The Mihalik Blog

New Year’s Resolution: Planning for Improvement

Our office reopened on January 2^nd after a year-end break. 

Late December into early January is a period when not much new happens in the areas of accreditation and regulatory compliance.  That makes it a very good time to plan for the coming year.  The quality improvement calendar is a critical part of the planning process—and one that I find is often not used to its full potential. 

The problem that I typically see is a timing issue.  QI program evaluations and revised program descriptions are typically not completed until late first quarter or early second quarter.  Many health care organizations include the annual QI calendar as part of the revised program description.  Consequently, the QI committee has not explicitly planned activities for the first three or four months of the year. 

As a New Year’s Resolution, I suggest you do away with treating the QI calendar as a once-a-year task.  Quality Improvement is a dynamic process and planned activities should be modified during the year based on new information. 

Set up your QI calendar in a table format.  Each activity should occupy one row.  Set up columns for the information you want to include, such as the name of the indicator, the responsible party, the goal, etc.  End your table with a series of twelve columns, one for each month.  In each of these cells, describe what should be happening during that month for the specific activity.  Leave the cell blank if nothing should be happening.  Developing a set of abbreviations will make it easier to maintain the calendar; things like M for measure, R for report to committee, etc.

On a regular basis, as you are preparing the minutes of the most recent QI committee meeting, add enough new columns to the calendar to project a full twelve months into the future.  In the new cells, describe what should be happening during each newly added month, if you know.  For example, if a particular indicator is reported on a quarterly basis, you can project out when the next reports will be due. 

Every three to six months, make the calendar update a specific agenda item for the QI committee.  With the committee’s input, revise the calendar to customize it to the reality of what is happening. That quarterly report you added might need to be revised if there’s some sort of a delay, for example.  If you schedule one of these calendar updates for the last QI committee meetings of the year, you’ll be starting the new year with the most up to date plan possible. 

Although it is easier to word process in a word processing program, using a spreadsheet program for the calendar will enable you to print just the columns that you want to print.  So, while your spreadsheet might have two years’ worth of planned activities, you can choose to print just the next twelve, without loosing the history.

Making Quality Happen

I just got back from a brief jaunt to the East Coast where I gave a presentation on HEDIS and Quality Improvement and then facilitated a small group session to identify interventions to improve performance.  All in all, this is a fairly typical role for me.

What struck me for some reason this time around, was how much more often I used to facilitate quality improvement processes than I do now.  I’m not sure what caused the change but I’m more convinced than ever that quality improvement efforts at health plans and health care facilities would improve significantly with good facilitation.  Honestly, I think that the health care field isn’t paying enough attention to good technique when it comes to the tools and techniques of QI. 

As part of my talk, I described brainstorming techniques, much as I did in a previous blog.  Despite the “just in time” training, and knowing that I was sitting in the back watching, the groups were not able to implement what they had just been taught.  Brainstorming sounds simple but learning to do it well is like learning many other skills.  It takes practice, modeling, and mentoring. 

The group members quickly fell into the all-too-common pattern of having long, discussions about their thoughts of what would improve performance.  When I was asked to help facilitate, I took a moment to refocus the group on the task and then went back to the book.  The book on structured brainstorming, that is. 

I had everyone take 5 minutes to write down his/her ideas for possible interventions to improve performance.  We spent the next 25 minutes transcribing everyone’s ideas onto the flip chart.  On a number of occasions, had I not “facilitated” the process, the group would have fallen back into the old habit of discussing ideas. 

In the course of 30 minutes the group had generated over two dozen credible interventions to improve outcomes for a specific high-risk patient group.  In the thirty minutes before I began facilitating, they hadn’t generated any. 

Clearly the ideas were there—they just needed to be set free.  Good facilitation was the key. 

Although it might sound self-serving, I truly encourage you to think about involving The Mihalik Group in deployment of your quality improvement program.  When you need to understand the causes of key outcomes or develop interventions to improve performance (like maybe your HEDIS rates), our facilitation skills may be just what you need. 

Give me a call or send me an email and we can discuss how The Mihalik Group can help. 

Quality Improvement in Health Care

I started working in health care administration in the late 80’s.  I ran a teaching service at a university hospital for a year and liked it so much that I took a position as the medical director of a hospital—then the medical director of a really big hospital in the public sector.  That’s when I got serious about learning about the Joint Commission.  Of course, the fact that the hospital underwent a state regulatory survey during my first month, a Medicare survey during my second month, and a Joint Commission survey during my third month helped kindle my interest just a bit. 

A little more than a year later, I became a Joint Commission surveyor (in the days when surveyors could still have full-time jobs and do a handful of surveys a year).  This began to pique my interest in quality improvement.  Shortly thereafter, I and two other physicians from the public sector made an ambitious attempt to implement an honest-to-gosh quality improvement program in our public sector facilities (think Deming, Crosby, and Juran).  We were encouraged by articles about how the US Military, a government bureaucracy much larger than ours, had had some significant successes doing the same. 

My education in quality improvement began in earnest. 

In the early 90’s I became Associate Director in the Department of Standards at the Joint Commission.  This was just when the Joint Commission was making a big shift from accreditation “silos” to cross-functional integration and quality improvement.  I began teaching education programs on quality improvement.  My favorite ones were the weekend long programs (Friday evening, all day Saturday, and half-a-day on Sunday) where I and another faculty member taught quality improvement skills-building workshops for physicians.  My co-presenters were all hospital-based physicians with impressive experience in quality improvement from whom I learned a tremendous amount. 

Interestingly, I learned even more about quality improvement when studying for my MBA.  (Crazy me, I did this while working full-time at the Joint Commission, part time as a managed care medical director, and Saturdays in clinical practice.)  But I digress.  Learning about statistical process control (the true underpinnings of quality improvement if you ask me) from the perspective of a manufacturing industry or for inventory control suddenly made some of the concepts that didn’t quite fit in a health care context make sense.

I began adding information about the differences in quality improvement for service-based industries as opposed to product-based industries to my seminars. 

A little while later I left the Joint Commission, became a full-time managed care medical director, and joined the NCQA orbit.  I was given free-reign to develop a quality improvement program for the managed care company.  It was an incredible experience building it from the ground up: identifying data sources, developing data bases, figuring out the best graphic displays for performance data, implementing cross-functional teams (yes, really, teams—not just committees) each responsible for understanding and improving a single, important organizational process. 

I kept teaching educational programs.  I did more and more health care consulting work.  I continued to survey for NCQA and I helped develop NCQA’s behavioral health standards. 

After an incredibly successful and heady run as a managed care medical director, with my consulting business tugging at me, I made a career shift into full-time consulting.  In the early years, a number of managed care organizations were interested in learning about quality improvement and applying the principles, tools and techniques to their operations. 

Over the last five years or so, I’ve seen a declining interest in quality improvement.  Maybe it’s a lack of knowledge about what QI can really do, but it seems like folks just want the answer.  I’m frequently asked by clients and seminar attendees what changes to implement to improve performance. 

It’s not that easy.  To improve performance you need to understand the causes of current performance.  To do that, you need to apply quality improvement tools and techniques.

Personally, I’d like to see a renewed interest in QI.  If used well, I think we’d begin to see improvements in member and practitioner satisfaction, improvements in health status, and improved job satisfaction for managed care employees. 

Even if it’s only a couple of hours a month, engaging staff and outside stakeholders in a “real” quality improvement endeavor provides a jolt of creativity and out-of-the-box thinking that boosts morale as it boosts performance.

Stay tuned for some pointers on how to do this.