solved For this Assignment, review Case 3, “Barriers to an Effective

For this Assignment, review Case 3, “Barriers to an Effective QI Effort,” in Chapter 11 of the text, Managing Health Services Organizations and Systems. Reflect on how you as a current or future health care administrator might address strategies to implement a quality improvement initiative. Consider the following questions: What considerations should you keep in mind to address quality? How does one measure quality and identify strategies to improve quality in an HSO? Then, review the Week 6 Case Questions document in this week’s Learning Resources to complete the Assignment.
Barriers to an Effective QI Effort District Hospital is a 260-bed, public, general acute care hospital owned by a special tax district. Its service area includes five communities with a total population of 180,000 in a southeastern coastal state in one of the nation’s fastest-growing counties. It is one of three hospitals owned by the special tax district. The seven other hospitals in District Hospital’s general service area make the environment highly competitive. District Hospital has a wide range of services and the active medical staff of 527 represents most specialties. The emergency department (ED) is a major source of admissions. Last year, 26,153 patients visited the ED and 3,745, or 14.3%, were admitted. This was 42% of total hospital admissions. Some admissions were sent to the ED by private physicians and some came by ambulance, but most were self-referred. The hospital chief executive officer, W.G. Lester, noted that the number of visits to the ED was decreasing. Over a 3-year period, they had declined from a high of 29,345 to the current low of 26,153. Only part of this reduction seemed attributable to competition. Lester was also concerned about an increasing number of complaints concerning the quality of ED services. The complaints related to waiting time, poor attitudes of physicians, and questions about the quality of care. Investigation found that many complaints were justified, but the causes of these problems were difficult to discern. Registered nurses (RNs) employed in the ED want a larger role in triaging and treating patients, but the dominance of ED physicians limits the RNs’ duties and frustrates other staff, as well. This is manifested among RNstaff by high turnover, low morale, and difficulty in recruitment and retention. Another factor is the emergency medical technician (EMT) program started in the county a few years ago. The EMTs are an important community medical resource and are very influential in deciding the hospital to which patients in ambulances will be transported. It will be necessary for District Hospital, through the ED physicians, to participate actively in training and managing the EMT program if District Hospital is to receive its share of emergency patients. ED physicians have refused to participate in teaching or directing the program, however. In fact, they often alienate the EMTs. Lester is concerned, too, that the position of full-time director of emergency medicine at District Hospital has been vacant for 4 years. Residency programs in emergency medicine are producing physicians who are seeking positions with higher salaries and better working conditions than those available at District Hospital. There has been little turnover among the six physicians who staff the ED; they include one general surgeon (retired from private practice), two internists, and three non–U.S.-trained medical graduates with specialties in family practice. The ED physicians seem to lack a clear commitment to District Hospital. All of them contract separately with the hospital to provide ED services. District Hospital bills ED patients and collects the physicians’ fees: moneys above the guaranteed minimum are paid to them pro rata. They participate in District Hospital’s fringe benefits and are covered by its professional liability insurance policy. One ED physician, Dr. Balck (the retired surgeon), recognizes the progress being made nationally in emergency medicine. She made several unsuccessful attempts to move District Hospital in the same direction. With great effort, she instituted programs on intradepartmental education and mandatory attendance at approved courses in emergency medicine. Qualityrelated activities, however, are done perfunctorily. Also, she has tried to obtain full recognition of the ED and its work by other members of the PSO. The members of the PSO seem satisfied with the situation. Its executive committee does not understand the changing status of emergency medicine. As evidence of its unwillingness to grant full recognition to the department, the PSO has consistently denied the ED’s request for full departmental status. 
chapter 7
The management model in Figure 5.7 shows how health services organizations (HSOs) and health systems (HSs) convert inputs into outputs. The inputs of structure, tasks and technology, and people are integrated to achieve individual and organizational outputs (productivity). The types and nature of inputs and the conversion process determine the quality of output. This chapter and the next discuss quality and its two dimensions. Chapter 7 provides the conceptual framework for quality improvement (QI), which is the first dimension of quality. This framework is drawn from theorists and pioneers in QI. Prominent among them are Florence Nightingale, Ernest A. Codman, Walter A. Shewhart, W. Edwards Deming, and Avedis Donabedian. These individuals made vital contributions to the theory of quality and to applying the theory to performance improvement and measuring the results. Deming was the most significant of the contemporary quality improvement theorists. Joseph M. Juran and Philip B. Crosby were contemporaries of Deming and developed important applications of QI in the workplace. Hoshin planning is described as a means of aligning the organization’s quality efforts. Process improvement is the second dimension of quality. Chapter 8 describes how to organize for quality and provides a primer of methodologies, techniques, and tools to make continuous quality improvement (CQI) a reality. Their application in the organization, especially its operating units, is discussed. HSOs and HSs that use CQI to become moreproductive and cost-effective have a significant competitive advantage. Improving Quality and Performance Attention was first paid to the quality of clinical practice in HSOs in the late 19th century. At that point, technology and efficacious surgery were centralizing clinical services in the acute care hospital. The methodology used to measure quality was peer review, defined as physician review of the care provided by physicians and other categories of caregivers. In 1912, the American College of Surgeons (ACS) began to develop the concept of peer review. By 1918, it published The Minimum Standard, part of which addressed peer review of medical treatment in hospitals: “The [medical] staff [shall] review and analyze at regular intervals their clinical experience in the various departments of the hospital.” 1 The first survey using The Minimum Standard showed how inadequate 150 hospitals were; the results were burned in the furnace of the Waldorf Astoria Hotel in New York City. The role of Dr. Ernest A. Codman in developing The Minimum Standard and establishing the American College of Surgeons’ Hospital Standardization Program is discussed later in the chapter. Chapter 1 noted that The Joint Commission continued the work of the ACS upon its establishment as the Joint Commission on Accreditation of Hospitals in 1951. The process of peer review was called medical audit, terminology that continued into the 1960s. Enactment of Medicare codified utilization review (UR), which focused on appropriate use of services. UR did not directly affect the quality of care in hospitals, except that reviewing appropriateness of admission, use of ancillary services, and length of stay may have helped reduce nosocomial (institution-caused) and iatrogenic (physician-caused) problems. The focus of UR in Medicare was discussed in Chapter 1. A major shortcoming of medical audit and UR was that they made no attempt to solve the problems identified. Efforts to measure quality continued to evolve. In the early 1970s, The Joint Commission required quality assessment activities, a variation on medical audit. In the middle 1970s, the words were changed to medical careevaluation, but it remained essentially medical audit. By 1980, the concept of quality assurance (QA) had become a Joint Commission standard. QA meant that The Joint Commission standards had evolved from finding and describing problems (medical audit) to be more proactive and dynamic by stressing problem solving to improve clinical quality. As noted earlier, performance improvement is now the umbrella concept for all quality-related Joint Commission standards. Historically, quality has been defined as the degree of adherence to standards or criteria. As applied in health services, ensuring quality means using prospectively determined criteria to measure performance, with the measurement being done retrospectively. Newer definitions of quality are discussed here in the context of CQI. These include conformance to requirements and fitness for use, or fitness for need. They are customer driven because they focus on customer expectations and do not exclusively reflect criteria or standards developed using professional expertise. It is suggested that quality should be defined as meeting latent needs—identifying “needs” customers may not even know they have, but will be pleased to have identified for them and met by the provider. CQI defines customer broadly to include all who receive goods or services. Measuring quality using the concepts of QA required that the HSO/HS establish standards (criteria), typically through peer judgments. Developing criteria was but the first step. Two other elements were necessary: a means of surveillance to identify deviations requiring action, and stopping the deviation or minimizing its recurrence—the corrective action. These steps are simple in theory and may be in practice as well, depending on what is being measured. Much of the conceptual framework used to measure quality was developed by Avedis Donabedian, a physician, whose nomenclature of structure, process, and outcome became standard in health services. Structure and process were the major foci of The Joint Commission’s QA standards in the 1980s. Donabedian noted the difficulties of defining the quality of medical care and measuring the quality of the interpersonal relationship between physician and patient—a relationship essential to the process of care, as reflected in the outcome of care. Technical aspects of care are more definable and measurable than are interpersonal relationships. 2 Regardless, measuringquality under traditional QA began with criteria developed internally or externally imposed or both. Structure, Process, and Outcome in Quality Theory Donabedian defined structure as the tools and resources that providers of care have at their disposal and the physical and organizational settings in which they work. 3 Process is the set of activities that occurs within HSOs and between practitioners and patients. Here, judgments of quality may be made either by direct observation or by reviewing recorded information. Donabedian considered this means of measuring quality to be largely normative, in that the norms come either from the science of medicine or from the ethics and values of society. 4 Outcome is a change in a patient’s current and future health status that can be attributed to antecedent healthcare. 5 Donabedian defined outcome broadly to include improvement of social and psychological function, in addition to physical and physiological aspects. Also included are patient attitudes, health-related knowledge acquired by the patient, and health-related behavioral change. 6 Donabedian concluded that “good structure, that is, a sufficiency of resources and proper system design, is probably the most important means of protecting and promoting the quality of care.” 7 He added that assessing structure is a good deal less important than assessing process and outcome. Comparing process and outcome, Donabedian concluded that neither is clearly preferable. Either may be superior, depending on the situation and what is being measured. He emphasized that it is critical, however, to know the link between the content of the process and the resulting outcome. Only by knowing this link (preferably at the level of a causal relationship) can what is done or not done in the process be modified to improve the outcome. Not knowing how a desirable outcome was achieved means replication is but a matter of chance. Table 7.1 shows the advantages and disadvantages of focusing on process and outcome to measure quality. Outcome indicators in Donabedian’s taxonomy focus on the overall outcomes of medical care, such as health status and disability. Donabedian’s emphases on system (structure of care) and process (of care) are emblematic of how QI is presentlyconceptualized and applied. Development and application of QA peaked in the late 1980s with adoption of a 10-step QA process. From then to the present, The Joint Commission began its evolution to use of outcome indicators (measures). In 1987, its Agenda for Change initiated a major shift to adopting CQI. These activities were subsumed into what became known as the ORYX® initiative. 8 It was generally conceded that the QA implemented in the 1980s did little to improve the quality of care. “On the whole, to the extent that quality measurement tools have been developed at all, they tend to unveil the fact of flaw, not its cause.” 9 The first clinical indicators developed were hospitalwide care and obstetrical and anesthesia care. 10 In early 1989, 12 key principles of organizational and management effectiveness were announced by The Joint Commission, and pilot testing began. The purpose was to characterize an acute care hospital’s commitment to continuously improving its quality of care. A central tenet was that identifying and monitoring outcome indicators were necessary for a hospital to focus its QI activities. By 1991, indicators had been developed for anesthesia, obstetrics, cardiovascular medicine, oncology, and trauma care. 11 These indicators focused on the high-risk, high-volume, and problem-prone aspects of care. Hospitals could choose from among hundreds of performance measurement systems and thousands of performance measures. A major goal of ORYX® is to develop standardized, evidence-based measures. 12 As of 2013, there had been 14 core performance measure sets identified for hospitals, including acute myocardial infarction, heart failure, pneumonia, perinatal care, and surgical infection prevention. 13 A major initiative of the Centers for Medicare and Medicaid Services (CMS) is reducing the number of hospital readmissions after discharge from an inpatient stay. Hospitals with excess readmissions risk reduced Medicare payments. 14 The number and range of evidence-based performance measures by which hospital outcomes can be compared will increase and are strongly supported by CMS. Importance of QI The importance of evaluating and improving quality was suggested in Chapter 1 and is expanded here. The Joint Commission and other accreditors such as the Community Health Accreditation Program, American Osteopathic Association, and Det Norske Veritas Health-care, Inc., require organized, effective QI activities. HSOs not accredited by a CMS-approved accreditor are not in “deemed” status and can be reimbursed for services to federal beneficiaries only by meeting the conditions of participation established by the Department of Health and Human Services (DHHS). Accreditors of medical education programs require the HSO to be accredited, but not necessarily by The Joint Commission. Insurers of all types expect HSOs/HSs to be accredited. Lending institutions and organizations that rate bond offerings consider accreditation in their decisions. Chapter 2 details the importance of credentialing clinical staff, an activity indispensable to QI. In addition, failing to effectively assess quality increases the likelihood of adverse malpractice judgments because the HSO may be seen as not meeting the legal standard of care. QI is considered important by managerial, clinical, and support staff who want to do their best. They strive to do so because they have internalized the motivation to provide high-quality care and achieve excellence in their HSO/HS. This necessitates learning what is being done well, what is not, and closing the gap. QI and QA Compared HSOs/HSs that immerse themselves in the philosophy and techniques of CQI have achieved a paradigm shift away from traditional approaches to quality. As will be described QI uses powerful tools that result from a radically different philosophy about relationships between managers and staff. Table 7.2 suggests the differences between QI and QA; several should be highlighted. QA is a negative process. It focuses on the “who” and seeks to identify those who seem to cause problems. Focusing on persons as the cause of problems is a natural human tendency and can be found even in HSOs that are trying to apply CQI concepts. QI seeks the “why.” Workers are not thefocus. QI implements the philosophy of W. Edwards Deming, whose theories are detailed later in the chapter, that 85%–94% of problems result from the process; few are caused by those who work in a process. Commonly, QA measures only the quality of clinical practice, which was The Joint Commission’s focus until the 1990s. QI measures clinical outcomes, but it is more concerned with myriad processes and systems that support delivery of clinical services, as well as those that are administrative, such as admitting and patient accounts. The clinical and administrative aspects of many processes cannot be separated easily, and QI seeks to improve integrated or cross-functional processes as well as those that are intradepartmental. Improving quality in support and administrative processes positively affects clinical processes and, thus, delivery of care, because there is greater organizationwide quality consciousness and because, without exception, these areas affect clinical services. For example, inefficient intradepartmental or interdepartmental admitting processes directly and indirectly affect patient care. It is certain that they affect patient satisfaction.
chapter 8
Quality improvement (QI) focuses on doing the right things and doing the right things right. This chapter builds on the theory of quality/productivity improvement (Q/PI) discussed in Chapter 7 and introduces a continuous quality improvement (CQI) process improvement model. The chapter also discusses the relationship between problem solving and the use of teams in process improvement. The applications of benchmarking, six sigma, lean manufacturing, and reengineering are discussed. Accreditation and registration, through organizations such as the Joint Commission on Accreditation of Healthcare Organizations (The Joint Commission) and the International Organization for Standardization (ISO), respectively, are addressed. Productivity improvement 1 (PI) methods to improve work systems and job design; capacity and facilities layout; and production control, scheduling, and materials handling are described. Also addressed are thenecessity for and means of achieving physician involvement in quality improvement. The chapter concludes with a discussion of patient and worker safety. Undertaking Process Improvement Quality improvement begins by selecting a process to improve and choosing the members of the quality improvement team (QIT). Improving quality consumes significant staff time, both for team members and for those who provide support. This means that the health services organization (HSO) is best served if high-value processes are improved first. Success in improving simple but important processes—picking the low-hanging fruit—will produce results quickly, demonstrate the value of CQI, and help convince skeptical staff of the usefulness of CQI. Figure 8.1 shows the flow of QI activities. Data sources (many of them outcome indicators) focus the attention of the quality improvement council (QIC), which is the coordinating body. As noted in Chapter 7, the QIC approves (sanctions) formation of cross-functional QITs to analyze processes and recommend changes to improve them. Intradepartmental and functional QITs are established by departments and/or those who are part of the functional area(s), monitored locally. In addition, departments or functional areas may assign individual staff who may be process owners to monitor and improve processes. Although unlikely, the QIC may have authority to approve changes and expenditures resulting from QIT recommendations. More likely corporate executive officer (CEO) and/or governing board (GB) approval will be required. QITs The basic component for undertaking quality improvement is the QIT, sometimes known as a process improvement team (PIT), despite the latter’s less-than-desirable acronym. As noted, QITs may be internal to a function or department or may be cross-functional. The PDSA cycle described in Chapter7 is the basic methodology applied by the QIT. QITs are composed of persons who have process knowledge and who can document the process as it functions currently. Understanding the process in its current state is essential. Processes tend to succumb to entropy over time, which is to say that they devolve to a lower level of performance than that intended in the Quality Planning phase as described by Juran. The QIT identifies the key quality characteristic (KQC) of the process—an outcome that can be used to measure quality, such as patient satisfaction, waiting time, or accuracy of medication. Sometimes, there is more than one KQC. Next, the QIT develops an understanding of the process. Flowcharts, also known as flow diagrams or process maps, are used to visualize and understand the process in its current state. To be useful this visualization must show the process in all its complexity. Process complexity and the handoffs from one step to the next are common sources of delay, error, and rework. Only by understanding the process in all its complexity can one effect improvement