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McLaughlin and Kaluzny, Continuous Quality Improvement in Health Care, 3rd Ed. CHAPTER 4 MEASUREMENT AND STATISTICAL ANALYSIS IN CQI LEVELS OF QUALITY CONTROL 4. Design for Quality – requires process ownership, organizational investment, low inherent variability 3. Process Control – statistically based, needs larger samples, case mix adjustments on the fly 2. Measuring & Improving the Process – walk before you run 1. Inspection – take names and kick butts WHAT ARE ALTERNATIVE MEANS OF GATHERING SERVICE QUALITY INFO? Disinterested observer – grand rounds can be an example Cognitive record of service deliverer - chart After-the-fact reporting of recipient satisfaction – gets at different constructs Objective outcome measures – health care system not currently equipped to go there CYA investigation – inspection at its worst VARIANCE REDUCTION ISN’T EVERYTHING Sources of variation Customers/patients/enrollees Servers/providers Processes/systems Measurements Information Interactions among these THE SEVEN ORIGINAL TOOLS Cause and effect diagram Histogram Pareto chart Check sheet Control chart Bar graph Scatter diagram ABOUT METHODS Lots of run charts where there are 3 sigma limits: Was process ever under control? Is there a symmetrical loss function? Real control charts are statistically sophisticated Time series analysis is important, but don’t overdo it. Statistical needs can vary widely. MedErrors 14 Figure 10-4. Knowledge about the medication error process. UCL 12 10 8 6 4 2 LCL . Jul May Mar Jan Nov Sep Jul May Mar Jan 0 MedErrors Figure 10-5. Decisions have been taken to improve the medication delivery process 14 12 10 8 6 4 2 Jan Oct Jul Apr Jan Oct Jul Apr Jan Oct Jul Apr Jan 0 Figure 4-3 Sequence of Questions Who are your Customers, Stakeholders, Markets? What do they expect / require of your services? How you select, design, and improve your services. How you measure your success. Figure 4-9 Root Causes Of Medication Errors Unable to read order due to illegible writing People Procedures Wrong drug selected for patient condition Lack of knowledge Unfamiliar with patient population Reliance on memory Policies not followed Equipment malfunction patient distractions in work environment Manual systems similar packaging for different drugs Plant & Equipment Problem: Adverse Drug Event lack of training drug dose route lack of adverse event reporting time Policies History-Taking Obtain Medicationrelated History Document Medication History FIGURE 4-7 Flow Chart of Medication Administration Reprinted with permission by VHA and First Consulting Group from the VHA 2002 Research Series publication, Surveillance for Adverse Drug Events: History, Methods and Current Issues by Peter Kilbridge, M.D. and David Classen, M.D. First Consulting Group. Medication Inventory Management Ordering Diagnostic/ Therapeutic Decisions Made Medication Ordered Formulary, purchasing decisions Order verified and submitted Surveillance Inventory management Pharmacy Management Evaluate order Incident/adverse event surveillance and reporting Select medication Prepare medication Dispense/ distribute medication Administration Management Monitor/Evaluate Response Intervene as indicated for adverse reaction/error Assess and document patient response to medication according to defined parameters Document Document administration and associated information Administer Medication Administer according to order and standards for drug Select the correct drug for the correct patient Education Educate patient regarding medication Educate staff regarding medications Figure 4-6 Flow Chart of Medication Administration Process medication ordered is medication in unit stock? no request from pharmacy yes administered to patient documented in patient’s record observe patient status dispensed by pharmacy McLaughlin and Kaluzny, Continuous Quality Improvement in Health Care, 3rd Ed. CHAPTER 5 MEASURING CONSUMER SATISFACTION SOURCES OF SERVICE QUALITY DATA Direct observation of transaction by third party Supervisor, Cognitive record of process (by provider) Medical mystery shopper, recording device record Consumer reports of the experience By patient or family QUALITATIVE MODALITIES Management observation Employee feedback programs Work teams/quality circles Focus groups Mystery shoppers QUANTITATIVE MODALITIES Comment cards Mail surveys Point-of-service interviews Telephone interviews ROLES FOR MEASURES OF CONSUMER SATISFACTION Best sources of information about: Communication Education Pain management Met market place demands for such information Keep analyses patient-centered THREE TYPES OF CONSUMER DATA Measures of preferences – what consumer wants Evaluations by users Reports of health care experiences Buyer-Decision Process WHO ARE THE CONSUMERS? Patients, obviously, plus: Physicians – referrals, downstream processes Facilities Insurers/ Managed care organizations Government/ Other regulators Families Communities CAHPS DOMAINS Nurse communications Nursing services Physician communications Physical environment Pain control Communication about medications Discharge information Overall rating of care/ Recommendation to others TIMING IS IMPORTANT Patient recall times limiting Evidence of outcomes varies with time Comparability of intra-institutional data Comparability of cross-institutional data Impact on response rates THE BALANCE SCORECARD Suggested factors to balance: Finances Human resources Internal processes Customer satisfaction Remember the Donabedian grid