Key Driver 2: Implement a Data-driven Quality Improvement Process to Integrate Evidence into Practice Procedures
Evidence is always evolving, so practices have to change if they are to stay current. Quality improvement (QI) is a systematic, data-driven process for managing that change. QI starts with the assumptions that opportunities to improve are abundant, that quality problems and solutions rest with the system as a whole, and that change is possible. Practices serious about incorporating new evidence will dedicate resources to a QI Team that can drive the changes required to respond to new evidence. Once a practice chooses a QI approach and tools and sets improvement goals, it can identify and test specific changes to care delivery processes and workflows. A key step is to choose QI measures that provide information to guide implementation, and to collect and review data regularly. Small practices can start simply, using common sense and a can-do attitude to get the process going. Practices that are part of larger systems may have more QI resources to draw on and likely will need to align themselves with interests of the larger system while working to keep QI priorities and activities practice-driven. Regardless of a practice’s size, the important point to remember is that QI is a continuous activity, not a one-time effort. With QI teams that consist of care team members and other staff, practices can systematically apply evidence, improve patient care and outcomes, and make incremental progress towards their goals.
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Adopt a consistent QI approach and use QI tools to make changes
Attempts to implement new evidence can be inefficient and ineffective unless practices use a systematic approach to achieve identified goals. Several QI approaches have become popular in health care. These include the Model for Improvement (focused on continuous change made by rapid cycle testing), Lean (focused on efficiency), Six Sigma (focused on standardization), and several patient safety approaches (e.g., root cause analysis, failure mode and effects analysis). Each of these QI approaches employs a set of QI tools, such as run charts, process and workflow maps, cause and effect diagrams, patient shadowing protocols, patient and family feedback forms, and Plan-Do-Study-Act (PDSA) or A3 worksheets. Regardless of which QI approach a practice chooses, the QI team can use it to set goals and develop and implement a QI plan. A QI plan can specify what changes will be made, when they will be made, for how long they will be tested, and how the success of the changes will be assessed. Which QI approach is selected is not critical, and ambitious practices may choose to use more than one. What matters is that practices choose at least one, learn how to use it, set goals, and start making changes.
Develop an inter-professional quality improvement team that meets regularly
Quality improvement is a team sport – improving quality is everyone’s job. However, practices should recruit team members to lead QI work and carve out time to plan and execute QI activities. To be successful, the QI team should include enthusiastic clinical and non-clinical staff who occupy diverse roles at all levels of the practice. In some practices, patients and patients’ family members have been productive members of the QI Team. It is helpful to have a core group that understands QI processes, but the QI team will need to be dynamic, drawing in different people who will be affected by the changes being considered, including front office and data management staff. When involving new staff on the QI team, it is important to be clear about the expectations of what they will contribute and because of organizational hierarchies, to empower non-physicians and non-clinicians on the QI Team. In very small practices, the QI Team may encompass the entire staff. Even so, dedicated time to do QI work is important. Holding regular meetings, with planned agendas to ensure productive sessions, signals that QI is a practice priority and can help prevent the press of clinical or administrative workloads from crowding out QI work.
Engage care teams and other staff to support implementation of new evidence
Although the QI Team shoulders the load in terms of QI planning and data collection, most of the practice workforce is likely to be involved in making changes. Engaging those not serving on the QI team – both clinical staff and others involved in implementing new evidence (e.g., practice managers) – at the outset of the improvement process increases the likelihood of success. Practice staff are the experts in what is feasible and can prioritize which changes to make first, suggest new changes to try, assess ideas on changing workflows or roles, and identify consequences of changes that members of the QI Team did not anticipate. Transparency is critical to the effectiveness of the QI enterprise. If all members of the practice do not serve on the QI Team, the QI Team should regularly report to the rest of the practice on what progress is being made and also solicit their input regarding QI processes and goals.
Select internal QI measures, collect data, compare with goals and benchmarks, and act on data regularly
QI measurement answers the question, “Did we do what we set out to do?” Change is difficult. There is a tendency to revert to familiar ways of doing things. Practices will want to collect data to see if the changes that have been agreed upon have in fact been made and that they have achieved the desired results. When selecting quality improvement measures, practices will want to remember that, unlike accountability measures, they are for internal purposes and only need to be accurate and quick enough to guide improvement activities. Comparing results – including team-specific results – with practice goals will confirm if planned changes have occurred. Experienced practice facilitators report that using QI measures help practices make decisions on more than anecdotes. Practices should also regularly compare quality measures to practice-level goals and external benchmarks to ensure that quality improvement activities are helping them meet and exceed their expectations for patient care.
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