Objectives Mary Jo Goolsby, EdD, MSN, NP-C, CAE, FAANP

Mary Jo Goolsby, EdD, MSN, NP-C, CAE, FAANP
JoEllen Wynne, RN, MSN, FNP-BC
y Discuss at least one performance improvement model, as it relates to one’s practice.
y Describe range of performance measures, proposed by quality organizations.
y Given commonly encountered conditions or situations, identify at least two relevant
potential aims and measures.
y Discuss strategies to facilitate successful performance improvement in a clinical
y Implement performance improvement including relevant aims, measurable
outcomes/performance measures, engaged team and resources, within one’s practice
PI Principles
y Performance/Practice Improvement should be:
y Based on issues important to the providers and their patients
y Based on best available evidence
y Designed to include patient health status and outcomes,
satisfaction, measures of access
y Reflect appropriate variation in practice
PI Principles
y Performance/Practice Improvement (cont’d):
y Practical
in light of available resources
in regards to data collection and analysis
Conducted in context of CQI
Revised and updated at regular intervals
y PI provides a structured and ongoing process through
which HCPs:
y Explore specified measures related to their practice
y Retrospectively assess their practice
y Apply improvement plans over a specified period of time
y Reevaluate performance
Priority Selection
y The impact on burden
Disability, mortality, costs
y Improvability
Narrowing/closing gap between current practice and
y Opportunity to improve areas such as safety, effectiveness,
patient-centeredness, efficiency, timeliness
y Inclusiveness
Consideration of populations and differences such as
gender, age, economics, condition types, settings
IOM Priority Areas
y Care coordination P,B,C
y Self-management and health
literacy P,B,C
y Asthma: Mild-to-moderate
persistent C
y Evidence-based
cancer screenings
y Children with special needs C
y DM: early management C
y EOL with advanced organ system
failure (CHF, COPD) C
y Frailty w/ old age, falls, PU,
functionality, advanced plans C
y HTN: early management P,C
y Immunizations P
y IHD: prevent/ reduction,. . P,C
y Major depression: screening/
treatment P,B,C
y Medication Mgt: preventing errors,
abx overuse C
y Nosocomial infections
y Pain control in advance CA C
y Pregnancy and childbirth P
y Mental illness-severe and
persistent B
y Stroke: early intervention and
rehab C
y Tobacco dependence P,B,C
y Obesity (emerging area) P,B,C
IOM categories by preventive care P, behavioral health B, and chronic conditions C
Setting Aims
y Need agreement in the goal/aim
y Seek quantification (increase X by 75%)
y Set time-frame to stretch (increase X by 75% within 12
y Be clear to avoid interpretation over time (increase X by
75% vs significantly increase X)
y Consider when narrow focus necessary (all patients vs
those with cardiac conditions)
IOM Broad Aims
y Safety: Safe care avoids errors and injuries
y Effectiveness: Effective care is based on best-available evidence
y Patient-Centeredness: Patient-centered care is respectful of and
responsive to patients’ needs, values, decisions
y Timeliness: Timely care avoids waste and harmful delays
y Efficiency: Efficient care avoids waste and optimizes
y Equity: Equitable care quality is not dependent on
socioeconomic status, gender, etc
Goals not Synonymous
with Measures
y Goals describe the AIMS for the project and measurement
y Aims include broader concepts such as improving patient
satisfaction ,safety, costs
y Aims should drive the measurements so that they are
specific, measurable, attainable, relevant, and timely
Performance Measures
y Evaluate to determine which are
y Important
y Measurable
y Achievable
Considering measures
y Consider importance:
y Evidence-base
y Potential for improved outcomes
Directly or indirectly
Substantial and relevant
y Consider measurability:
y Reliable and valid
y Well-defined
Identify rationale/intent
Specify relevant population
Determine the denominator
Specify inclusion/exclusion criteria
Define the data elements and sources
Identify data collection processes
Establish means to verify data
Ensure interpretable findings
y Consider achievability
y Achievable and reasonable goal
y Feasibility
Available data
Protection of confidentiality
Reasonable number of measures
Consistency of measures and processes
Adequate instructions on procedures
Room for appropriate variation by clinician and patient
Cost-effectiveness of processes
Types of Measures
y Outcomes
y Clinical: A1c, blood pressure,
y Number of days to appointment
y Time waiting to be seen
y Satisfaction
y Processes
y Percentages of patients with A1c, BP recorded
y Average time to be appointed
y Average wait time in clinic
Selecting from Outcome and
Process Measures
y Practicality
y Need to establish reality
y Diabetes example:
y Need to know the % of patients with DM for whom A1c
documented twice a year
y Need to determine % of patients with DM with A1c above
or below determined value
Effective Measurement
y Measured over time
y Usefulness, not perfection
y Sampling
y Integration into daily processes
y Collect qualitative data, as well
Determining Sampling
y Baseline
y Frequency: ongoing vs intervals
y Selection: all vs every nth
PI Models: Examples
y DMAIC (define, measure, analyze, improve, control)
y PDCA (plan, do, check, act)
y IMPROVE (identify, measure definitions, problem
analysis, remedy cause, operationalize effectiveness,
y PDSA (plan, do, study, act)
y Plan: Identify the aim, predict what can be achieved,
develop a plan that includes who, what, when, where.
y Do: Implement a test, documenting problems,
observations, beginning analysis
y Study: Complete analysis, comparing data to
predictions, and summarizing what learned
y Act: Make refinements, determining necessary
modification and planning next steps
Conceiving General Plan
y What are you trying to accomplish? (Aims)
y How will you know that a change represents an
improvement? (Measures)
y What changes can you make to result in an improvement?
y Keep feasibility and practicality in mind
y Obtain necessary approvals
Engaging Team
y Including the right people
y Number and contributions
y Who will be affected
y Who is familiar with processes involved
y Who has needed skills: system leadership, clinical expertise,
front-line leadership/members
y Clarify responsibilities and roles
Implementing the Change
y Have well-defined processes
y Team leadership and engagement
Establish team feedback loops
Willing participants
y Ensure change is evidence-based
y Small scale pilot
y Standardize steps, changes
Avoid reinvention of wheel
y Reality checks along way
Prepared to halt, if indicated
y Monitor measurements/data
y Track and trend over time
y Compare reality to goals
y Reflect on results of individual steps/changes
y What did/did not work
y Consider next steps
y PDSA cycle repeated
y Refinements
y Broadening
y Adding steps, processes, measures
PI-Based CE
y Growing interest in designing CE programs to help HCPs
improve competencies by translating content through PI
y Integration of evidence-based educational content within
PI programs, with measurement of outcomes
y Credit awarded based on completion of retrospective chart
review, integration within practice, measurement of
Opportunity to Pilot PI-Based
y Intent to participate
y Selection of area, aim(s) and measure(s)
y Retrospective review of records
y Review of relevant content
y Design and implementation of improvement plan
y Summary of process and outcomes
y CE credit for practice achievements