Quality Assurance Amelia Broussard PhD RN MPH Christopher Gibbs JD MPH Understanding Quality Improvement and Quality Assurance Quality Assurance and Quality Improvement are often confused as the same process ID: 526690
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Quality Improvement/ Quality Assurance
Amelia Broussard, PhD, RN, MPH
Christopher Gibbs, JD, MPHSlide2
Understanding Quality Improvement and Quality AssuranceQuality Assurance and Quality Improvement are often confused as the same processTerms used interchangeably but not the sameOne is focused on observations only and one time opportunity
Other is continuous process documenting improvement
Both based on standards for performance
Both important to organizationBoth focus on quality services to patients
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Definition of Quality AssurancePlanned systematic activities implemented in quality systemQuality requirements for product or service fulfilledActivities typically based on standards of practiceCan help identify problem but no solution
Compliance with standards goal
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Definition of Quality ImprovementQI is continuous ongoing process designed to improve patient outcomes, services or processFocus is ongoing rather than one time reviewTeam is multidisciplinary with representatives from all departmentsFocus on process or service not individual
Proactive rather than reactive
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Goals of QI
Goals of Quality Improvement
Understand process
Reduce & eliminate errors
Improve efficiency
Improve communication
Requires measurement
Focuses on outcomes
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Core Concepts of Quality ImprovementExceed expectations of patients or clientsProcess usually problem not peopleDoes not seek to blame but to improve processMost effective when part of everyday workFocus on everything, you can not focus on anything
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Quality Improvement and FTCAQI plan integrates all departments in activitiesOne QI plan for organizationMinutes document QI activitiesPlan should have certain components outlining process of committee
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Quality Improvement Plan ComponentsStatement of Purpose or Intent of PlanScope of PlanAdministrative ResponsibilityRisk Management Systems (some make this separate plan)Role of Peer Review in QI
Committee Composition
Committee Accountability
Methods for conducting QI activities
Tracking of QI Activities
Approval and Review
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Statement of PurposePlan includes statement of purpose or intentExampleThe purpose of the Quality Improvement Program is to support improved health care delivery and outcomes for the patient population receiving care. Objective is to promote continuous Quality Improvement within the organization and support the objectives and scope of Quality Improvement Program.
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Scope of PlanScope refers to what the QI committee will doIncludes monitoring of select measures, evaluation of performance and improvement in organizational performanceDiscusses which activities are applicable to QIIncludes risk management tracking as reported to QI, results of peer review and measures to be followed during year
Areas of consideration include medical/clinical, operational/administrative, governance and finance
Resources available in notes section
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Administrative ResponsibilityHealth center identifies by title individual with overall responsibility for QI programApproval requirements are stated (who must approve plan)Individual consulted in development of QI/QA Plan and activitiesIdentification of who will receive information about decisions and activities of QI/QA program
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Risk Management SystemsHealth center identifies the following:Policies/procedures regarding appropriate supervision of clinical and non-clinical staffPolicies/procedures to identify and document system process or breakdownPolicies/procedures for addressing and investigating medical malpractice claims
Resources available in Notes section of slides
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Role of Peer ReviewPeer review is the process of all providers reviewing a peer’s medical records Specific time frame for review is defined (i.e. quarterly, monthly, bi-monthly)Results of peer review should be communicated in aggregate form to QI committee for possible QI projects to improve patient care
Review should consist of two parts
Medical care review
Review for completion and documentationResources in Notes section
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Committee CompositionEstablishes QI committeeMembership is definedMultidisciplinary membershipCommittee chairperson & vice chair person identifiedCommittee must have defined meeting frequency. Meeting 6 times per year strongly encouraged*
Agendas and minutes for committee meetings maintained
* Application requires 6 sets of minutes within past year.
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QI Committee AccountabilityShort statement that defines accountability of QI committeeDefines frequency of reports to Board of DirectorsDefines time frame for updating QI plan and schedule
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QI Committee for Multiple SitesStill one QI committee for organizationSite QI committees may be established and described in overall QI planSite QI plans must mirror overall plan and report on a regular basis to overall QI committeeMain QI plan sets agenda for organization
Additional QI projects may be done at satellites based on center needs in addition to main QI program
Reporting from each site is very important in the overall QI committee
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Methods for QI ActivitiesQI plan should include methods used to conduct QI projectsIncludes process for collecting data and sourcesAllocation of resources definedProcess most common: Improvement Model and use of PDSA Process
Schedule of activities for monitoring measures
Defines QI activities based on subcommittees
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Tracking of QI ActivitiesDefines reports to be given by subcommittees to overall organizational QI committeeQI activities reported by subcommittees to overall QI committeeReport baseline on project, interventions attempted, results of interventions and continued monitoringCommittee members track measures over time for QI activity impact
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Approval and ReviewIdentifies individuals who must approve QI planSignature page in place with dates Appropriate signatures in place on review pageFrequency of review and updates for individuals who are responsible for approval
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QI/QA Committee Meeting MinutesFTCA weighs minutes very heavilyShould be enough information for reviewer to verify successful implementation of QI programProvide written documentation of QI activitiesMust include information on monitoring activities for measures listed in QI plan
Must document multidisciplinary team by name and title during attendance
Must report on QI activities conducted during meeting interval
Data used to measure objectives of QI plan and track improvement activities
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Sample QI Meeting MinutesInclude:AttendeesAgenda itemsDiscussion topicsRecommendations
Action items
Clearly label with
consistent titlesProvide sufficient detail
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Conducting the QI MeetingAgenda should always be setReview QI data/progress toward goalsAnalyze trends and identify problem areasBrainstorm for improvement strategies
Develop improvement plans
Develop, revise and implement QI plans
Document meeting minutes and keep on file
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QI/QA Reports to BoardQI/QA information reported at least 6 timesBoard meeting minutes reflect:QI committee findings and activitiesShort summary of QI projects conducted by staff
Objectives, data, improvement goals
Board review of QI plan on a regular basis (usually annually)
Board is also responsible for reviewing and approving credentialing/privileges of all medical providers
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Submission of Information for FTCASubmit QI plan as developed by organization with appropriate signatures and approval Must also indicate board review during last three yearsMeeting minutes: 6 months of QI meeting minutes
6 months of Board meeting minutes with reports from QI program
Multiple site minutes
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