Continuous Quality Improvement Program

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It has been nearly four years since this column has featured a discussion on Standard A-06 Continuous Quality Improvement Program. Since that time, CQI remains one of the most challenging standards, with many questions from those who must implement a CQI program at their facility. However, the 2014 Standards for Health Services manuals for jails and prisons seek to clarify some of the areas of confusion and make CQI programs more user-friendly.

To begin to understand the concept of CQI, the standard itself and its intent must be reviewed. The standard requires a CQI program that monitors and improves the health care delivered in the facility. It intends to ensure that a facility uses a structured process to find areas in the health care delivery system that need improvement and when such areas are found, that staff develop and implement strategies for improvement. Two key concepts in these statements are to find and improve.

Site-Specific Problems
While correctional facilities may be similar in their missions, each facility is different with its own unique challenges. This should be recognized when developing a CQI program. For example, corporate calendars often require the same studies of major service areas for several facilities, which is acceptable and encouraged under A-06. However, each facility must also find its own areas of deficiency and implement strategies for improvement. Simply studying and restudying areas that continuously meet or exceed established thresholds does not meet the intent of this standard. Again, the CQI program must find deficiencies and improve health care delivery.

New in 2014
One of the most notable changes in the 2014 standards is the omission of the terms “basic” and “comprehensive” programs. A quality improvement committee is now required regardless of facility size. Previously, a committee was required only for facilities with an average daily population of more than 500 inmates. The committee must consist of health staff from various disciplines, but may be fluid depending on the issues being addressed. Although the responsible physician maintains a leadership role in the CQI committee, the role is less defined. Many of the duties previously tasked to the responsible physician, such as establishing thresholds, interpreting data and solving problems, have been shifted to the committee, which must meet as required but no less than quarterly. The physician must still be involved in routinely reviewing events such as acute care hospital admissions, medical emergencies and deaths.

Another notable change is in the requirement for the type and frequency of studies. Previously, facilities with an ADP of 500 or less were required to complete one process and one outcome study per year, while facilities with an ADP over 500 had to complete two of each. In 2014 standard, when the committee identifies a health care problem from its monitoring, a process and/or outcome study must be initiated and documented. The committee may decide which type of study is the most appropriate for the problem. Problems may be identified by monitoring high-risk, high-volume or problem-prone aspects of health care or by using data that are regularly monitored through the facility’s administrative reports and patient safety systems.

Whether conducting a process or outcome study, the components are similar. First, a problem must be clearly identified. For a process study, the problem will be related to the health care delivery process (e.g., delayed sick-call appointments, discontinuity of medications, delayed receiving screening). A process study will reveal whether the health care delivery is effective and efficient. For an outcome study, the focus will be on a patient clinical care problem (e.g., poor asthma control, poor diabetes control). An outcome study will reveal whether patients are getting better under the care provided.

The second component of a process or outcome study is to conduct a baseline study (e.g., task analysis, root cause, staffing plan). Understanding the depth and possible cause of the problem will assist in the third component, which is development and implementation of a corrective plan (for process studies) or a clinical corrective plan (for outcome studies). The fourth component is to restudy the problem to assess the effectiveness of the corrective action plan.

Often one or more components of a study are missing, which leads to an ineffective system for finding problems and improving health care delivery. A good CQI program will have clearly documented all four components of a study.

Success in compliance with A-06 is not measured by the number of studies done but by the relevance of the studies and the effectiveness of the corrective action. One of the benefits of a successful CQI program is that problems can be identified early and strategies can be developed for their resolution before they worsen. All health care delivery systems, regardless of size, can benefit from a well-designed CQI program.

[This article first appeared in the Summer 2014 issue of CorrectCare.]

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