Practice Facilitation Handbook
Module 14. Creating Quality Improvement Teams and QI Plans
Forming a Quality Improvement Team at a Practice
Improvement work invariably involves work across multiple systems and disciplines within a practice. The quality improvement (QI) team or committee (QIC) is the group of individuals within a practice charged with carrying out improvement efforts. The team may report to the organization’s chief executive officer. To be effective, the team should include individuals representing all areas of the practice that will be affected by the proposed improvement, as well as patient representatives.
The QI team meets regularly to review performance data, identify areas in need of improvement, and carry out and monitor improvement efforts. For these activities, the teams will use a variety of QI approaches and tools, including the Model for Improvement (MFI), Plan Do Study Act (PDSA) cycles, workflow mapping, assessments, audit and feedback, benchmarking, and best practices research.
The team should have a clearly identified “champion” who is committed to the ideal and process of continuous improvement. This individual should be interested in building capacity in the practice for ongoing improvement and implementing effective “processes” that will enable improvement. Such processes may include gathering and reflecting on data, seeking out best practices, and engaging voices and perspectives of individuals involved in all aspects of the process/activity under scrutiny. The role of the QI team champion is to ensure that the team functions effectively and fulfills its charter for the organization.
Who Should Be on a Quality Improvement Team?
The Institute for Healthcare Improvement (IHI) recommends that every team include at least one member who has the following rolesi:
- Clinical leadership. This individual has the authority to test and implement a change and to problem solve issues that arise in this process. This individual understands how the changes will affect the clinical care process and the impact these changes may have on other parts of the organization.
- Technical expertise. This individual has deep knowledge of the process or area in question. A team may need several forms of technical expertise, including technical expertise in QI processes, health information technology systems needed to support the proposed change, and specifics of the area of care affected. For example, a team implementing an intensive care management clinic for people with poorly controlled diabetes might need technical expertise in change management, the clinic’s electronic health record, and the patient treatment protocols that will be used.
- Day-to-day leadership. This individual is the lead for the QI team and ensures completion of the team’s tasks, such as data collection, analysis, and change implementation. This person must work well and closely with the other members of the team and understand the full impact of the team’s activities on other parts of the organization as well as the area they are targeting.
- Project sponsorship. This individual has executive authority and serves as the link to the QI team and the organization’s senior management. Although this individual does not participate on a daily basis with the team, he or she may join periodically and stays apprised of its progress. When needed, this member can assist the team in obtaining resources and overcoming barriers encountered when implementing improvements.
The optimal size of a QI team is between five and eight individuals, although this may vary by practice. The most important requirement is not size, but diversity of the participants. It is important that the team include a diverse group of individuals who have different roles and perspectives on the patient care or other processes under consideration. This group should include whenever possible input from the “end user” of health care, the patient.
Potential members of a QI team might be:
- Chief executive officer.
- Medical directors.
- Nursing staff.
- Physician assistants.
- Medical assistants.
- Patient representatives.
- Operations manager/director.
- Health educators.
- Community health workers.
- Peer mentors.
- Community representatives.
- Directors of clinical services.
- Practice managers.
- Medical records staff.
- Lab technicians.
- Pharmacy or dispensary staff.
- Case managers.
- Physical plant operations.
- Billing department staff.
- Finance director.
i Adapted from the Institute for Healthcare Improvement. Science of Improvement: Forming the Team. Available at: http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementFormingtheTeam.aspx.
Creating a Quality Improvement Plan With a Practice
One of the first tasks to complete with the QI team is to identify goals for the improvement work and associated performance metrics. It is useful to have preliminary performance data available to use in setting improvement goals whenever possible. Goals are fluid and will likely change during your work with the practice as more information is gathered on practice performance and functioning and as the team achieves preliminary goals and is ready to move on to new ones.
Using Key Driver Models To Focus Quality Improvement Plans
Key driver models are roadmaps to particular outcomes that help focus the work of a facilitation program, as well as the work of individual facilitators and facilitation teams at the practice level. Key drivers define the pathway to a desired transformation. Key driver models graphically display the strategies and activities needed to achieve goals and aims of the practice improvement effort (DeWalt, et al., 2010).
Facilitation programs typically use two levels of key driver models:
- One at the programmatic level that outlines the facilitation program’s overarching goals and underlying model for change, and
- One at the practice level, which tailors the programmatic model to the needs and priorities of individual practices.
Program-level and practice-level key driver models include:
- Desired outcomes for the practice improvement effort,
- Big changes or “key drivers” that are most likely to accomplish these goals, and
- Specific changes or action items that must occur to produce the desired big changes.
Example of a Key Driver Model
Figure 14.1 shows a program-level key driver model for improving diabetic and asthmatic patient outcomes based on the Care Model (see Module 16). This key driver model was developed for the Improving Performance in Practice Initiative funded by the Robert Wood Johnson Foundation and provided by Dr. Darren DeWalt.
The far left column shows specific QI goals. The middle column contains the organizational and care processes thought to improve care and patient outcomes. These key drivers function as a menu from which practices can choose the approaches they will use to achieve their goals. The far right column contains the “change concepts” or action items/steps to implement a particular key driver.
Designing a Key Driver Model With a Practice
You should work with the practice to develop a practice-level key driver model that links to the outcomes identified by the practice and targeted by the facilitation intervention. The practice’s QI plan should be based on the practice-level key driver model to reflect the change concepts included in the model. If your program has a predefined key driver model for the intervention, you should review the prescribed model with the practice’s QI team and work with them to identify the drivers and change concepts they want to implement first, second, and third. You should also ask the practice to identify what other items not currently represented on the key driver model they are interested in changing, and make these additions accordingly.
If your facilitation program does not have a key driver model for the change work the practice wants to do, consult the guide Developing and Running a Primary Care Practice Facilitation Program (Knox, et al., 2011). You will find guidance on creating a key driver model, including a couple of samples showing different forms key driver models can take.
A first step in developing a key driver model is to choose goals that are clearly defined. Goals and outcomes should be SMART:
- Relevant, and
- Time bound (IOM).
When defining its change goals, the practice should include numeric targets. Distinguish between goals that will be accomplished during the period you are facilitating (if it’s time limited) and longer term goals. They should be based on the results of the practice assessment and focus on the areas needing improvement.
As you work with the practice on developing its practice-level key driver model, point out materials and resources to support the improvement activities and tasks associated with each key driver. For example, the Integrating Chronic Care and Business Strategies in the Safety Net Toolkit (AHRQ, 2008) contains many tools useful to practices implementing the Care Model. You will need to familiarize yourself with resources that you can use to support these changes in the practice.
As part of developing this plan, you will also need to help the practice establish an inventory of the resources, assets, and personnel talents that currently exist in their practice and can be leveraged to support Care Model implementation and its associated key drivers and change concepts.
Creating a Quality Improvement Plan
A QI plan should provide guidance to the practice on who is to participate on the QI team, how often it is to meet, and what its goals and key activities are. In addition, the plan should lay out the process that will be used to drive improvement in the practice, such as the MFI and PDSA cycles, how these are to be documented, and the way current and ongoing status is going to be monitored using data. A good QI plan includes among other things:
- A statement of the quality vision.
- A description of the program structure.
- A membership for the QI team or committee that is diverse.
- A meeting schedule.
- A defined process for how QI will be conducted.
- A list of improvement goals or priorities that are specific, measurable, achievable, relevant, and time bound.
- A plan for how both the plan and the goals will be evaluated.
- A plan for how performance data will be acquired and reported.
An important role you can play as a practice facilitator will be to assist practices in developing a plan or to review the plan they already have.
Monitoring Progress on the Quality Improvement Plan
With new QI teams, another role you can play is to help the team develop systems that will allow them to track progress toward their improvement goals and monitor their performance on key quality indicators. To do this, you will need to work with practice leadership and staff to set up data systems that can produce practice performance reports on key quality metrics on a monthly or quarterly basis. As much as possible, you should assist the practice to automate the development of these reports so that the burden on staff is minimized or to design the data collection process so staff can carry it out in addition to their existing duties. An elegant system that cannot be sustained is no better than having no system at all.
You will need to work with the QI team to develop a standard template for the performance report and identify the time period for reporting. You will also need to assist them in identifying the staff needed to prepare the reports and the time they will need to accomplish this task. In addition, you will need to work with the team to revise staff job descriptions to include this task, as well as their performance evaluation. You will also need to help them train staff on these tasks.
A QI dashboard or data wall can be a useful tool for QI teams to help them track progress toward key improvement goals. QI dashboards or data walls are one- to three-page summary reports that provide a graphic summary of progress toward key process and outcome metrics. Often they include a “stoplight” system of red, yellow, and green color coding to signal that an activity or performance metric is on track, partially off track, or having serious problems. It can be helpful to include a dashboard of progress toward the elements of the key driver model if one was included as part of the QI plan. In addition, it can be useful to include copies of any PDSA cycles that are underway or completed with the dashboard to enable the QI team to easily review its progress.
The report will create a written record of the team’s progress and help increase ownership and accountability in the QI team and practice for follow-through on improvement work. It also can help you identify QI teams that have hit a roadblock and may need some additional assistance from an expert consultant or a facilitator with a different set of skills. You can add this expertise to your facilitation team if it is needed.
Integrating chronic care and business strategies in the safety net. (Prepared by Group Health’s MacColl Center for Health Care Innovation, in partnership with RAND and the California Health Care Safety Net Institute, under Contract No./Assignment No: HHSA2902006000171). AHRQ Publication No. 08-0104-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2008.
Knox L, Taylor EF, Geonnotti K, et al. Developing and running a primary care practice facilitation program: a how-to guide (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO5.) Rockville, MD: Agency for Healthcare Research and Quality; December 2011. AHRQ Publication No. 12-0011. Available at: http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/pcmh_implementing_the_pcmh___practice_facilitation_v2. Accessed April 4, 2013.
SMART Objectives. The Smart Bites Toolkit. Institute of Medicine. Available at: http://www.iom.edu/About-IOM/Making-a-Difference/Community-Outreach/~/media/Files/About%20the%20IOM/SmartBites/Planning/P1%20SMART%20Objectives.ashx. Accessed April 26, 2013.