Continuous Quality Improvement

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The purpose of continuous quality improvement programs is to improve health care by identifying problems, implementing and monitoring corrective action and studying its effectiveness. Standard A-06 is meant to ensure that a correctional facility uses a structured process to find areas in the health care delivery system that need improvement, and that when such areas are found, staff develop and implement strategies for improvement. An essential element of quality improvement is the monitoring of high-risk, high-volume or problem-prone aspects of health care; not every aspect of every major service needs to be studied. General areas of study include access to care, the intake process, continuity of care, emergency care and adverse patient events, including all deaths.

While the overall goal of CQI programs is universal, there are a variety of ways to conduct CQI studies. NCCHC does not stipulate a particular method or format for these studies; there are many online resources for CQI methodologies, including the popular Plan-Do-Study-Act (PDSA) model.

NCCHC is often asked to explain the difference between a CQI process study and a CQI outcome study. According to the Standards for Health Services (jail and prison), a process study examines the effectiveness of the health care delivery process and an outcome study examines whether expected outcomes of patient care were achieved. Both types of studies should identify a facility problem, conduct a study, develop and implement a plan, monitor and track results, and demonstrate improvement or restudy the problem (Compliance Indicators 3b and 4c).

For outcome studies, a CQI committee would ask whether health services are achieving desired outcomes as far as patients’ conditions. Are patients worsening as a result of the care being provided? Are patients’ symptoms decreasing? Perhaps the CQI committee has identified that diabetes care should be examined and you wish to assess the degree of control in a sample of patients with diabetes. You could develop a form or an audit tool with key indicators to evaluate during your chart reviews of those patients.

Process studies tend to focus on procedural or policy-oriented issues. For example, the CQI committee might investigate how to complete a process or activity more efficiently, or more cost effectively. Let’s say that the committee would like to schedule patients for chronic care clinics in a timelier manner. It might implement a new scheduling log and then monitor those results to determine if the intervention was effective.

Remember, the CQI program focuses on system issues. It studies specific root causes and analyzes objective aggregate data to identify improvements in organizational structure and function. Corporate or pre-set schedules for CQI topics are a great tool to use on a regional or systemwide basis and can augment the facility’s CQI program, but the CQI committee must be involved in identifying facility-specific problems (see Compliance Indicator 1 and 3bi or 4ci), as well. If on-site health staff have no input into problem identification, actual facility issues might not be addressed.

Basic vs. Comprehensive Programs
Facilities with an average daily population of 500 or less should implement a basic CQI program, and those with an average daily population of greater than 500 should establish a comprehensiveCQI program (Compliance Indicator 3 or 4). An important distinction is that basic CQI programs are required to monitor fundamental aspects of the health care system though one process and one outcome study at least annually, whereas comprehensive CQI programs need to conduct two process and two outcome studies.

Comprehensive CQI programs are to be managed by a committee comprised of health staff from various disciplines (e.g., medicine, nursing, mental health, dentistry, health records, pharmacy, laboratory). The multidisciplinary approach lends itself to enhanced staff cooperation and satisfaction, as well as opportunities to solve problems jointly across disciplines. Meetings are held as necessary but no less than quarterly to design quality improvement activities, establish objective criteria for use in monitoring, develop plans for improvement based on findings, assess the effectiveness of these plans after implementation and refine the plans as necessary (Compliance Indicator 4a).

Corrective actions identified through the mortality review process should be implemented via the CQI program and monitored for systemic issues. Patient safety system failures of policy or procedure also should be examined through CQI. However, CQI generally does not focus on individual clinical performance (see A-10 Procedure in the Event of an Inmate Death and B-02 Patient Safety).

An annual review of the effectiveness of the CQI program itself is required for both types of programs (Compliance Indicator 3a or 4b). This might consist of a review of CQI studies, minutes of administrative and/or staff meetings or other relevant materials. Physician chart review is no longer a part of this standard for jails and prisons; now part of standard E-12 Continuity of Care During Incarceration, the purpose is to assure that clinically appropriate care is ordered and implemented by attending health staff. Keep in mind that involvement of the responsible physician remains a key component of basic and comprehensive CQI programs through identifying thresholds, interpreting data and solving problems (Compliance Indicator # 2).

For more details on how to organize CQI programs, see Appendix B in the jail and prison Standards manuals.

[This article first appeared in the Winter 2010 issue of CorrectCare.]

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