CHAPTER 9. Continuous Quality Improvement
Meg Beturne
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Define quality in health care.
2. Describe the process of continuous quality improvement (CQI).
3. Describe the concept of total quality management (TQM).
4. Recognize major changes in health care that have had an impact on quality improvement (QI).
5. Identify aspects and key dimensions of quality.
6. List useful sources of data collection.
7. List useful tools for identifying patterns or trends.
8. Recognize issues in perianesthesia settings that affect quality.
I. QUALITY IN HEALTH CARE
A. Doing the right things right the first time
B. According to Donadbedian, quality depends on:
1. Practitioner assessment and/or patient and health system contributions
2. How health and responsibility for health are defined
3. Whether maximally or optimally effective care is sought
4. Whether the optimum is defined according to individual or social preference
C. Juran Institute defines quality as:
1. Freedom from deficiencies: any avoidable intervention required to achieve an equivalent patient outcome
2. Product features: both services and goods that attract and satisfy patients, meet customer expectations, and distinguish one practitioner or organization from others
D. Institute of Medicine (IOM): quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
E. Agency for Healthcare Research and Quality: quality in health care means:
1. Providers deliver the right care to right patient at the right time in the right way.
2. Patients can access timely care, have understandable and accurate information about benefits and risks, are protected from unsafe care services and products, and have understandable and reliable information on their care.
3. Clinicians and patients have their rights respected.
F. Concept of value
1. Require proof (positive outcomes) that the quality of care received is the best possible for dollars spent and minimize adverse patient outcomes
2. Value-added is key—it includes issues related to access, convenience, service, relationships with physicians, safety, and innovation.
G. Incremental stages of quality
1. Technical quality relies on quality tools, processes, and technology with customer perspective of “persuade them.”
2. Functional quality relies on people and judgment with customer perspective of “satisfy them.”
3. Competitive quality relies on time and flexibility with a customer perspective of “attract them.”
4. Forward quality relies on long-term planning and intuition with customer perspective of “building trust.”
II. CQI
A. Systematic approaches/models to the continuous study and improvement of the processes of providing health care services to meet the needs of individuals and others
B. Shewhart cycle: statistical quality control and cycle for continuous improvement PDCA (plan, do, check, act)
C. FOCUS PDCA model
1. Find
2. Organize
3. Clarify
4. Understand
5. Select
D. Feiggenbaum
E. Organizational Dynamics FADE approach
1. Focus on problem.
2. Analyze problem.
3. Develop a plan for improvement.
4. Execute the plan.
F. Ernst and Young IMPROVE model
1. Identify problem.
2. Measure impact.
3. Prioritize causes.
4. Research root causes.
5. Outline alternatives.
6. Validate solutions.
7. Execute solutions and standardize.
G. QI process
1. Use of team collaborative efforts to study and improve specific existing processes at all levels
2. Prioritizing and analyzing causes of existing process failure, dysfunction, or inefficiency
3. Systematically instituting optimal solutions to chronic problems
4. Analyzing and disseminating best-practice information to staff, patients, and families
5. Using scientific problem-solving method to improve process performance and achieve stated goals
6. Holding the gains through monitoring system
H. Six Sigma strategy
1. Disciplined approach to process improvement
2. Define costs and benefits.
3. Measure input and output.
4. Analyze causes of current or anticipated defects.
I. Lean-thinking approach
1. Use of thought process based on lean principles of:
a. Understanding value
b. Identifying value stream
c. Making service flow
d. Pulling flow from demand (flexibility)
e. Setting targets for perfection
J. The Joint Commission (TJC)
1. Continuous improvement of patient care outcomes
2. Identification of functions and processes with the most significant impact on outcomes
3. Emphasis on integrated system rather than independent units
4. Emphasis on consistent performance standards
5. Use of national performance measurement system for patient outcomes and care processes
6. Continual data collection, risk adjustment, and analysis
7. Use of comparative data for performance improvement
K. Traditional ways of monitoring, evaluating, and measuring quality
1. Retrospective: chart audit
a. Peer review process used in hospitals until 1970s
b. Small sample of patient records reviewed by medical staff with judgment made as to the quality of care provided
c. Problems confirmed and solutions identified
d. Increased emphasis on appropriateness of care in 1980s
2. Prospective, concurrent, and focused monitoring and analysis processes in place
a. On-line clinical data
b. Observation of actual process of care
c. Referrals
d. Special study, case mix, or other data summaries
e. Incident/occurrence reports
3. Evaluation process
a. In-depth assessment of quality of care when
(1) A threshold (trigger point) is reached
(2) A compliance level is/is not met
(3) Control limits are exceeded
4. Indicators
a. Monitor the quality of all aspects of care.
b. Gauge actual performance and compare with targeted objective or standard.
c. Include
(1) Clinical criteria
(2) Clinical standards
(3) Practice guidelines
(4) Protocols
(5) Performance database
d. Stated in objective terms
e. Condition or procedure specific
f. Focus on discrete populations.
g. Accuracy, risk adjustment, and cost are measured through control of information technology.
h. Identify opportunities to improve care.
i. Based on current knowledge or structure and projected needs, standards, or industry changes
j. Classified as outcome or process
k. Address issues of structure.
5. Structure standards
a. Qualifications of the providers
b. Physical facility, equipment, and other resources
c. Characteristics of the organization and its financing
6. Outcomes
a. Things that do (or do not) happen as a result of medical interventions
(1) Complication rates
(2) Functional capacity and performance
(3) Cost-effectiveness
(4) Patient satisfaction
b. Serve as red flags
c. Objective measurements of outcomes
(1) Patient satisfaction
(2) Efficiency
(3) Cost reduction
(4) Results of service
d. Most important concerns
(1) Positive patient outcomes
(2) Cost-effective delivery of care
(3) Provide return on investment
e. Number one competitive factor next to cost in health care
f. Integrative: include contributions of providers and patients
g. Survey target areas for The Joint Commission and Accreditation Association for Ambulatory Health care
h. One of most crucial expectations of managed care and third-party payers
i. Endpoint of outcomes research—clinical practice guidelines, which are intended to assist practitioners and patients in choosing appropriate health care for specific conditions
7. Nursing-sensitive quality indicators
a. Performance measures that capture patient care or its outcomes most affected by nursing care
b. Can be used to create a nursing report card for the organization
c. Examples: pressure ulcers, patient falls, nosocomial infection rate for central lines, staffing mix, patient satisfaction, and staff satisfaction
L. Common steps in QI process
1. Identify/focus on priority areas.
2. Collect data/measure performance.
3. Assess performance.
4. Take action for improvement.
5. Effective team development and interaction
6. Use of statistical, analytical, and consensus tools
7. Failure mode and effects analysis
a. Improvement projects with significant impact
b. Wise to conduct proactive team
c. Identify risks of any process step failure.
d. Analyze the potential severity if any process step fails.
e. Select appropriate responses to minimize impact.
M. CQI key processes relative to data
1. Identify current available data sources.
2. Identify critical information needs.
3. Define data elements.
4. Determine data collection plan.
5. Acquire/collect data.
6. Aggregate and display data.
7. Analyze data.
8. Interpret data/information.
9. Act on information/knowledge.
10. Report data/information/knowledge/decision.
11. Collect more data to monitor/analyze the decision.
N. QI team approach
1. An ongoing interdisciplinary/cross-functional team selected from those who collect or use data and are trained in group process
2. Each site, discipline, department, team, and committee collecting data identified
3. Data to be collected determined by indicators/performance measures
4. Resources provided for the team to hit targets and meet objectives
5. Mechanisms in place for information management education
6. Reviews/monitors internal report from teams
7. Establishes improvement priorities
8. Determines how data defined
O. CQI demands
1. Corporate and organizational commitment to mission, money, management, material
2. Organization-wide culture that talks and acts like quality
3. Identification and understanding of customers, their needs and expectations
4. Ongoing pursuit of customer satisfaction
5. Team emphasis on perfecting systems in delivery of patient care to affect good outcomes
6. Constant learning and improving
7. Interdisciplinary and cross-functional collaboration
8. A planned, systematic approach organized around flow of patient care
P. Responsibility of health care professionals with process and report to administrative and governing bodies
1. Understand principles.
2. Articulate process of
a. Data measurement
b. Analysis
c. Improvement
d. Development of effective strategies
3. Recognize and be sensitive to the differences in quality services as opposed to products.
4. Move quality to the top through the commitment to excellence.
5. Validate current practice or identify opportunities for improvement using these criteria:
a. Total cost
b. Impact
c. Benefit/cost relationship
d. Cultural impact
e. Resistance to change
f. Risk
g. Health, safety, and the environment
III. TQM
A. Evolved from Japanese industry after World War II
1. Edward Deming
a. Developed sampling and data QI strategies and assisted the Japanese in developing high-quality merchandise
b. Expanded statistical methodologies beyond manufacturing to sales and service
c. Created a constancy of purpose toward improvement with the aim of becoming competitive
d. Advocated for leadership perpetuating continuous improvement
e. Promoted the attainment of profound knowledge
f. Demonstrated an understanding of harnessing sources of variation
g. Believed QI means all employees trying every day to do their jobs better to accomplish the transformation
h. Philosophy for QI adapted by American automakers in the 1980s
2. Joseph Juran
a. Expert in quality control who assisted Japanese to apply this method in business functions such as design, marketing, distribution, sales, and service delivery
b. Quality control handbook considered the bible for the QI movement
c. Identified the elements of a system to measure, improve, and lead to optimal outcomes
d. Efficiency (resource use) and quality (performance) viewed as aspects of the whole
e. Developed the Juran Quality Trilogy: simple, logical model for understanding quality management
f. Principles adopted by health care organizations in the late 1980s
3. Kaoru Ishikawa
a. Use of total quality control for open communication
b. Changed product design in accordance with customer tastes and attitudes
c. Encouraged gaining knowledge
d. Promoted company-wide quality assurance emphasizing the importance of customer
e. Believed in quality first, respect for humanity, full participatory and cross functional management to solve problems
4. Philip B. Crosby
a. Known for “zero defects” as performance standard
b. Focused on prevention
B. TQM philosophy
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1. Broad management philosophy promoting quality and leadership commitment; provides the energy and rationale for implementation of the process of CQI
2. Creates an environment of continuous improvement of people skills and processes and builds excellence into every aspect of organization
3. Processes continuously improve quality resulting in:
a. Increased customer satisfaction
b. Increased productivity
c. Increased profits
d. Increased market share
e. Decreased costs
4. Key concepts
a. Top management leadership
b. Creating corporate framework for quality
c. Transformation of corporate culture
d. Customer and process focus
e. Collaborative approach to process improvement
f. Employee education and training
g. Learning by practice and teaching
h. Benchmarking
i. Quality measures and statistics
j. Recognition and reward
k. Management integration
5. Fosters a belief in the value of customers, employees/staff, management, and teamwork
6. Views quality as an entity subject to measurement, scientific method, and data-driven problem solving
7. Offers something new to health care
a. New way of looking at delivery of care
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