Developing an Organizational Infrastructure for a Successful and Sustainable Quality Improvement Program

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Quality may be defined as doing the right things the right way at the right time the first time, every time..... Quality is not a department, a program, nor a person ? it's a culture.. Objectives. Understand the implementation concepts for a good Quality Program Understand leadership's role in th

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Developing an Organizational Infrastructure for a Successful and Sustainable Quality Improvement Program

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1. Developing an Organizational Infrastructure for a Successful and Sustainable Quality Improvement Program Laurie P. Frye, MS/MIS, MPH, CPHQ Director of Quality Improvement for Adventist Health Central California Network

2. Quality may be defined as doing the right things the right way at the right time the first time, every time....

3. Objectives Understand the implementation concepts for a good Quality Program Understand leadership’s role in the Quality Program’ infrastructure Learn how a CHC implemented a Quality Program from

4. Quality Program Implementation Concepts A truly integrated quality system is based on 3 principles: customer focus, process improvement and total involvement. Customer: Internal and External Process Improvement: Front Office, Back Office, IZ immunization…etc. Total Involvement: Daily activites that act on the 1st 2.A truly integrated quality system is based on 3 principles: customer focus, process improvement and total involvement. Customer: Internal and External Process Improvement: Front Office, Back Office, IZ immunization…etc. Total Involvement: Daily activites that act on the 1st 2.

5. CHC Leadership & Quality

6. Quality Expectations BPHC POLICY INFORMATION NOTICE: 98-23 The Program Expectations are comprised of four sections: Section II., “Clinical Program” highlights the services, staffing and systems which contribute to the provision of high quality health care. “The organization should support and establish a locus of responsibility, such as an interdisciplinary quality improvement committee, for the quality improvement program. Quality improvement activities and results should be reported to the clinical and management staff as well as the governing board” To carry out a QA/QI process the health center needs to establish a framework that meets the needs of the organization and the requirements of the BPHC. The framework should be set forth in a policy statement. Essentially, the framework involves a QA/QI Committee working closely with the departments, programs, and sites of the health center; a planning process also involving departments and programs; and the externally imposed standards. Provides a model for health centers to use in formulating their quality improvement policy. The model incorporates the BPHC and JCAHO requirements and addresses the QI Committee, recurring and special audits, credentialing, patient complaints, and mid-level practioner supervision. To carry out a QA/QI process the health center needs to establish a framework that meets the needs of the organization and the requirements of the BPHC. The framework should be set forth in a policy statement. Essentially, the framework involves a QA/QI Committee working closely with the departments, programs, and sites of the health center; a planning process also involving departments and programs; and the externally imposed standards. Provides a model for health centers to use in formulating their quality improvement policy. The model incorporates the BPHC and JCAHO requirements and addresses the QI Committee, recurring and special audits, credentialing, patient complaints, and mid-level practioner supervision.

7. Health center quality improvement systems should have the capacity to examine topics such as: patient satisfaction; patient access to care; quality of clinical care; quality of the work force; quality of the work environment; cost and productivity; and health status outcomes Quality Expectations To carry out a QA/QI process the health center needs to establish a framework that meets the needs of the organization and the requirements of the BPHC. The framework should be set forth in a policy statement. Essentially, the framework involves a QA/QI Committee working closely with the departments, programs, and sites of the health center; a planning process also involving departments and programs; and the externally imposed standards. Provides a model for health centers to use in formulating their quality improvement policy. The model incorporates the BPHC and JCAHO requirements and addresses the QI Committee, recurring and special audits, credentialing, patient complaints, and mid-level practioner supervision. To carry out a QA/QI process the health center needs to establish a framework that meets the needs of the organization and the requirements of the BPHC. The framework should be set forth in a policy statement. Essentially, the framework involves a QA/QI Committee working closely with the departments, programs, and sites of the health center; a planning process also involving departments and programs; and the externally imposed standards. Provides a model for health centers to use in formulating their quality improvement policy. The model incorporates the BPHC and JCAHO requirements and addresses the QI Committee, recurring and special audits, credentialing, patient complaints, and mid-level practioner supervision.

8. Leadership is CRITICAL If leaders are to bring about system-level performance improvement, they must channel attention to and take action…

9. Board of Directors The overall responsibility for continuous improvement resides with the Board of Directors. The Board delegates the authority to conduct the process of QI to the Chief Executive Officer, the Quality sub-Committee of the Board and the Quality Steering Committee

10. Quality Board Committees The Quality sub-Committee of the Board will provide advice and recommendations to the Board of Directors for program and patient care management, QI plan with prioritized QI activities and overall customer satisfaction.

12. QI Plan Components 1. PURPOSE a. Quality Mission Statement b. Quality Defined c. Quality Philosophy d. Quality Culture 2. LEADERSHIP a. Board of Directors b. Quality Committee of the Board c. Quality Steering Committee 3. QUALITY STEERING COMMITTEE a. Membership b. Meetings c. Authority d. Roles and Responsibilities i. Overseeing Sub-Committees Ii Monitoring QI Measures and Reports iii. Identifying and Prioritizing QI opportunities iv. Overseeing QI Teams 4. QUALITY IMPROVEMENT TEAMS a. Team Parameters b. Team Progress Reporting c. Team Follow-up (Holding the Gains) d. Team Member Roles QUALITY IMPROVEMENT METHODOLOGY Plan Do Study Act

13. Now Put it to Work for Your Organization!

14. Questions/Discussion

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