American University of Beirut Medical Center Quality, Accreditation and Risk Management Program (QARM) Quality Improvement Workshop

Transcription

1 American University of Beirut Medical Center Quality, Accreditation and Risk Management Program (QARM) Quality Improvement Workshop April 2011 Purpose of the Workshop This four-day condensed workshop is designed for healthcare quality professionals and other professionals seeking to sharpen their healthcare managerial skills. The workshop is an intensive review of the comprehensive body of knowledge that is designed to provide the participants with the required skills to practice performance improvement functions. It includes healthcare quality principles, quality management and related material applicable by the quality professional in the hospital settings. Participants in this workshop who possess the basic education and some background experience in hospital quality will maximize their knowledge and skills in performance improvement. The participants will be exposed to presentations by healthcare quality experts and will participate in professional discussions related to the topics listed in the outline. Various audio-visual educational methods will be used during this workshop to ensure that the participants grasp in-depth knowledge on quality-related topics including practical applications. To assess the benefits gained from this workshop, the participants will take a pre-and post-tests at the beginning and end of the workshop. Subjects Covered in this Workshop Healthcare Quality Concepts Leadership and Quality Quality Structure in Hospitals Hospital Accreditation Patient Safety Quality Reviews Data Collection for Performance Improvement

2 Risk Management Credentialing & Privileging of Medical Staff Preparation of Policies, Procedures and Plans Learning Objectives By the end of the workshop participants will be able to: Explain the basic healthcare quality concepts Participate in organization-wide strategic planning including development of mission, vision, goals, objectives and leadership values and commitment Facilitate the establishment of a performance improvement oversight group, performance Improvement teams and quality champions Integrate quality concepts within the organization Perform or coordinate patient safety and risk management activities Contribute to development and revision of the performance improvement and risk management plans Integrate technology to enhance the patient safety program Maintain confidentiality of performance improvement activities, reviews and reports Perform or oversee data collection methodology using knowledge of epidemiological theory of data collection and analysis Use basic statistical techniques to describe and analyze data Understand the epidemiological theory in data collection and analysis Participate in the development of clinical guidelines and pathways Participate in the credentialing and privileging process Conduct quality and related function review and service specific review Understand the prevention and control of infection processes Participate in quality improvement teams and evaluate team performance Incorporate performance improvement findings into the employee performance appraisal system Integrate results of data analysis, outcomes of risk management and utilization management into the performance improvement process Integrate quality findings into governance and management activities (bylaws and administrative policies and procedures) Integrate accreditation standards into the organization Develop and provide performance improvement training

3 Evaluate effectiveness of training Facilitate change within the organization through education Develop and participate in accreditation and survey activities Interact with medical staff and support personnel regarding performance improvement issues Promote organizational values and commitment among hospital staff Compile and prepare performance improvement reports Coordinate the dissemination of performance improvement information within the organization Define quality, its principles and dimensions Understand quality trilogy and the relationship between quality planning, quality measurement and quality improvement Identify the principals of quality management Understand the Casual Relationship between structure, process and outcome Understand foundations of quality of care and accreditation including assessment, methods and implementation issues Apply knowledge about quality improvement tools to support quality improvements in healthcare organizations Understand how to develop measures, indicators, and targets for quality improvement plans including performance reporting Learn about the basic performance improvement tools and how to use them to enhance quality of care Understand how to develop policies and procedures related to quality and safety Identify the relationship between quality and patient safety Identify quality and safety issues and develop quality improvement and risk management plans Training Methods The faculty members of this workshop will use a variety of adult learning methods to ensure that participants capture the basic concepts and the knowledge in a way that takes into consideration the variations in their background. Training methods include but not limited to: PowerPoint presentations and discussions Demonstrations Small group work Case studies

4 Who Should Attend This workshop is designed for: Quality/performance improvement coordinators Hospital accreditation officers Utilization review and case managers Patient safety and risk managers Hospital management staff Health information managers Patient relations officers Government staff employed in healthcare agencies Infection control professionals Healthcare professionals employed in health insurance agencies Medical staff officers Survey coordinators Healthcare consultants Capacity The workshop will accommodate a maximum of twenty (20) participants to allow for optimal exposure to the material used and to help in one-to-one contact between the trainer/faculty and the participants. Workshop Evaluation - Pre and post tests - Classroom interaction and participation - Analysis of case studies and live examples - Performance in group work References The official and main textbook that will be adopted in this workshop is: The Healthcare Quality Handbook: A Professional Resource and Study Guide by Janet A. Brown. The

5 contents of this textbook will serve as a supplement reading material. (All participants are encouraged to acquire this textbook). Other references will be posted in due course.

6 Workshop Program Day 1 Time Subject Facilitator 08:30 09:00 Introduction of the Workshop (Khalil Rizk) 09:00 09:30 Pre Test (Shatha Abi Ghanem) 09:30 10:00 Break 10:00 12:00 Healthcare Quality Concepts Principles of healthcare quality Definition of quality Quality trilogy Dimensions of quality Quality systems and processes Principles of customer service Coordinate the PI process Develop and provide staff training and education on quality principles Evaluate effectiveness of PI training Analyze patient/customer satisfaction Evaluate applicability of PI models Identify the need to develop PI systems and processes (Layal Mohtar) 12:00-13:00 Lunch Break 13:00 15:00 Leadership and Quality Leadership Vs. management Coping Strategic planning The role of leadership in quality improvement The boar s role in quality improvement (Khalil Rizk) Facilitate development of leadership values and mission statement Assess and develop organization s quality culture Facilitate establishment of priorities for process improvement activities Facilitate/participate in the selection of processes and outcome measures Integrate quality findings into governance and management activities Link patient safety objectives with the strategic goals

7 Day 2 Time Subject Facilitator 08:30 10:00 Quality Structure in Hospitals Building an effective quality structure Role of leadership Quality council Quality champions Teams (Rihaf Yazbeck) Identify the appropriate team structure Evaluate team performance Coordinate the PI process Facilitate development or selection of PI projects and action plans Organize information for committee meetings Coordinate / participate in PI projects Develop and provide staff training and education on PI processes Facilitate change within the organization through education Identify PI champions 10:00 10:30 Break 10:30 12:00 Hospital Accreditation What is accreditation The accreditation process Accreditation standards Tracer methodology Review process Continued preparedness (Lisa Sekilian & Shatha Abi Ghanem) Participate in the selection of accreditation agencies Develop and provide survey preparation training Integrate accreditation standards into the organization 12:00 13:00 Lunch Break 13:00 15:00 Patient Safety Medical errors Safety culture International patient safety goals Patient safety program (Abdellatif Marini) Facilitate assessment of the organization s patient safety culture Identify applicability of the patient safety goals Facilitate the development of patient safety program Link patient safety activities with the PI program Coordinate the patient safety program Integrate technology to enhance the patient safety program

8 Day 3 Time Subject Facilitator 08:30 10:00 Quality Reviews Types of reviews Peer review Medical record review Blood use review Utilization review Medication use review Surgical and procedure case review Mortality review Code blue review Sentinel events review (Rihaf Yazbeck) Prepare the performance review/study design Conduct PI reviews Analyze /interpret performance reports Maintain confidentiality of PI findings Compile and prepare PI reports 10:00 10:30 Break 10:30 12:00 Data Collection for Performance Improvement Sampling Sources of data Types of data collection Data collection tools Organization of data Performance indicators Benchmarking (Lina Mekawi) Integrate results of data analysis into the PI process Participate in the prioritization and monitoring of PI indicators Evaluate applicability of PI tools Perform / coordinate data collection methodology Collect quantitative and qualitative data Utilize appropriate analytical tools Aggregate and summarize findings for reporting Utilize basic statistical tools to describe data Interpret statistical reports Integrate outcome data to support decision making 12:00-13:00 Lunch Break 13:00 15:00 Risk Management Risk management in healthcare Basic functions Professional liability - physicians Professional liability - nurses Negligence (Aida Habbal / Khalil Rizk)

9 Risk management and quality improvement Failure mode and effects analysis Sentinel events and root cause analysis The Risk management plan Understand the basic principles of risk management Appreciate the relationship between PI and risk management Perform/coordinate risk management - complaint analysis, incident review and root cause analysis Integrate risk management and utilization review activities into the PI program Day 4 Time Subject Facilitator 08:30 10:00 Credentialing & Privileging of Medical Staff Human Resources and PI Credentialing Basic functions Appointment / reappointment Medical Staff Role in Performance Improvement Physician profile Hospital Medical Staff Characteristics Mechanisms for Granting and Renewing Clinical Privileges (Khalil Rizk) Interact with medical staff and professional personnel to promote PI culture Perform/coordinate practitioner profiling Incorporate PI findings into the privileging process Interpret PI results and correlate them with staff performance appraisal 10:00 10:30 Break 10:30 12:00 Preparation of Policies, Procedures and Plans Policies and procedures protocol Required organization plans Objectives Program Principles Structure Procedures Staff Education Review of the P I Plan (Lisa Sekilian & Shatha Abi Ghanem) Facilitate evaluation or selection of evidence-based practice guidelines or pathways Participate in the development of written quality and patient safety

10 plan Prepare policies and procedures to promote PI culture and practice 12:00 13:00 Lunch Break 13:00 13:30 Post Test (Shatha Abi Ghanem) 13:30 14:00 Program Evaluation Participants 14:00 14:30 Distribution of Certificates Participants Prepared by: Khalil Rizk, MHA, CPHQ Quality, Accreditation & Risk Manager