Quality Improvement Strategy

Code: E12.2

Date: 17/06/2014

Purpose:

To codify a system by which:

• Quality improvement opportunities may be identified.

• Action/implementation plans for quality improvement can be developed

• The effect of the plans can be tested and reviewed

Responsible Staff:

Implementation: Clinical Director

Action: All Staff

Audit: Quality Control Officer

Audit:

Training Resources:

Linked Policies:

Significant Event Management Policy

Enabling Resources:

Quality improvement pro-forma.

Policy:

Quality improvement must be a continuous process.

A Quality Control Officer shall be responsible for monitoring quality including:

• Executive oversight of the rolling audit process

• Compliance with new and existing requirements (DHB, MOH etc)

• Management of the quality improvement process outlined below.

Quality improvement opportunities arise in may scenarios. These include:

• During care episodes

• As a result of significant incident analysis

• Suggestions from clients

• Publication of new evidence

• Availability (or withdrawal) of various treatments

• Complaints

It may not always be practicable or necessary to act on some suggestions. Others may be easy to implement quickly.

Wherever possible, quality improvement ideas should be recorded on paper and given to the Quality Control Officer. Any suggestions should be discussed at the next practice meeting (agenda item: Quality Improvement)

This should not prevent easily implemented quality control initiatives from being actioned on an ad-hoc basis though where possible, these should be recorded formally to ensure that we can meet our collegial obligations and continuing professional development obligations easily.

If it becomes evident that there have been no quality improvement activities undertaken, the Quality Improvement Officer shall ensure that the item is added to the agenda of a practice meeting at least once in every six months, to encourage staff to participate actively in the process.

If improvement ideas are not forthcoming within the practice, external consultants might be considered.  The RNZCGP provides a number of suggested actions.

Quality improvement issues must be prioritised at the initial practice meeting where they are raised:

• High – eg: pharmaceutical recalls or serious hazards. Rapid action is likely to have significant benefits or inaction is likely to result in serious harm.

• Medium – eg: new therapies. There is plenty of time to consider action though it should not be delayed unduly.

• Low – eg: redecoration. There is no need for immediate action

For all priorities of items, development of an action plan is required.

For those which cannot be resolved immediately:

• Determine the necessary action at the meeting:

• Information required

• action to be taken

• Appoint staff to oversee the implementation of the action plan.

• Set an appropriate time for reporting back based on the perceived risk/benefit and the resources available.

A sample action plan pro-forma is available.

Where time is limited in a meeting, low and medium priority planning may be deferred though the meeting should set a timescale for medium priority items.

Annual Quality Improvement Priority Activity

In addition to opportunistic improvement activities, the team should discuss assigning special priority to a particular area of health improvement.

Examples might include:

• Ensuring that ethnicity data is recorded for all clients

• Record a height and weight for all adults

• Record a smoking status for all clients over the age of 15.

Significant Events

The Quality Improvement activities are intended to be proactive rather than reactive in nature.

The specific management of significant events is dealt with through the linked Significant Event Policy.

Change Log:

17/06/2014

Minor wording changes

Removal of the deprecated practice manager role.

Audit changed to Quality Control Officer.