Quality Improvement

Justine Strand, MPH, PA-C

Patricia Castillo, MS, PA-C
Victoria Kaprielian, MD
 Goal:

Apply principles and practices of Quality

Improvement.
What is QI?
QI Opportunities and Benefits

QI can give you the opportunity to …..

• Look at things differently

• Come up with new options and solutions
• Eliminate things that make you crazy
 QI: A Historical Perspective
• based on the theories of Deming and
Juran
• 1980s – Japanese auto industry
• 1990s – American manufacturers and
health care industry
Health Care: Cost and Access

• Improvements in technology
• Higher prices
• Greater demand
• Integrated medical delivery systems
 Perspectives on Quality

• Providers
• Payers
• Employers
• Consumers
 QI is a “Hot Topic”

• “…The quality of health care

received by the people of the
United States falls short of what it
should be.”
IOM, 2001
 US Health System Rankings
• 37th place overall (out of 191) because
of significant health disparities
• Tied for 82nd place (out of 171) on polio
vaccination rate
• Number 1 on both dollars spent per
capita, and proportion of GDP spend on
health care
 Medical Errors

• How extensive is the problem of

medical errors?

• More people die in a year from medical

errors than from motor vehicle
accidents, breast cancer, or AIDS
 “Crossing the Quality Chasm”
IOM 2001

• Under use – helpful services not

delivered
• Overuse – useless interventions
• Mistakes – inevitable human error
 Medical Errors

• Not the fault of individuals

• Lessons from industry

 QI in Health Care

• How can you measure quality in health

care?
• What do you want to measure?
• How can you do it?
• What are the challenges?
 Issues in Measurement

• Structure
• Process
• Outcome
 Process vs. Outcome
• Process:
– How health care is provided
– How the system works
• Outcome:
– Health status
– Does it make a difference?
 Proxy Measures

• Used when you can’t exactly measure

what you want or need
• Measure something that is close
enough to reflect similarly
 Information Systems
• Can be a valuable tool
• Can facilitate quality efforts
• Examples:
– Databases
– Disease registries
 Convenience Samples
• Takes a limited number
• Extrapolates to the whole population
• Not necessarily randomized
 QI: Issues in Measurement
• Process vs. Outcome
• Proxy measures
• Information systems
• Convenience samples
 “FADE” Methodology

u FOCUS
u ANALYZE
u DEVELOP
u EXECUTE/EVALUATE
The FADE model

Written statement of problem

Select
one Verify/
Generate
problem define
a list of
Record problem Baseline
problems
of Decide data
impact FOCUS what you
Monitor
impact need to
A know
E
X N
A Collect
Execute Execute E data
plan plan C FADE L baselines/
U Y patterns
T Z List of
Gain E E Determine most
commitment influential influential
DEVELOP factors factors
Organizational
commitment Develop Generate
implementation promising
plan Select solutions
solution
Solution for
A plan for problem
implementation
 Example 1

The state child health report indicates no

well child care is being done in your
primary care clinic.

What do you do?

 Quality Improvement vs.
Performance Improvement
• Quality Improvement focuses on quality
of care
• Performance Improvement focuses on
administrative systems
• The goal is improvement in quality
The Diagnostic Process
 Example 2

An audit shows your immunization rate for

well children to be 45%

What do you do?

 Evaluation results

About 18 months later, your

immunization rate is now 82%

What would you do now?

Is 82% good enough?
QI: Rapid Cycle Improvement

• EVALUATE
• FOCUS
• ANALYZE
• DEVELOP
• EXECUTE
• EVALUATE
 “PDSA” Methodology

• PLAN
• DO
• STUDY
• ACT
 “PDSA” Methodology

• PLAN
• DO
• STUDY
• ACT
 Example 3
Improving a phone message system
PLAN
DO
STUDY
ACT
 QI vs. Research
QI: Research:
• Confidential • Publish/present
• Existing standard of • Tests new methods
care
• Creating new
• Improving care generalizable
knowledge

• No IRB approval • Needs IRB approval

needed
 Summary
• Improving health care quality is our
responsibility

• Identify the cause before making changes

• Be creative in developing solutions

THINK OUTSIDE THE BOX!