Developing a QI Program
The Joint Commission, under its 1994 initiative Agenda for Change, first outlined its integration of performance measurement data into the health care organization accreditation process.
Although several years old at this point, the The Joint Commission's generic model for monitoring and evaluation is helpful by listing important elements of a QI program. It notes the ongoing cyclical nature and the requirement for continual reassessment to ensure that the practice criteria establish and maintain a quality service based on performance. A QI program should:• assign individual responsibility and accountability;
• define the scope of care;
• determine the important aspects of care, including clinical outcomes;
• characterize the important aspects of care and identify indicators;
• establish thresholds for evaluation that are appropriate to the individual service;
• obtain data for indicators using QI tools;
• evaluate the data in a multidisciplinary manner, and identify concerns about quality of service;
• recommend corrective action, and monitor its implementation;
• reassess, stressing the continuum, to develop new strategies for improving; and
• report the findings, and evaluate the improvement process.
Effective QI programs use the techniques and strategies described to ensure that standards of care are being met and that transport services' customers (ie, patients and families, referral institutions, etc) feel the service they receive is valuable. This is typically a collaborative multidisciplinary effort involving transport team personnel, medical directors, administrative personnel, risk management personnel, and other disciplines needed to identify opportunities to improve care. These activities are best coordinated by a QI coordinator.
The objectives of a QI program should be defined and include the following:
• Develop and support a multidisciplinary QI committee and regularly scheduled meetings in which to present service needs and areas for improvement.
• Identify important performance/quality metrics for the transport service.
• Establish regular review of performance/quality metrics, customer kudos and concerns, and serious or adverse service events. Expectations under The Joint Commission standards for an organization's response to sentinel events include root cause analyses and action plans. Definitions and further explanations are available at http://www.jointcommission.org.
• Plan strategies to address areas for improvement opportunities
Accountability for oversight of various tasks should be assigned by the transport administrative team. Accountability rests with the QI coordinator, the QI committee, and the members of the transport team. The QI coordinator should be a person with expertise in neonatal-pediatric medicine, transport, and quality monitoring. The QI coordinator is responsible for organization and direction of the QI program (Table 8.2). Crucial to the support of such a role is the vision that each team member has a role in the QI process.
Table 8.2: Typical Responsibilities of a Transport Team QI Coordinator
1. Lead the transport team's QI committee
2. Plan and organize QI committee meetings
3. Identify service or performance areas to monitor and evaluate
4. Direct data collection/monitoring process and ensure accuracy of data
5. Coordinate and implement tests of changes for improvement projects
6. Facilitate analyzing and interpreting data by the QI committee
7. Formulate recommendations with the QI committee that should include the following:
• Changes to staff education, training, and development
• Development and revisions of patient care standards, policies, procedures, and protocols
8. Oversee implementing change recommendations
Establishing a multidisciplinary QI committee provides the framework needed to set goals for meetings, attendance, and reporting mechanisms; oversee monitoring; establish ownership and commitment to the QI process; and recommend changes and determine the viability of the changes.
The participants of this committee should include transport team members and personnel external to transport, such as additional medical advisors, those with QI expertise, and administrative staff. The committee should report to the transport service management and, if appropriate, to hospital administration.Medical director involvement is critical to a transport QI program's success. The medical director may serve in various capacities as a resource, supervisor, moderator, evaluator, researcher, and educator. Activities medical directors use to monitor quality are prospective and retrospective, not unlike research projects.
Prospective activities may include interviewing, hiring, educating personnel, developing treatment protocols, and directing overall transport operations. Overseeing patient care during transport (online medical control) via direct communication such as radio, telephone, video, computer links, or teleconferencing directly affects the quality of the service provided. Retrospective activities review care after it has been provided, including chart review of documentation, review of transports when triggers were activated, recorded audio and/or video tapes, individual case review, and morbidity and mortality data.
Although all transport-related disciplines are important in the monitoring, review, and problem solving necessary to improve patient care, the medical director must participate in the QI process if it is to be a viable component of the transport program. The medical director's formal and informal influence on clinical decisions, efficiency, and safety is critical to the QI process.