Managing and Improving Quality 6
Key Terms Continuous quality
improvement (CQI) Dashboards DMAIC Incident reports Indicator Just culture
1. Describe how total quality management, continuous quality management, Six Sigma, Lean Six Sigma, and DMAIC address quality.
2. Describe national efforts to improve the quality of health care.
3. Explain how evidence-based practice, electronic medical records, and dashboards can improve quality.
4. Point out how nurses are involved in reducing risks.
5. Discuss how to create a blame-free environment.
Learning Outcomes After completing this chapter, you will be able to:
Outcome standards Lean Six Sigma Peer review Process standards Quality management Reportable incident Risk management
Root cause analysis Six Sigma Standards Structure standards Total quality management
(TQM)
70 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
I n today’s highly competitive health care environment, each member of the health care organization must be accountable for the quality and cost of health care. Concern about quality gained national attention after publication of the Institute of Medicine’s (IOM) reports on medical errors in 1999 (IOM, 1999) and their later recommendations for health pro- fessionals’ education (IOM, 2003). Additionally, concern about cost continues unabated. Both quality and cost containment are found in the concept of total quality management, which has evolved into a model of continuous quality improvement designed to improve system and process performance. Risk management is integrated within a quality management program.
Quality Management Quality management moved health care from a mode of identifying failed standards, problems, and problem people to a proactive organization in which problems are prevented and ways to improve care and quality of care are sought. This paradigm shift involves all in the organization and promotes problem solving and experimentation.
A quality management program is based on an integrated system of information and accountability. Clinical information systems can provide the data needed to enable organizations to track activities and outcomes. For example, data from clinical information systems can be used to track patient wait times from admitting to outpatient testing to admission in an inpatient care unit. Delays in the process can be identified so appropriate staff and resources are available at the right time to decrease delays and increase efficiency and patient satisfaction. Methods can be devised to discover problems in the system without blaming the “sharp end,” the last individual in the chain to act (e.g., the nurse gives a wrong medication). The system must be accepted and used by the entire staff.
Total Quality Management Total quality management (TQM) is a management philosophy that emphasizes a commitment to excellence throughout the organization. The creation of Dr. W. Edwards Deming, TQM was adopted by the Japanese after World War II and helped transform their industrial development. Dr. Deming based his system on principles of quality management that were originally applied to improve quality and performance in the manufacturing industry. They are now widely used to improve quality and customer satisfaction in a number of service industries, including health care.
TQM Characteristics Four core characteristics of total quality management are:
● Customer/client focus ● Total organizational involvement ● Use of quality tools and statistics for measurement ● Key processes for improvement identified
Customer/Client Focus. An important theme of quality management is to address the needs of both internal and external customers. Internal customers include employees and departments within the organization, such as the laboratory, admitting office, and environmental services. External customers of a health care organization include patients, visitors, physicians, managed- care organizations, insurance companies, and regulatory agencies, such as the Joint Commission, which accredits health care organizations, and public health departments.
Under the principles of TQM, nurses must know who the customers are and endeavor to meet their needs. Providing flexible schedules for employees, adjusting routines for a.m. care to meet the needs of patients, extending clinic hours beyond 5 p.m., and putting infant changing tables in restrooms are some examples. Putting the customer first requires creative and innova- tive methods to meet the ever-changing needs of internal and external customers.
Total Organizational Involvement. The goal of total quality management is to involve all employees and empower them with the responsibility to make a difference in the quality of
CHAPTER 6 • MANAGING AND IMPROVING QUALITY 71
service they provide. This means all employees must have knowledge of the TQM philosophy as it relates to their job and the overall goals and mission of the organization. Knowledge of the TQM process breaks down barriers between departments. The phrase “That’s not my job” is eliminated. Departments work together as a team. On occasion, nursing personnel might clean a bed for a new admission from the emergency room or an administrator might transport a patient to the radiology department. Sharing processes across departments and patient care functions increases teamwork, productivity, and patient positive outcomes.
Use of Quality Tools and Statistics for Measurement. A common management adage is, “You can’t manage what you can’t (or don’t) measure.” There are many tools, formats, and designs that can be used to build knowledge, make decisions, and improve quality. Tools for data analysis and display can be used to identify areas for process and quality improvement, and then to benchmark the progress of improvements. Deming applied the scientific method to the concept of TQM to develop a model he called the PDCA cycle (Plan, Do, Check, Act) depicted in Figure 6-1.
Identification of Key Processes for Improvement. All activities performed in an organization can be described in terms of processes. Processes within a health care setting can be:
● Systems related (e.g., admitting, discharging, and transferring patients) ● Clinical (e.g., administering medications, managing pain) ● Managerial (e.g., risk management and performance evaluations).
Processes can be very complex and involve multidisciplinary or interdepartmental actions. Processes involving multiple departments must be investigated in detail by members from each department involved in the activity so that they can proactively seek opportunities to reduce waste and inefficiencies and develop ways to improve performance and promote positive outcomes.
Continuous Quality Improvement TQM is the overall philosophy, whereas continuous quality improvement (CQI) is used to im- prove quality and performance. TQM and CQI often are used synonymously. In health care orga- nizations, CQI is the process used to investigate systematically ways to improve patient care. As the name implies, continuous quality improvement is a never-ending endeavor (Hedges, 2006).
CQI means more than just meeting standards and thresholds or solving problems. It involves evaluation, actions, and a mind-set to strive constantly for excellence. This concept is sometimes difficult to grasp because patient care involves the synchronization of activities in multiple de- partments. Therefore, the importance of developing and implementing a well-thought-out pro- cess is key to a successful CQI implementation.
There are four major players in the CQI process:
● Resource group ● Coordinator
PlanPlan
DoAct
Check
Figure 6-1 • PDCA cycle.
72 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
● Team leader ● Team
The resource group is made up of senior management (e.g., CEO, vice presidents). It estab- lishes overall CQI policy, vision, and values for the organization and actively involves the board of directors in this process, thereby ensuring that the CQI program has sufficient emphasis and is provided with the resources needed. The CQI coordinator is often appointed by the CEO to pro- vide day-to-day management of the CQI process and related activities (e.g., training programs).
CQI teams are designated to evaluate and improve select processes. They are formally established and supported by the resource group. CQI teams range in size from 5 to 10 people, representing all major functions of the process being evaluated.
Each CQI team is headed by a team leader who is familiar with the process being evaluated. The leader organizes team meetings, sets the agenda, and guides the group through the discussion, evaluation, and implementation process.
Components of Quality Management A comprehensive quality management program includes:
● A comprehensive quality management plan. A quality management plan is a systematic method to design, measure, assess, and improve organizational performance. Using a multidisciplinary approach, this plan identifies processes and systems that represent the goals and mission of the organization, identifies customers, and specifies opportunities for improvement. Critical paths, which are described in Chapter 3, are an example of a quality management plan. Critical paths identify expected outcomes within a specific time frame. Then variances are tracked and accounted for.
● Set standards for benchmarking. Standards are written statements that define a level of performance or a set of conditions determined to be acceptable by some authorities. Standards relate to three major dimensions of quality care:
a. Structure b. Process c. Outcome
Structure standards relate to the physical environment, organization, and management of an organization. Process standards are those connected with the actual delivery of care. Outcome standards involve the end results of care that has been given.
An indicator is a tool used to measure the performance of structure, process, and outcome standards. It is measurable, objective, and based on current knowledge. Once indicators are identified, benchmarking, or comparing performance using identified quality indicators across institutions or disciplines, is the key to quality improvement.
In nursing, both generic and specific standards are available from the American Nurses Association and specialty organizations; however, each organization and each patient care area must designate standards specific to the patient population being served. These standards are the foundation on which all other measures of quality are based.
An example of a standard is, “Every patient will have a written care plan within 12 hours of admission.”
● Performance appraisals. Based on requirements of the job, employees are evaluated on their performance. This feedback is essential for employees to be professionally accountable. (See Chapter 18 for more on performance appraisals.)
● A focus on intradisciplinary assessment and improvement. There will always be a need for groups to assess, analyze, and improve their own performance. Methods to assess performance should, however, focus on the CQI philosophy, which involves group or intradisciplinary performance. Peer review, discussed later in the chapter, is an example of intradisciplinary assessment.
CHAPTER 6 • MANAGING AND IMPROVING QUALITY 73
● A focus on interdisciplinary assessment and improvement. Multidisciplinary, patient- focused teamwork emphasizing collaboration, communication, coordination, and integra- tion of care is the core of CQI in health care. It is important not to disband departmental quality functions, such as patient satisfaction, utilization review, or infection control, but rather to refocus information on improving the process.
Resources are used to collect data, such as the number of postoperative infections or the number of return clinic visits, to guide the decision-making process. Throughout the evalua- tion and implementation process, the team’s focus is the patient. Implementation is continu- ally evaluated using a patient satisfaction survey, which is just one of the methods used to monitor nursing care. For example, some organizations follow up outpatient surgery clients with direct phone calls from nursing staff to ensure patients understand discharge instructions and that pain was controlled following discharge. Any potential complications are referred to the surgeon.
Six Sigma Six Sigma is another quality management program that uses, primarily, quantitative data to monitor progress. Six Sigma is a measure, a goal, and a system of management.
● As a measure. Sigma is the Greek letter—ó—for standard, meaning how much performance varies from a standard. This is similar to how CQI monitors results against an outcome measure.
● As a goal. One goal might be accuracy. How many times, for example, is the right medication given in the right amount, to the right patient, at the right time, by the right route?
● As a management system. Compared to other quality management systems, Six Sigma involves management to a greater extent in monitoring performance and ensuring favorable results.