Quality Improvement/
Quality Assurance
Amelia Broussard, PhD, RN, MPH
Christopher Gibbs, JD, MPH
Understanding Quality
Improvement and Quality
Assurance
• Quality Assurance and Quality Improvement are often
confused as the same process
• Terms used interchangeably but not the same
• One is focused on observations only and one time
opportunity
• Other is continuous process documenting improvement
• Both based on standards for performance
• Both important to organization
• Both focus on quality services to patients
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Definition of Quality Assurance
• Planned systematic activities implemented in quality system
• Quality requirements for product or service fulfilled
• Activities typically based on standards of practice
• Can help identify problem but no solution
• Compliance with standards goal
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Definition of Quality Improvement
• QI is continuous ongoing process designed to improve
patient outcomes, services or process
• Focus is ongoing rather than one time review
• Team is multidisciplinary with representatives from all
departments
• Focus on process or service not individual
• Proactive rather than reactive
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Goals of QI
• Understand process
Goals of Quality
Improvement
• Reduce & eliminate errors
• Improve efficiency
• Improve communication
• Requires measurement
• Focuses on outcomes
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Core Concepts of Quality
Improvement
• Exceed expectations of patients or clients
• Process usually problem not people
• Does not seek to blame but to improve process
• Most effective when part of everyday work
• Focus on everything, you can not focus on anything
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Quality Improvement and FTCA
• QI plan integrates all
departments in activities
• One QI plan for
organization
• Minutes document QI
activities
• Plan should have certain
components outlining
process of committee
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Quality Improvement Plan
Components
• Statement of Purpose or Intent of Plan
• Scope of Plan
• Administrative Responsibility
• Risk Management Systems (some make this separate plan)
• Role of Peer Review in QI
• Committee Composition
• Committee Accountability
• Methods for conducting QI activities
• Tracking of QI Activities
• Approval and Review
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Statement of Purpose
• Plan includes statement of purpose or intent
• Example
– The purpose of the Quality Improvement Program is to
support improved health care delivery and outcomes for
the patient population receiving care. Objective is to
promote continuous Quality Improvement within the
organization and support the objectives and scope of
Quality Improvement Program.
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Scope of Plan
• Scope refers to what the QI committee will do
• Includes monitoring of select measures, evaluation of
performance and improvement in organizational
performance
• Discusses which activities are applicable to QI
• Includes risk management tracking as reported to QI,
results of peer review and measures to be followed during
year
• Areas of consideration include medical/clinical,
operational/administrative, governance and finance
• Resources available in notes section
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Administrative Responsibility
• Health center identifies by title individual with overall
responsibility for QI program
• Approval requirements are stated (who must approve plan)
• Individual consulted in development of QI/QA Plan and
activities
• Identification of who will receive information about decisions
and activities of QI/QA program
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Risk Management Systems
• Health center identifies the following:
– Policies/procedures regarding appropriate supervision of
clinical and non-clinical staff
– Policies/procedures to identify and document system
process or breakdown
– Policies/procedures for addressing and investigating
medical malpractice claims
• Resources available in Notes section of slides
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Role of Peer Review
• Peer review is the process of all providers reviewing a
peer’s medical records
• Specific time frame for review is defined (i.e. quarterly,
monthly, bi-monthly)
• Results of peer review should be communicated in
aggregate form to QI committee for possible QI projects to
improve patient care
• Review should consist of two parts
– Medical care review
– Review for completion and documentation
– Resources in Notes section
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Committee Composition
• Establishes QI committee
• Membership is defined
• Multidisciplinary membership
• Committee chairperson & vice chair person identified
• Committee must have defined meeting frequency. Meeting
6 times per year strongly encouraged*
• Agendas and minutes for committee meetings maintained
* Application requires 6 sets of minutes within past year.
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QI Committee Accountability
• Short statement that defines accountability of QI committee
• Defines frequency of reports to Board of Directors
• Defines time frame for updating QI plan and schedule
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QI Committee for Multiple Sites
• Still one QI committee for organization
• Site QI committees may be established and described in
overall QI plan
• Site QI plans must mirror overall plan and report on a
regular basis to overall QI committee
• Main QI plan sets agenda for organization
– Additional QI projects may be done at satellites based
on center needs in addition to main QI program
• Reporting from each site is very important in the overall QI
committee
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Methods for QI Activities
• QI plan should include methods used to conduct QI projects
• Includes process for collecting data and sources
• Allocation of resources defined
• Process most common: Improvement Model and use of
PDSA Process
• Schedule of activities for monitoring measures
• Defines QI activities based on subcommittees
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Tracking of QI Activities
• Defines reports to be given by subcommittees to overall
organizational QI committee
• QI activities reported by subcommittees to overall QI
committee
– Report baseline on project, interventions attempted,
results of interventions and continued monitoring
• Committee members track measures over time for QI
activity impact
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Approval and Review
• Identifies individuals who must approve QI plan
• Signature page in place with dates
• Appropriate signatures in place on review page
• Frequency of review and updates for individuals who are
responsible for approval
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QI/QA Committee Meeting Minutes
• FTCA weighs minutes very heavily
• Should be enough information for reviewer to verify
successful implementation of QI program
• Provide written documentation of QI activities
• Must include information on monitoring activities for
measures listed in QI plan
• Must document multidisciplinary team by name and title
during attendance
• Must report on QI activities conducted during meeting
interval
• Data used to measure objectives of QI plan and track
improvement activities
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Sample QI Meeting Minutes
Include:
• Attendees
• Agenda items
• Discussion topics
• Recommendations
• Action items
• Clearly label with
• consistent titles
• Provide sufficient detail
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Conducting the QI Meeting
• Agenda should always be set
– Review QI data/progress toward goals
– Analyze trends and identify problem areas
– Brainstorm for improvement strategies
– Develop improvement plans
• Develop, revise and implement QI plans
• Document meeting minutes and keep on file
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QI/QA Reports to Board
• QI/QA information reported at least 6 times
• Board meeting minutes reflect:
– QI committee findings and activities
o Short summary of QI projects conducted by staff
– Objectives, data, improvement goals
– Board review of QI plan on a regular basis (usually
annually)
– Board is also responsible for reviewing and approving
credentialing/privileges of all medical providers
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Submission of Information for
FTCA
• Submit QI plan as developed by organization with
appropriate signatures and approval
• Must also indicate board review during last three years
• Meeting minutes:
– 6 months of QI meeting minutes
– 6 months of Board meeting minutes with reports from QI
program
– Multiple site minutes
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