BUILDING A CULTURE OF SAFETY THROUGH QI PROCESS IMPROVEMENT

Problem:  Rural facilities are challenged to maintain and sustain high impact Quality Improvement (QI) Programs due to limited access to QI experts and resources.  Additionally, QI teams lack system-wide support of QI and Process Improvement (PI) Projects developed to drive change. While the rural facility meets the Centers for Medicare and Medicaid (CMS) Conditions of Participation requirement to have a facility-wide QI Plan/Program, many QI teams lack commitment from all levels of their organization to achieve a “continuous” QI Plan/Program to improve processes and outcomes of healthcare delivery.

Potential Solution:  Develop a QI Plan/Program utilizing systematic, data guided activities and QI strategies to enable all staff to identify opportunities to improve processes and outcomes.

Quality Improvement Plan/Program

The QI Plan/Program is a framework for the ongoing measurement and assessment of performance improvement activities.  Components of the plan/program should include:

  1. Process Improvement Teams-These teams are developed based on particular issues/concerns and are within the total QI umbrella (TQM.) Team members, under the direction of the team facilitator/leader, identify opportunities to improve processes and outcomes.  The team should consist of front line experts and be interdisciplinary in nature.
  2. Data Guided activities- Interdisciplinary efforts to improve quality must be measured. Measurement should demonstrate how what you have put into place has :
    1. Lead to change
    2. Contributed to results
    3. If needed, required additional efforts to reach the desired change
  3. Benchmarking (Measure your degree of success):
    1. Public reporting of quality (core measures, eCQM and other data sets)
    2. Evaluating organizational performance-Used to identify best practices within an organization and to compare over time-Internal benchmarking
    3. Comparing improvement results with those best performers-External benchmarking
  4. QI/PI Tools and Strategies:
    1. Plan, Do, Study, Act (PDSA)
    2. Lean/Six Sigma
    3. Root Cause Analysis
    4. Healthcare Failure Mode Effect Analysis (HFMEA)

When working your QI Plan/Program, teach QI fundamentals system-wide.  Keep an open mind to change, you can’t improve what you don’t know; focus on process/system not people; seek simple solutions whenever possible; stop and address the problem when it first occurs; acknowledge problems are opportunities; and encourage others to be part of the solution.

QI is continuous, there is no final destination on the Quality Improvement journey.

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