Transcript QUALITY IMPROVEMENT AND SERVICE

QUALITY IMPROVEMENT
&
SERVICE PROVISION
Post Graduate Certificate in
Hospice Palliative Care
Julie Maher
Programme Co-ordinator/Lecturer
Whitireia New Zealand
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OBJECTIVES
• Discuss the history of quality
• Provide an overview of quality
improvement
• Identify the Audit process
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• Ephesus 5 – 6mins
• https://www.youtube.com/watch?v=TZM6lI8u
w9o
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The History of Quality
From the building of the pyramids through
Middle ages- craftsman & guildsman
Industrial revolution
1930s America: systematic approach to quality e.g.
Statistical Quality Control
• Post war rebuilding of Japan
• The car industry quality control to quality
improvement
• Progression from Quality Control to Quality
Assurance to Total Quality Management etc
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So what is a quality?
• A quality management system is the
documented and implemented method
for management of all the aspects of
the service that will impact on meeting
the customers needs.
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Why have a Quality System
• to meet Ministry and professional
requirements
• to improve the effectiveness of service
delivery
• to identify, prevent and/or minimize risk
• to maintain consumer & public confidence
• to thrive in an increasingly competitive &
changing world
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A Quality System
Strategic plan (and action plans)
Risk management processes
Policy documents
Monitoring processes
Implementing improvements or corrective
action
• Evaluating effectiveness of improvement or
corrective action
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External Influences
on a quality management system
Ministry standards
Service specifications
Funding agency requirements
Consumer expectations
The Primary Health Care Strategy (2001)
Professional standards
Hospice NZ Standards of Palliative
Care (HNZ, 2012)
• Local demographics
• Accreditation standards
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NZ H&DS 8134:2008
(Standards NZ, 2008)
• Health & disability services are required to
meet service standards relevant to the type
of health & disability service they provide
• 2.1.2 Organisational performance is aligned
with and regularly monitored against the
identified values scope, strategic direction
and goals
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NZ H&DS 8134:2008
(Standards NZ, 2008)
• 2.2.4 QI data collection, analysis and evaluation…
• 2.2.6 A process to measure achievement…
• 2.3 The organisation has an established,
documented and maintained quality & risk
management system that reflects continuous quality
improvement cycles
• 2.3.5 Key components of service delivery are linked to
the quality management system
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What are standards?
• A document, established by consensus and
approved by a recognized body, that provides
for common and repeated use, rules,
guidelines or characteristics for activities or
their results, aimed at the achievement of
the optimum degree of order in a given
context (IEC/ISO Guide 2)
• They are a set of rules for ensuring a quality
service or product
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Quality Improvement
Defined as the
“combined and unceasing efforts of everyone
(providers, patients and families, researchers
and educators) to make the changes that will
lead to better patient outcomes (health),
better system performance (care), and better
professional development (learning)
(Batalden & Davidoff, 2007).
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Risk Management
• is the chance of something happening
that will have an impact on objectives.
It is measured in terms of consequences
and likelihood (AS/NZ 4360:2004)
• is integral to an effective quality
management system
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IMPLEMENTING THE NZ HEALTH
STRATEGY (2011)
• Improvements to deliver high quality pt centred
health services
• System wide improvement in DHBs to improve
performance & service delivery
• DHB greater fiscal responsibility & significant
reduction in deficits.
• Health Quality & Safety Commission (2010) est’d to
improve quality & safety for patients.
• Improve Clinical leadership, medication safety,
reducing medical errors & hospital acquired
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infections
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HOSPICE NZ STANDARDS
Standard 1 – Values based care
Standard 2 – Ensuring equitable access
Standard 3 – Coordinating care
Standard 4 – Providing whole person
assessment
Standard 5 – Meeting the cultural needs of
diverse family and whanau
Standard 6 – Providing person centred care
planning
Standard 7 – Ensuring ongoing assessment
and planning are undertaken to meet the needs and
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wishes
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HOSPICE NZ STANDARDS
(CONTINUED)
• Standard 8 – Caring for patients who are
dying
• Standard 9 – Caring for the carer/s
• Standard 10 – Providing bereavement care
• Standard 11 – Building community capacity
• Standard 12 – Quality and research
• Standard 13 – Professional development
• Standard 14 – Reflective practice and self
care
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STANDARD 12 – QUALITY &
RESEARCH
Establishes that “services are committed to providing
the best quality of care for people living with a life
limiting condition, by participating in audit, quality
projects and research projects to meet these goals”
(Hospice New Zealand, 2012, p.41)
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AUDITS
• Clinical audit is a quality improvement
process that seeks to improve patient care
and outcomes through systematic review
against explicit criteria and the
implementation of change (Patel, 2010).
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AUDIT
Clinical audit as defined by Ingram and Khan
(2014), is
“a quality improvement process that seeks to
improve patient care and outcomes through
systematic review of care against explicit criteria
and the implementation of change” (p. 574)
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AUDIT
• “Audit is a procedure used in the assessment
of the quality of care, which has been defined
as the degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes and are
consistent with current professional
knowledge” (Rosario, Padros, Bernet & Leon,
2012, p. 533).
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A clinical audit is guided by 3
questions
1. What should we be doing?
2. Are we doing it?
3. If not, how can we improve it?
(Dartford and Gravensham NHS Trust, 2014)
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Key Components of an Audit
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Aim
Collection of data
Analysis of data collected
Reporting of findings/results
Improvement and/or correction plan
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Why Audit
• to meet reporting obligations:
– Ministry
– Funding agencies
– Own board
• to measure practice against POLICY/STANDARD
• to assess perceived or identified deficit/s
• to assess the effectiveness of a newly
implemented activity or an improvement
• provides evidence when scrutiny is applied from
other sources (e.g. complaints, external audits)
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Most importantly though to ensure patients and family/whanau
receive the service they are entitled
to.
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CYCLE OF QUALITY OF
IMPROVEMENT
• The continuous cycle of QI ensures safe high
quality evidenced based practice for patient
and family and whanau care with a focus on
outcomes, promoting QOL and individualised
care.
• Centres on the patient and formalises best
practice & quality becomes standard for all
patients
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Benefits of Audits
• Affirms practice
• Identifies/justifies need for added
resources
• Provides educational opportunities
• Provides opportunities for
improvement
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Ethics
• Confidentiality
• Follow your own organization's audit
policy & criteria
• Accuracy
• Independence:
- no bias
- suspend preconceived ideas
- non punitive
- non emotive
language
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KPIs ?
Key performance indicators:
• are specific questions designed to elicit a
specific response
• measure performance against policies
therefore
• reflect policy criteria which in turn…
• reflect professional , mandatory
and accreditation standards
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KPI
KPI’s can be defined as a measure of
performance which aids in determining how
well an organisation is performing against
expectations or targets (Health Information and
Quality Authority, 2013)
and can assist in defining and measuring the
progress towards other goals evaluating success
or failure of a specific activity or aspect of care
(Suhartono & Suhartono, 2015).
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KPI examples
NEW REFERRALS POLICY STATEMENT: All new
referrals will be followed up within 24 hours
Audit KPI: What is the time frame between receipt
of referral and the first contact?
HEALTH RECORDS POLICY: All entries in the health
record are legible
HR audit KPI: entries in the health record are legible
Yes
No
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Audit of Standard operating procedure
BOWEL CARE
KEY
PERFORMANCE
INDICATORS
1
2
3
4
5
6
7
8
9
10
%
ACHIE
VED
1.Bowel status
assessed on
admission
Y
Y
N
Y
N
Y
Y
Y
Y
Y
80
2.Bowel
observation
chart x3/24hrs
from admission
N N
N
N
N
Y
N
N
N
N
10
3.Interventions
as per SOP or
medical pxs
Y
N
N
N
N
Y
N
Y
Y
Y
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4.Evalu. of
interv.
documented
N N
Y
N
N
N
Y
Y
Y
Y
50
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Trust Code
Name of the NHS hospital trust
County the trust is in
Name of the site participating in the audit in alphabetical order
REM
RCF
RWP
RTK
RVL
Aintree
Ashford and
Worcestershir
Barnet and
University Airedale NHS
St Peter's
e Acute
Chase Farm
Hospitals NHS Foundation
Hospitals NHS
Hospitals NHS
Hospitals NHS
Foundation
Trust
Foundation
Trust
Trust
Trust
Trust
West
Worcestershir
Merseyside
Yorkshire
e
Surrey
Middlesex
Aintree
Ashford and
Barnet and
University Airedale NHS
St Peter's
Alexandra
Chase Farm
Hospitals NHS Foundation
Hospitals NHS
Hospital
Hospitals NHS
Foundation
Trust
Foundation
Trust
Trust
Trust
KPI 1: Access to information relating to death and dying.
KPI 1 score (range 0 to 5)
3
5
4
KPI 1 score of 5 achieved
Not achieved Achieved Not achieved
KPI 2: Access to specialist support for care in the last hours or days
of life.
KPI 2 score (range 0 to 5)
4
2
2
KPI 2 score of 4 or 5 achieved
Achieved Not achieved Not achieved
KPI 3: Care of the Dying: continuing education, training and audit.
KPI 3 score (range 0 to 20)
10
10
20
KPI 3 score of 10 or higher achieved
Achieved
Achieved
Achieved
KPI 4: Trust Board representation and planning for care of the
dying.
KPI 4 score (range 0 to 4)
1
4
4
KPI 4 score of 4 achieved
Not achieved Achieved
Achieved
KPI 5: Clinical protocols for the prescription of medications for the
5 key symptoms at the end of life.
KPI 5 score (range 0 to 5)
5
5
5
KPI 5 score of 5 achieved
Achieved
Achieved
Achieved
KPI 6: Clinical provision/protocols promoting patient privacy,
dignity and respect, up to and including after the death of the
patient.
KPI 6 score (range 0 to 9)
7
7
9
KPI 6 score of 9 achieved
Not achieved Not achieved Achieved
National
qualityCare
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of the
Dying Audit
http://www.rcplondon.ac.uk/resources/n
4
Not achieved
5
Achieved
RFF
Barnsley
Hospital NHS
Foundation
Trust
South
Yorkshire
Barnsley
Hospital NHS
Foundation
Trust
5
Achieved
2
1
2
Not achieved Not achieved Not achieved
0
Not achieved
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Achieved
9
Not achieved
3
Not achieved
4
Achieved
4
Achieved
5
Achieved
5
Achieved
5
Achieved
9
Achieved
9
Achieved
7
Not achieved
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WHO
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Quality team
Other teams
Resource people
Students doing assignments
Researchers
Individuals/ team members, i.e. you & I
Quality of care is of interest to EVERYONE
receiving or providing palliative care
(Lemmans, Cohen, Francke, Vander Stichele,
Claessen, Van den Block & Deliens, 2013)
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How ?
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Specific
Measurable
Achievable
Related to the aims of your project
Theoretically sound- based on best
practice
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Clinical Audit Cycle
1. Select
topic
8. Re-audit
2. Agree
standards of
best practice
7. Implement
change
Action
6. Make
recommendations
Planning
3. Define
methodology
Audit
5. Analysis and
Reporting
4. Pilot
and data
collection
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PDCA Cycle
• Plan your audit- purpose
• DO trial audit
• Check to ensure it meets your
requirements
• Act -remedy any deficits
• Conduct the “audit proper”
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Plan
• What is the purpose of the audit
• What is the subject/area
• Decide how will you analyse & report the
completed audit
• What is the scope of the audit
• What is your client base
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DO
• Create your audit tool/template
• Keep it simple & user friendly
• Formulate your KPI questions to elicit yes/no
answers or simple responses
• Create your analysis template/tool to reflect
your audit tool
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Check
• Trial your audit on a few sample case
notes etc
• Check it with a colleague
• Make any necessary adjustments
• Now you are ready to conduct your audit
= ACT
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Analysis
•
•
•
•
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Counting
Percentages and ratios
Sorting and grouping
Matrices
Comparisons
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Reporting
• To management and the team audited in a
timely manner
• User friendly format
• Concise & factual
• Outline the purpose, scope & methods used
• Link any deficits identified to the
standard/policy directive
• State variables
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Audit Failure
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Why Audits Fail
Lack of clarity over the reason for the audit
Inadequate instructions
Poor KPIs
Poor policy and /or audit documents
Incorrect and/or incomplete data entry
Failure to take corrective action arising from
previous audit
• Poor analysis & reporting
• Lack of timeliness
•
•
•
•
•
•
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CYCLE OF QUALITY OF
IMPROVEMENT
• The continuous cycle of QI ensures safe high
quality evidenced based practice for patient and
family and whanau care with a focus on
outcomes, promoting QOL and individualised
care.
• Centres on the patient and formalises best
practice & quality becomes standard for all
patients
Clinical Audit Cycle
1. Select
topic
8. Re-audit
2. Agree
standards of
best practice
7. Implement
change
Action
6. Make
recommendations
3. Define
methodology
Audit
5. Analysis and
Reporting
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Planning
4. Pilot
and data
collection
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• Florence nightingale statistician – joy of stat
• https://www.youtube.com/watch?v=yhX0OR1
_Vfc
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References
•
Batalden, P. & Davidoff, F. (2007). What is quality improvement and how can it
transform
healthcare? Quality and safety in healthcare, 16. Retrieved from Proquest database.
•
Dartford & Gravesham NHS Trust (2014).. Improving Patient Care through Clinical audit. A How to
Guide. http://www.cyma.org.cy/index.php/en/file/tl9Xvyo7kSrGpdeP_+CepQ==/
•
East Kent Clinical Audit Service (NHS) Audit Cycle (No Date). Retrieved from
http://www.ekclinicalauditservice.nhs.uk/homepage/what-is-clinical-audit/the-audit-cycle
•
Guidance on Developing Key Performance Indicators and Minimum Data Sets to Monitor Heealthcare Quality
(2013). Retrieved from
https://www.google.co.nz/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwizu8rHh7rMAhVDFZQK
HT20CoIQFggaMAA&url=https%3A%2F%2Fwww.hiqa.ie%2Fsystem%2Ffiles%2FKPI-Guidance-Version1.12013.pdf&usg=AFQjCNEIRc62vh_CzIOoNR_FmbHi2ODHZg&bvm=bv.121070826,d.dGo
•
February 2013
•
Hill, S., & Small, N., (2006). Differentiating between research, audit and quality improvement:
governance implications, 11(2), 98-107. Retrieved from Proquest database.
•
Hospice New Zealand (2012). Hospice New Zealand Standards for Palliative Care: Quality Review
programme and guide 2012.
•
Jones ,T., & Cawthorn, S. (2006) , Clinical Audit and Effectiveness. Retrieved from Proquest
database.
•
•
Health Quality and Safety Commission (2011) Retrieved from http://www.hqsc.govt.nz/
Hospice New Zealand (2012) Hospice New Zealand Standards for Palliative Care. Retrieved from
http://www.hospice.org.nz/cms_show_download.php?id=647
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References
•
•
•
•
•
•
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IEC/ISO (2001). IEC/1S0 Guide . Retrieved from
http://www.iec.ch/members_experts/refdocs/iec/isoiec-dir2%7Bed6.0%7Den.pdf
Ingram, S., & Khan, B. (2014). Discharge planning in a cardiology out-patient clinic: A clinical audit.
International Journal of Health Care Quality Assurance, 27(7), 573-80. Retrieved from
http://search.proquest.com/docview/1660689368?accountid=15035
Leemans, K., Cohen, J., Francke, A.L., Vander Stichele, R., Claeseen, S.J.J., Van den Block, L., &
Deliens, L, (2013). Towards a standardized method of developing quality indicators for
palliative care: protocol of the Quality indicators for Palliative Care (Q-PAC) study. BMC
Palliative Care, 12(6), doi:10.1186/1472-684x-12-6
Ministry of Health (2002). Towards clinical excellence – an introduction to clinical audit, peer
review and other clinical practice improvement activities. Retrieved from
hhtp://www.moh.govt.nz/moh/nsf
Ministry of Health (2003). Improving quality (IQ): A systems approach for the New
Health and Disability Sector.
Ministry of Health (2001) . The Primary Health Care Strategy. Retrieved from
http://www.health.govt.nz/publication/primary-health-care-strategy
McEwan, J., (2008). Implementing effective health audits. Training Tool.
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Zealand
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References (continued)
•Patel, S. (2010). Identifying best practice principles of audit in health care. Nursing
Standard, 24(32), 40-48. Retrieved from Proquest database.
•Rosario, M., Padros, C., Bernet, B. & Leon, B. (2012). Quality of Care in Palliative Sedation: Audit
and Compliance Monitoring of a Clinical Protocol. Journal of Pain and Symptom Management, 44(4),
532-541. Doi:10.1016/j.jpainsymman.2011.10.029
Royal College of Physicians London (2013). National Care of the Dying Audit in Hospitals. Retrieved
from http://www.rcplondon.ac.uk/resources/national-care-dying-audit-hospitals
•Russell, J. P. , & Regel, T., L,. (2000). After the quality audit- closing the loop on the audit process.
(2nd ed.). American Society for Quality.
Suhartono, M. & d. Suhartono, D. (2015). Variability model implication on Key Performance Indicator
application. International Journal of Innovation, Management and Technology, 6I(1), 77-80.
Retrieved from
https://www.google.co.nz/#q=defining+and+measuring+the+progress+towards+other+goals+evalua
ting+success+or+failure+of+a+specific+activity+or+aspect+of+care+(Suhartono+%26+Suhartono%
2C+2015).
Standards New Zealand (2008). Retried from
http://www.standards.co.nz/services/publications/8134+2008+Information+page.htm.
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