Finance and Others as needed) will be engaged in QI Team activities n an as-needed basis. The ACT Team will crdinate QI effrts at BRDHD including: reviewing a cmprehensive Quality Imprvement Plan ; preparing t meet lcal health department accreditatin standards related t QI; develping and evaluating rapid cycle quality imprvement tests; prvide technical assistance t QI teams. AIM Statement: A brief set f statements that clarify the gal r purpse f a quality imprvement prject. The statements answer the questins: What are we trying t accmplish? Hw and what d we need t measure t knw that a change is an imprvement? What changes can we make that will result in imprvements?

2 Big QI vs. Little QI: Big QI dentes the verall effrt tward quality imprvement at the department r divisin level; while little QI represents small, limited quality imprvement effrts at the prgram r prcess level. Cntinuus Quality Imprvement (CQI): An nging effrt t increase an agency s apprach t manage perfrmance, mtivate imprvement, and capture lessns learned in areas that may r may nt be measured as part f accreditatin. Als, CQI is an nging effrt t imprve the efficiency, effectiveness, quality, r perfrmance f services, prcesses, capacities, and utcmes. These effrts can seek incremental imprvement ver time r breakthrugh all at nce. Amng the mst widely used tls fr cntinuus imprvement is a fur-step quality mdel, the Plan-D-Check-Act (PDCA) cycle, als knwn as the Plan-D-Study-Act (PDSA) cycle. Metrics: A cllectin f terms used in setting gals, indicatrs, measures, standards, baseline and benchmarks. The metrics are defined during the Plan phase f PDSA and are vital in mnitring the prgress f a quality imprvement prject. Measure a basis fr cmparing perfrmance r quality thrugh quantificatin. Indicatrs a measure which helps quantify the achievement f a gal; end result which lets us knw if we are achieving a gal; measurable; refers t ppulatins, whether r nt they receive services. Standards an established level f perfrmance r quality; the minimum acceptable measurement expected r desired. Gal brad, general statement f what will be achieved and hw things will be different; what it takes t reach the visin (may nt be measurable). Benchmark target t be reached; a near-term standard with which an indicatr r particular perfrmance measure is cmpared a level f perfrmance established as a standard f quality. Baseline an initial measurement f ppulatin r prgram. Perfrmance measure a measure f hw well a prgram is wrking; wrk perfrmed and results achieved; its efficiency and effectiveness; refers t client ppulatin/thse wh receive services; may relate t knwledge, skills, attitudes, values, behavir, cnditin, r status, (e.g., % f patients wh keep appintment). PDSA/PDCA: The Plan D Study/Check Act methd is the mst widely used, simple apprach fr use in quality imprvement prjects. The terminlgy f PDSA and PDCA may be used interchangeably. When described as the PDSA Cycle, the methd is a cntinuus effrt f repeated iteratins f PDSA. BRDHD favrs the PDSA methd r apprach fr QI prjects given its universal applicatin; hwever, BRDHD encurages the use f ther mdels when apprpriate fr a specific QI prject. Quality: An essential characteristic r attribute f a prduct, prgram, service, r prcess that helps determine the level f excellence r intrinsic value. Quality is essentially determined by the end-user r

3 custmer f the prduct; given the subjective nature f custmer satisfactin, quality can vary frm custmer t custmer. Quality can be expressed in a range frm lw r pr quality t high quality. Quality Assurance (QA): A prcess that measures cmpliance with a previusly established standards and expectatins, including the prtcls f the Kentucky DPH Cre Clinical Service Guide (CCSG) and requirements f the Administrative Regulatin (AR). Quality Imprvement (QI): An integrative prcess that links knwledge, structures, prcesses and utcmes t enhance quality thrughut an rganizatin. The intent is t imprve the level f perfrmance f key prcesses and utcmes within an rganizatin. Quality Imprvement Methds: A variety f practices that build n an assessment cmpnent in which a grup f selected indicatrs that are used by an agency are regularly tracked and reprted. The data shuld be regularly analyzed thrugh the use f cntrl charts and cmparisn charts. The indicatrs shw whether r nt agency gals and bjectives are being achieved and can be used t identify pprtunities fr imprvement. Once selected fr imprvement, the agency develps and implements interventins, and re-measures t determine if interventins were effective. The PDSA/PDCA r Shewhart Cycle was ppularized by W. Edmnds Deming during the pst-wwii effrt t reindustrialize Japan. Other ppular methds include Lean, Six-Sigma, Lean Six-Sigma, DMAIC, Perfrmance Excellence (4th Generatin Management), Mdel fr Imprvement, and Malclm Baldrige Natinal Quality Standards. Quality Imprvement Plan (QIP): A plan that identifies specific areas f current peratinal perfrmance fr imprvement within the agency. These plans can and shuld crss-reference ne anther, s a quality imprvement initiative that is in the QIP may als be in the Strategic Plan. Quality Imprvement Team: Any grup f individuals chsen t wrk n a QI prject. Quality Imprvement teams will utilize the PDSA Cycle t imprve prcesses within the agency, dcument their prgress and submit final reprts t the PQC Team. Quality Imprvement Tls: A variety f tls used t identify hw prcesses, prgrams, and services can be imprved. Tls include flw charts, cause-and-effect diagrams, fishbne diagrams, Paret charts, scatter diagrams, cntrl/run charts, brainstrming, lgic mdels, SWOT analysis, and numerus thers. Strategic Planning and Prgram Planning and Evaluatin: Generally, Strategic Planning and Quality Imprvement ccur at the level f the verall rganizatin, while Prgram Planning and Evaluatin are prgram specific activities that feed int the Strategic Plan and int Quality Imprvement. Prgram evaluatin alne des nt equal Quality Imprvement unless prgram evaluatin data are used t design prgram imprvements and t measure the results f the imprvements as implemented.

4 VMSG Dashbard Public Health Perfrmance Management System: VMSG is a clud-based, real-time, perfrmance management system designed specifically t assist BRDHD in the develpment, implementatin, and perfrmance management f the strategic and peratinal planning prcess frm end t end. Gvernance Structure The ACT Team will versee and mnitr all QI activities fr the BRDHD. The ACT Team will reprt prgress and updates t the Senir Management team/perfrmance Management team n a mnthly basis thrugh shared representatives frm Senir Management. Senir Management/Perfrmance Management Membership Public Health Directr Envirnmental Directr Cmmunity Health Prmtin Directr Cmmunity Health Imprvement Directr Finance Directr Planning, Quality, and Cmmunicatin Branch Leader Human Resurces Manager Directr f Nursing IS Directr Dental Health Services Directr Disaster Preparedness Directr Accreditatin Crdinatr Epidemilgist Maintenance Supervisr Rles and respnsibilities Regular cmmunicatin and reprting t Bard f Health. Prvide, apprve, and encurage staffing and administrative supprt. Apprve budget and resurce availability. ACT Team Membership & Rtatin The ACT Team will cnsist f at least 6 members, representing a crss-sectin f each level f the rganizatinal chart, including Administratin, prgram managers and prgram staff. Additinal ad-hc members (representing HIPAA cmpliance, Human Resurces, Strategic Planning, Finance and thers as needed) will be engaged in QI Team activities n an as-needed basis. Rles & Respnsibilities f Cmmittee

5 Develp a cmprehensive Quality Imprvement Plan every three years t be apprved by the directr and implemented by the agency. The plan shuld be reviewed annually fr any changes that may be necessary. Develp and evaluate rapid cycle quality imprvement tests. Establish standardized dcumentatin tls and mechanisms fr agency wide use. Review PHAB Accreditatin standards annually t ensure cmpliance. Prvide a fundatin fr cntinued QI grwth. Cmmunicate QI activities with the agency, Bard f Health, and public regularly thrugh: Recrding minutes f team meetings. Sharing prgress f QI prjects with agency thrugh Payday Newsday, , website, and prgram r departmental staff meetings (including Supervisrs meeting, Managers meeting and Senir Management meeting). Presenting prgress r strybard prjects t the Bard f Health n behalf f Senir Management. Sharing infrmatin, tls and templates, planning ntes and ther resurces between ACT Team members. Mentr, educate and prvide technical assistance t QI Teams and staff by: Assisting team with checklist t begin prcess which includes necessary steps, measurable gals and dcumentatin f prgress. Training and educatin f QI techniques (PDSA/PDCA, rapid cycle QI, 5 Whys, etc.). Instructing use f QI tls and standardized dcumentatin methds. Serving as a liaisn between QI team prjects and agency as a whle t crdinate and assure dcumentatin and psting f QI prject status reprts. QI Cmmittee members will be assigned t supprt n mre than tw prjects at a time. Pursue advanced QI training by cmpleting independent studies and planning and/r cnducting activities. Netwrking with ther quality imprvement prfessinals thrugh lcal, state, natinal websites and rganizatins (i.e. PHQIX). Cllect and mnitr baseline data. Select QI Prjects Assist in identifying and priritizing QI Prjects. Slicit/gather prject suggestins frm staff (i.e. surveys, fcus grups, suggestins, meeting discussins). Present prject suggestins t senir management. QI Team Maintain necessary nging dcumentatin f prject prgress. Ensure SMART gals/bjectives and timelines fr cmpletin f activities. Prvide required dcumentatin f PDSA within 30 days f prject cmpletin. Cmmunicate updates with ACT Team liaisn. Use established tls prvided by ACT Team.

6 Take active rle in educatin f PDSA prcess including data cllectin, tls, prcesses, prject team evaluatin. Utilize VMSG t initiate new QI prjects fr their team. Budget Planning/Mnitring BRDHD staff will cntinue t seek funding thrugh grants when available. Staff will cde time wrked fr QI prjects t a cst center designated fr quality imprvement activities. This cding will help plan and determine future budget needs fr the agency. Plan/Prject Identificatin and Selectin Quality Imprvement prjects are encuraged at all levels f the rganizatin agency, department r prgram level. Prject specificatins (team members, gals, bjectives, etc.) will be mnitred by the ACT Team with specific prject dcumentatin n the QI Tl. Final dcumentatin will be lcated n the strybard. BRDHD identifies prjects based n the criteria belw: Need fr Plicy/prcedure/regulatin Aligned with strategic plan Aligned with the missin/visin/values Aligned with the CHA-CHIP Cmmunity Needs (nt therwise identified) Data used t determine prjects: Surveys Gap Analysis Fcus Grups Nminal/Multi-vting Technique Methds used t determine priritizatin Use f Pick chart (High/Lw grid) Priritizatin Matrix Interrelatinship Digraph Nminal/Multi-vting Technique Quality Gals and Objectives BRDHD uses the SMART acrnym fr defining gals fr the rganizatin. S- Specific- State exactly what yu want t accmplish (Wh, What, Where, Why). M- Measurable- Hw will yu demnstrate and evaluate the extent t which the gal has been met. Achievable- challenging gals within ability t achieve utcme, what is the actin riented verb?

7 R- Relevant- Hw des the gal tie int yur key respnsibilities? Hw is it aligned t bjectives? T- Time-Bund- Set ne r mre target dates, the by when t guide yur gal t successful. QI Prgram Evaluatin BRDHD will utilize the NACCHO Radmap t a Culture f Quality Imprvement t assess and cntinue t implement strategies t mve the Agency twards a culture f quality. BRDHD will determine the phase f QI within BRDHD and address the assessment results t priritize and develp future gals. Cmmunicatin BRDHD will utilize its weekly newsletter and website t highlight prject achievements, training pprtunities, and updates regarding QI within the agency. Training infrmatin will be shared with staff directly thrugh and staff meetings. QI Teams may present their prjects t varius grups that meet in the Supervisr s meeting, Managers Meeting, Senir Management meeting, lcal staff meetings, prgram meetings, and Bard f Health meetings. Frms: Nne References: Nne Cntact Persn: PQC Team Branch Leader, ACT Team Chair Date Adpted: Plan Originatin, Revisin, and Review Tracking Plan Number Originatin Date Descriptin f Revisin r Reviewer Name PQC Team Branch Leader Plan Creatin