IMPROVING ORGANIZATIONAL PERFORMANCE

The year 1998 was a pivotal year in the quest for improvement in health care. In that year, the Institute of Medicine issued a report, To Err Is Human: Building a Safer Health System, detailing the problem of medical errors in health care. The Advisory Commission on Consumer Protection and Quality also released a report calling for a national commitment to improve quality, concluding that “there is no guarantee that any individual will receive high quality care for any particular health problem … the health care industry is plagued … with errors in health care” (Advisory Commission on Consumer Protection and Quality, 1998). It was found that these quality concerns occur typically because of ways in which care is organized. Health care organizations were challenged to ensure that services were safe, effective, patient centered, timely, efficient, and equitable.

Performance improvement (PI) has been shown to be a powerful tool to help health care organizations become safer and more efficient and patient centered. Total quality management (TQM), which is also referred to as PI or quality improvement (QI), had been used in industry since the 1950s and had been related to improvements in productivity and quality.

HISTORICAL PERSPECTIVES

In the 1950s, the Joint Commission on Accreditation of Healthcare Organizations was formed and the evaluation of care delivered in health care institutions began. During the 1960s, the American Nurses Association began to develop standards of nursing practice, which become the basis for early quality assurance (QA) programs. In the 1970s, the U.S. Congress established Professional Standards Review Organizations (PSROs) to review the quality and cost of care delivered to Medicare and Medicaid recipients. QA required audits of care. These audits measured basic compliance, emphasizing what was done “wrong,” but did little to advance a philosophy of learning from performance.

Health care costs became a major issue in the 1980s, and society began to question the efficiency and effectiveness of health care (Phelps, 1997). Health care administrators turned to industry for lessons learned in managing efficiency. Industry had adopted quality management techniques in the 1950s. An early proponent was W. Edwards Deming, who worked with the Japanese automotive industry after World War II. His 14-point management philosophy is the underpinning of TQM. The 14 points follow:

Deming believed that an industry consists of multiple processes and decisions, which are interrelated, and developed a “system of profound knowledge” (Deming, 2000b):

His model for improvement was the PDCA (Plan–Do–Check–Act) cycle, which remains in widespread use today. Juran (1989) elaborated on Deming’s work in TQM. He believed that quality “did not happen by accident” but was the result of a quality trilogy—planning, control, and improvement. In 1960, Crosby defined quality as the extent to which processes were in conformance with the requirements of the customer. He was known for believing that things should be done “right the first time” and for the philosophy of “zero defects” (Nielson et al., 2004). While these three proponents of quality improvement focused on work processes, Donabedian (1992) contributed the idea of outcome as part of the overall quality structure. Outcomes involve the results achieved, and they reflect the effectiveness of the process components. This outcomes focus allows institutions to measure themselves against the standards and the competition. A compendium of past and present quality terms is presented in Table 10-1.

KEY FOCUS OF PERFORMANCE IMPROVEMENT

This focus on outcomes has moved health care from a compliance model toward one of “best practice.” While accrediting bodies and federal regulators set minimum standards of compliance, many hospitals are now moving toward a model of “best in class.” Examples of organizations that recognize such “best practice” are American Nurses Association and its Magnet Award for Nursing and the Malcolm Baldrige National Quality Award for performance excellence. Hospitals winning the Magnet Award can be accessed at http://www.nursingworld.org/ancc/magnet/index.html. The hospitals that have been recognized by receiving the Malcolm Baldrige National Quality Award can be accessed at http://baldrige.nist.gov/Contacts_Profiles.htm.

The key focus of PI includes

It is vital to remember that all PI must be “data driven” and not based on anecdote.

DRIVERS OF QUALITY

The key focus of the quality movement is the meeting of the needs of the customer. In organizations striving for “best practice,” this may mean exceeding the needs of the customer.

Obviously, the key customers of health care are the patient and family; they are at the center of all drivers of quality. Other customers of the hospital include the physicians and the community. Bronson Methodist Hospital in Kalamazoo, Michigan, has defined the patient (and family) and the community as key customers, with key requirements and market segments as given in Table 10-2.

What is important is that each set of customers has specific requirements that need to be met by the health care organization. The degree to which these key requirements are met forms a base for the patient satisfaction measures of the institution. Other customers include regulators, partners, and payers.

Quality outcomes also are a key requirement of the patient and the community. How do hospitals measure quality outcomes? There are a variety of means.

OUTCOME MEASURES

The key to PI is the “result” of all actions taken to improve patient care. While it is important to “do what we say we do,” it is more important to “do it well.” So, just how well do we deliver patient care?

Patient care units have an abundance of data available to them. One common outcome used by patient care units is patient satisfaction. A majority of health care organizations across the United States measure patient satisfaction. Two of the common vendor satisfaction measures are Press Ganey and Gallup. These data can be segmented to list the performance of specific units/shifts. The key requirements of the patient/family at Bronson Methodist Hospital are listed in Box 10-2. They were identified as: communication, empathy, responsiveness, and efficiency.

Patient satisfaction surveys are customized to include information on the key requirements of the patients of an institution. With the use of nationwide surveys, hospitals can compare their performance with that of other local hospitals, of similar hospitals, and of best-in-class performers. See Figure 10-1 provides an example of a patient satisfaction data set.

Other data sets available to the nurse include the National Database of Nursing Quality Indicators® (NDNQI®), a program of the American Nurses Association National Center for Nursing Quality. The database collects and evaluates unit-specific nurse-sensitive data from hospitals in the United States and internationally. Participating facilities receive unit-level comparative data reports to use for QI purposes. Nursing-sensitive indicators reflect the structure, process, and outcomes of nursing care (Box 10-1) (National Center for Nursing Quality, 2007).

Box 10-1   MENU OF INDICATORS CURRENTLY BEING COLLECTED

• Patient falls

• Patient falls with injury

• Injury level

• Pressure ulcer rate

• Hospital-acquired pressure ulcer rate

• RN satisfaction

• Nursing hours per patient day

• Registered nurses (RN) hours per patient day

• Licensed practical/vocational nurses (LPN/LVN) hours per patient day

• Unlicensed assistive (UAP) hours per patient day

• Staff mix

• RN

• LPN/LVNs

• UAP

• Percent agency staff

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