Transcript: Getting Started with the AHRQ QI Toolkit
Speaker: Donna Farley, Adjunct Senior Health Policy Analyst, RAND
Interviewer: Lise Rybowski
Date: April 2012
Audio format: Getting Started with the Toolkit (MP3 audio file; 11 min., 26 sec.)
Interviewer: On behalf of the Agency for Healthcare Research and Quality, I'd like to welcome you to a series of interviews designed to orient and educate users of the AHRQ Quality Indicators Toolkit for Hospitals. This toolkit was designed to support hospitals seeking to improve their performance on the AHRQ Inpatient Quality Indicators and the Patient Safety Indicators.
Today I'm interviewing Donna Farley, who will talk about getting started with the toolkit. Dr. Farley is an adjunct senior health policy analyst at the Rand Corporation that was awarded the AHRQ contract for developing this toolkit, and she's been the principal investigator on this project. In this discussion, we will consider how hospital teams might use the toolkit to support their quality improvement initiative, including ways they might adapt use of the tools to their hospitals' unique situations. Donna, thanks for being here with me today.
Donna: Glad to be here, Lise.
Interviewer: Let me start by asking you, for what types of quality improvement initiatives should hospitals be using this toolkit?
Donna: Clearly the principal uses of the toolkit would be to support initiatives designed to improve hospital performance on two sets of the AHRQ Quality Indicators, those being the Patient Safety Indicators, or the PSIs, and the Inpatient Quality Indicators, the IQIs. These indicators are increasingly being used in public reporting as well as value-based purchasing. Over the last few years, AHRQ has done a great deal of work to develop, validate, and refine the PSIs and the IQIs, as well as their other Quality Indicators. Information about the indicators is available on the AHRQ Web site at http://www.qualityindicators.ahrq.gov. Also at that location, you'll find an e-mail address and phone number so that people can obtain support in working with the indicators as well as with this toolkit.
Many of the tools in the toolkit are designed specifically to provide guidance on how to work with these two sets of Quality Indicators. In particular, they are provided to support three general aspects of hospitals' quality improvement work. The first is analyzing a hospital's rates on the indicators and then using that information to set priorities for the performance issues that a hospital team concludes may be most important for it to address. The second is using the indicators to assess progress in tracking changes in their rates over time during the implementation of improvements for the quality improvement process. And third is continued monitoring of these rates after implementation is complete so that a hospital can achieve sustainability of the improvements they made during that initiative.
However, the quality improvement methods for the tools included in the toolkit are really quite generic. That is, they are the same methods that a hospital would use for any initiative to improve its performance for any aspect of its operation. So those tools that support quality improvement processes per se can be used for any quality initiative, even if it's not using the Quality Indicators to measure their performance outcomes.
Interviewer: I see. That's very helpful to know. If a hospital team wanted to use the toolkit, it sounds like there's a lot of material in there. Where should they start?
Donna: That's a really good question. When you first look at it, it's probably somewhat intimidating. My suggestion is that the first thing you want to do is to examine carefully the introduction and roadmap. This is a document that's posted on the AHRQ toolkit Web site, and there's a link to it so that you can download it. The roadmap shows that the toolkit is organized in a step-by-step order for each of the steps involved in a quality improvement process. In fact, the AHRQ Web pages on which the tools are posted in electronic form are organized according to this roadmap, so it really provides an overall frame that sets each of the tools in context with the bigger picture of the implementation process.
I would encourage users to download the PDF file of the introduction and roadmap and print it out so that you have it available for easy reference as you proceed with your work. You can check back against it and see what tools may be available for you as you go from step to step. The link for this file is on the main toolkit page at http://www.ahrq.gov/qual/qitoolkit.
The roadmap presents the tasks that an improvement team would carry out for each quality improvement step, and then for each task, it identifies the tools available to support the task, as well as the key people who need to be involved. A couple of examples here. First of all, one task is to assess the readiness of your hospital to carry out effective quality improvement efforts. The tool provided for this is a self-assessment form that hospital teams can complete to make that assessment, and the key audiences identified for that task in the tool are hospital senior management staff and quality leaders.
Another example of a task is to understand coding issues that may be affecting the accuracy of a hospital's PSI or IQI rates. The tool provided here is a document that contains guidance on how to achieve effective documentation and coding, and it gives specific attention to issues related to the PSIs. The key audiences here are physicians and other providers, clinical documentation specialists, coders, and quality leaders. So you can see, the audiences can vary quite widely, depending on the task and tool that you're working with.
The most important thing to keep in mind, though, when you decide how to use the toolkit is that it's the improvement process that should be driving choices on which tools to use and how to use them, not the other way around. The hospital leaders and team can decide which tools they think would be most useful to them based on their current capabilities.
Interviewer: You've mentioned a number of people who need to be involved in this work, so can you talk a little more about the different members of the hospital staff that need to be involved in using the tools?
Donna: I sure can. This is actually one of the most important topics, as far as I'm concerned. Your question asks specifically about involvement in the use of the tools, but I'm going to step back a bit and talk about stakeholders in general, because that's what's implicit in the question. Proper engagement of stakeholders is a key aspect of all quality improvement processes, and unfortunately, it's one that's often overlooked, occasionally with dire results. For example, I once witnessed a hospital team fail in an entire improvement strategy because the team neglected to seek input and feedback from the nurses regarding a form it was developing, and the nurses boycotted the use of the form.
So who are these stakeholders? In general terms, they are any group who will be involved in or affected by the changes being made in an improvement process. Obviously, they include physicians and nurses, but depending on the initiative, they also could include unit clerks, pharmacists, hospital IT staff, dietary, or even housekeeping.
Now, back to the toolkit. The concept of stakeholder engagement applies for use of the tools just like it does for the implementation process. Personnel are likely to gain a sense of ownership in that improvement effort as a result of applying their skills to working with the tools. The tasks being supported by each tool encompass a wide variety of actions and associated skills, so we've designed each tool to be used by those with the relevant skills. For example, analysts and programmers are audiences for tools involved in working with the rates for the PSIs or the IQIs, and financial officers are an audience for the investment analysis. The introduction to each tool identifies which type of personnel are the key audiences for its use, and that can guide how you can engage others in the process.
Interviewer: Great, thank you. That was very helpful. Can you talk now about what the hospitals can do with the tools to customize them to their needs?
Donna: Sure, and this is particularly important when hospitals are looking at their unique situation and what they really need to do, in their view, to be effective in communicating and working together on whatever initiative they are pursuing. As we developed the toolkit, one of the design principles that we established to guide the process was ease of use and opportunity for adaptation, and we worked hard to make this happen.
The tools are readily adaptable to individual hospital needs in several ways. The first way, in fact, is the variability of a hospital team to pick and choose which tools they will use. Secondly, some of the tools are actually templates that are specifically designed to be customized by each hospital. These include, for example, a template educational slide show, which is designed to provide information to the hospital board and staff on the Quality Indicators and how to use them. And another example is a slide show template for reporting hospital rates and trends in those rates over time.
Finally, most of the other tools are amenable to adaptation to a hospital's specific needs. This is particularly true for the tools that are involved in assessing issues and priorities and in developing action plans for improvements. A good example of this is the prioritization matrix, which can be modified to change either the set of issues that are being considered in the prioritization process or the candidate measures that are being examined as possible priorities.
However, we advise that hospital teams be careful when working with other tools that draw upon published research or scientific methods to provide guidance on how to carry out a task correctly. These tools are dealing with methods that we believe there is indeed a correct answer for what to do and how to do it. The set of best practices documents for the PSIs is an excellent example of this. You want to adhere to the basic science that's summarized in those documents even while adapting the way you apply it to your hospital situation.
Another example is the estimation of trend information in the QI rates or performing benchmarking comparisons. You want to be sure when you are doing those that you are calculating the rates correctly and you're using the correct rates for comparison for each of these processes, or you could end up with inaccurate findings regarding the hospital's performance. And our tool on applying the QIs to the hospital data spends quite a bit of time providing instructions on how to apply them correctly so that you're getting that valid information.
Interviewer: Thank you so much, Donna. Those are really great examples, and I think this has been a very nice introduction to the AHRQ Quality Indicators Toolkit for Hospitals. To learn more about the toolkit, please visit http://www.ahrq.gov/qual/qitoolkit. On that page, you can check out the roadmap, download and watch a video that introduces the full toolkit, or browse and download the tools. We'll be releasing additional interviews about the use of specific tools in the quality improvement process, so be sure to watch for announcements from AHRQ.
Thank you for listening.