Shewhart is referred to as the father of statistical quality control, a method we will explore in Chapter 4. In the s, W. Edwards Deming, a professor and management consultant, transformed traditional industrial thinking Following World War II, Japanese manufacturing companies invited Deming to help them imperformance feedback, and measurement-based quality manprove the quality of their products.
Over a period agement. The Deming model for continuous improvement is described in Chapter 5. Joseph Juran combined the science of quality with its practical application, providing a framework for linking finance and management. Whereas Deming focused on measuring and controlling process variation, Juran focused on developing the managerial aspects supporting quality.
Another individual who had a significant impact on contemporary quality practices in industry was Kaoru Ishikawa, a Japanese engineer who incorporated the science of quality into Japanese culture.
He was one of the first people to emphasize the importance of involvement of all members of the organization instead of only management-level employees. Ishikawa believed that top-down quality goals could be accomplished only through bottom-up methods Best and Neuhauser To support his belief, he introduced the concept of quality circles—groups of 3 to 12 frontline employees that meet regularly to analyze production-related problems and propose solutions Ishikawa Ishikawa stressed that employees should be trained to use data to measure and improve processes that affect product quality.
The science of industrial quality focuses on improving the quality of products by improving the production process. Improving the production process means removing wasteful practices, standardizing production steps, and controlling variation from expectations. These methods have been proven effective and remain fundamental to industrial quality improvement. The work of Shewhart, Deming, and Ishikawa laid the foundation for many of the modern quality philosophies that underlie the improvement models described in Chapter 5.
In the s, U. During these visits, Americans learned about the quality philosophies of Deming, Juran, and Ishikawa; the science of industrial quality; and the concept of quality control as a management tool. As a result, many U. Several quality gurus emerged, each with his own interpretation of quality management.
During the s, Juran, Deming, Philip Crosby, Armand Feigenbaum, and others received widespread attention as philosophers of quality in the manufacturing and service industries.
This national quality program, managed by the U. Quality circles Small groups of employees organized to solve work-related problems Criteria Standards or principles by which something is judged or evaluated 16 Baldrige National Quality Award Recognition conferred annually by the Baldrige National Quality Program to U.
Many of these criteria originated from the quality philosophies and practices advanced by Shewhart, Deming, Juran, and Ishikawa. For the first ten years, eligible companies were limited to three categories: manufacturing, service, and small business. In , two additional categories—education and healthcare—were added. Louis, became the first healthcare organization to win the Baldrige National Quality Award.
Critical Concept 2. The directions, values, and expectations should balance the needs of all stakeholders. The leaders need to ensure the creation of strategies, systems, and methods for achieving excellence in healthcare, stimulating innovation, and building knowledge and capabilities.
Patient Focus: The delivery of health care services must be patient focused. All attitudes of patient care delivery medical and nonmedical factor into the judgment of satisfaction and value. Satisfaction and value are key considerations for other customers, too. Learning is embedded in the operation of the organization. Valuing staff means committing to their satisfaction, development, and well being. Agility: A capacity for rapid change and flexibility are a necessity for success.
Health care providers face ever-shorter cycles for introductions of new and improved health care services. Faster and more flexible response to patients and other customers is critical.
Focus on Future: A strong future orientation includes a willingness to make long-term commitments to key stakeholders—patients and families, staff, communities, employers, payers, and health profession students. Important for an organization in the strategic planning process is the anticipation of changes in health care delivery, resource avail- Chapter 2: Quality Management Building Blocks!
Management by Fact: Measurement and analysis of performance are needed for an effective healthcare and administrative management system. Public Responsibility and Community Health: Leaders need to emphasize the responsibility the organization has to the public and need to foster improved community health. Results should focus on creating and balancing value for all stakeholders—patients, their families, staff, the community, payers, businesses, health profession students, suppliers and partners, stockholders, and the public.
Systems Perspective: Successful management of an organization requires synthesis and alignment. Synthesis means looking at the organization as a whole and focusing on what is important, while alignment means concentrating on key organizational linkages among the requirements in the Baldrige Criteria.
Source: Spath H e a l t h c a r e Q u a l i t y E v ol u t i o n Until the s, the fundamental philosophy of healthcare quality management was based on the pre—Industrial Revolution craft model: Train the craftspeople physicians, nurses, technicians, etc. A few years later, it developed the hospital standardization program to address the quality of facilities in which physicians worked.
Training improvement efforts were also underway in nursing; the National League for Nursing Education released its first standard curriculum for schools of nursing in While the standards stressed the need for physicians and other professional staff to evaluate care provided to individual patients, none of the quality practices espoused by Deming and Juran was required of hospitals.
The standards centered on structural requirements and eliminating incompetent people, not measuring and controlling variation in healthcare processes.
The Joint Commission accreditation standards served as a model for provider quality requirements of the Medicare healthcare program for the elderly, passed by Congress in Through the s, quality requirements in healthcare—whether represented by accreditation standards, state licensing boards, or federal regulations—focused largely on structural details and on the discipline of defective hospitals and physicians Brennan and Berwick , The quality revolution affecting other industries in the s also affected healthcare services.
The QA standard required organizations to implement an organization-wide program to The Joint Commission Quality assurance and quality control may be used interchangeably to describe actions performed to ensure the quality of a product, service, or process.
In the early s, following years of rapid increases in Medicare and other publicly funded healthcare expenditures, the government established external groups known as peer review organizations to monitor the costs and quality of care provided in hospitals and Chapter 2: Quality Management Building Blocks 19 outpatient settings IOM , 39— Throughout the s and s, healthcare quality management was increasingly influenced by the industrial concepts of continuous improvement and statistical quality control, largely in response to pressure from purchasers to slow the growth of healthcare expenditures.
Seeking alternative methods to improve healthcare quality and reduce costs, regulatory and accreditation groups turned to other industries for solutions. Soon the quality practices from other industries were being applied to health services. Today, many of the fundamental ideas behind quality improvement in the manufacturing and service industries shape healthcare quality management efforts.
For example, The Joint Commission leadership standard incorporates concepts from the Baldrige National Quality Award Criteria, and the performance improvement standard requires use of statistical tools and techniques to analyze and display data. Professional groups such as the Medical Group Management Association teach members to apply statistical thinking to healthcare practices to understand and reduce inappropriate and unintended process variation Learning Point Balestracci and Barlow The Institute for Quality Evolution Healthcare Improvement sponsors improvement projects aimed at standardizing patient care practices and minimizing inappropriate The methods and principles guiding healthcare quality imvariation.
Case studies illustrating the adaptation provement efforts have evolved at a different pace than those of industrial quality science to health services imguiding quality improvement efforts in other industries. Sevprovement are found throughout this book. Gradually, healthcare is Some industrial quality improvement catching up by applying the best quality management practices techniques are not transferrable to healthcare.
The manufacturing industry, for example, deals with machines and processes designed to be meticulously measured and controlled. At the heart of healthcare are patients whose behaviors and conditions vary and change over time. These factors create a degree of unpredictability that presents healthcare providers with challenges not found in other industries Hines et al. In addition to adopting the quality practices of other industries focused on reducing waste and variation, healthcare organizations still use some components of the pre— Industrial Revolution craft model to manage quality.
Adequate training and continuous monitoring are still essential to building and maintaining a competent provider staff. Structural details are also still important; considerable attention is given to maintaining adequate facilities and equipment. Many external forces influence business activities, including quality management.
Government regulations, accreditation groups, and large purchasers of health services are major influences on the operation of healthcare organizations. Regulations are issued by governments at the local, state, and national levels to protect the health and safety of the public. Regulation is often enforced through licensing. For instance, to maintain its license, a restaurant must comply with state health department rules and periodically undergo inspection.
Just like the restaurant owner who must follow state health department rules or risk closure, organizations that provide healthcare services or offer health insurance must follow government regulations, usually at the state level.
Regulations differ from state to state. If a healthcare organization receives money from the federal government for providing services to consumers, it must comply with federal regulations in addition to state regulations.
Both state and federal regulations include quality management requirements. For example, licensing regulations in all states require that hospitals have a system for measuring, evaluating, and reducing patient infection rates. Quality management requirements are also found in healthcare accreditation standards. Accreditation is a voluntary process by which the performance of an organization is measured against nationally accepted standards of performance.
Accreditation standards are based on government regulations and input from individuals and groups in the healthcare industry. All other groups that accredit healthcare organizations and programs also require quality management activities.
Table 2. Accreditation is an ongoing process, and visits are made to healthcare organizations at regularly scheduled or unannounced intervals to monitor their compliance with accreditation requirements. While accreditation is considered voluntary, an increasing number of purchasers and government entities are requiring it.
Purchasers of healthcare services also influence healthcare quality management. The largest purchaser of healthcare services is the government. Healthcare organizations participating in these government-funded insurance programs must comply with the quality management requirements found in state and federal regulations.
Quality management requirements for each provider category are in federal regulations called Conditions of Participation. These regulations are a contract between the government purchaser and the provider. If a provider wants to participate in a federally funded insurance program, it must abide by the conditions spelled out in the regulations. URAC www. The websites listed in Table 2.
Private insurance companies also pay a large amount of health service costs in the United States. For Commission the most part, these Continuing plans relycare onretirement government regulations and www.
However, some private companies additional quality Diagnostic Modality Accreditation Program insurance of the Freestandinghave and provider-based imagingmeasureservices, American of Radiology www. The HMO uses this information to measure the quality of customer service in the clinic. The measurement, assessment, and improvement requirements of private insurance companies are detailed in provider contracts. If a provider wants to participate in a health plan, the provider must agree to abide by the rules in the contract.
Some of these rules place quality management responsibilities on the provider. Conclusion Quality management activities in healthcare organizations are constantly evolving. These changes often occur in reaction to external forces such as regulation or accreditation standard revisions and pressure to control costs. Healthcare quality management is also influenced by other industries. Improvement strategies used to enhance the quality of products and services are frequently updated as new learning emerges.
Since their inception in , the Baldrige Quality Program Criteria have undergone several revisions. Healthcare quality management changed in when the Baldrige Criteria were adapted for use by healthcare organizations. In addition, the science of quality management, once reserved for the manufacturing industry, is now used in healthcare organizations.
The rules and tools of healthcare quality management will continue to evolve, but the basic principles of measurement, assessment, and improvement will remain the same. For instance, many people sort household garbage into two bins—one for recyclable materials and one for everything else. Foremost, quality management is the right thing to do. Competition among healthcare organizations is growing more intense, and demand for high-quality services is increasing. Healthcare organizations that study and cians and clinical and nonclinical employees.
How do quality practices that originated in the manufacturing industry differ from the traditional quality practices of healthcare organizations? How would applying the core values and concepts of the Baldrige Health Care Criteria for Performance Excellence improve healthcare quality? See Critical Concept 2. Consider the healthcare encounter you described in Chapter 1 see student discussion question 2.
If wasteful practices had been eliminated or steps in the process had been standardized, would you have had a different encounter? How would it have changed? American Society for Quality. Berwick, D. Best, M. Brennan, T. San Francisco: Jossey-Bass, Inc.
Butman, J. Juran: A Lifetime of Influence. New York: John Wiley and Sons. Catlin, A. Cowan, M. Hartman, S. Deming, W. Hines, S. Luna, J. Lofthus, M. Marquard, and D. Institute for Healthcare Improvement.
Ishikawa, K. Introduction to Quality Control, translated by J. New York: Productivity Press. Joint Commission, The. Accreditation Manual for Hospitals, edition. Kaiser Family Foundation. Merry, M. Spath, P. Uselac, S. Loudonville, OH: Mohican. For example, the dashboard on my car displays lots of data.
I can see how much gasoline is left in my tank, how fast I am traveling, and so on. These measures provide me with information about my car and my current driving situation. I decide how to use this information. Do I need to refill my gas tank soon, or can I wait a day or two? Do I need to slow down, or can I speed up a bit?
My reaction to the information is partially based on personal choices, such as my willingness to risk running out of gas or incurring a speeding ticket. My reaction to the information is also influenced by external factors, such as the distance to the nearest gas station and the speed limit. Information must be accurate to be useful.
If the information is accurate and useful to me, I need to be able to interpret it. If I want to compare information, the metrics must be consistent. Companies measure costs, quality, productivity, efficiency, customer satisfaction, and so on because they want information. They use this information to understand current performance, identify where improvement is needed, and evaluate how changes in work processes affect performance.
Like the information displayed on a car dashboard, the data must be accurate, useful, easy to interpret, and reported consistently. The organization uses measurement information to determine how it is performing. In the next step, assessment, the organization judges whether its performance is acceptable. If its performance is not acceptable, the organization advances to the improvement step.
In this step, process changes are made. After the changes are in 29 Measures Instruments or tools used for measuring Metrics Any type of measurement used to gauge a quantifiable component of performance Performance The way in which an individual, a group, or an organization carries out or accomplishes important functions and processes 30 Introduction to Healthcare Quality Management Figure 3.
Case Study The following case study illustrates the use of measurement information for quality management purposes.
Quality customer service is a priority for everyone in the clinic. Measurement: How Are We Doing? A locked, ballot-style feedback box is located in the waiting area. Your feedback will help us make things better. There are six questions on the one-page feedback form: Chapter 3: Measuring Performance 31 1. Please circle one. At the end of each week, the clinic manager collects the feedback forms from the locked box. The results are tabulated and shared with clinic staff every month.
At one monthly meeting, the clinic manager reports that many patients complain about the amount of time they must wait before they are seen by a care provider. The providers expect clinic staff to bring patients to the exam room within ten minutes of their arrival. To determine whether this goal is being met, the clinic gathers data for three weeks on patient wait times. Patients are asked to sign in and indicate their arrival time on a sheet at the registration desk.
The medical assistant then records the time patients are brought to an exam room. Assessment: Are We Meeting Expectations? Patient wait time data for the three weeks are tallied. On most days, patient wait times are ten minutes or less. However, the average wait times are longer than ten minutes on Monday afternoons and Thursdays.
Further investigation shows that the clinic services a large number of walk-in patients on Monday afternoons. The wait time data help the clinic pinpoint where improvements are needed. The clinic manager meets with the care providers to discuss ways of changing the current process to reduce bottlenecks and improve customer satisfaction.
The physicians ask that fewer patients be scheduled for appointments on Monday afternoons to give them more time to see walk-in patients. The nurse practitioner agrees to work on Thursday mornings.
Performance is measured to determine current levels of quality, identify improvement opportunities, and evaluate whether changes have improved outcomes. To test whether these changes have improved outcomes, the clinic continues to gather feedback on overall patient satisfaction and periodically collects and analyzes patient wait time data.
M e asur e me nt C h a ra cteri sti cs Performance measures 3. These numbers are called performance measures or quality indicators. There are many ways to communicate measurement data. Examples of measures and the most common numbers or statistics used to report data for healthcare quality management purposes are shown in Table 3. A measure expressed as a percentage is generally more useful than a measure expressed as an absolute number.
For example, the percentage of nursing home residents who develop an infection is more meaningful than the number of nursing home residents who develop an infection. To provide even more information, both the percentage and number of residents who develop an infection can be reported. An average, sometimes called an arithmetic mean, is the sum of a set of quantities divided by the number of quantities in the set.
In some situations, however, averages can be misleading. For example, if a few of the numbers in the data set are unusually large or small called outliers , they are commonly excluded when calculating an average. The excluded outliers are examined separately to determine why they occurred.
A ratio is used to compare two things. For instance, the nurse-to-patient ratio reports the number of hospital patients cared for by each nurse. In the same month, one hospital unit may report a ratio of 1 nurse for every 5.
A consistently calculated ratio facilitates comparison between units. Regardless of how a measure is communicated, to be used effectively for quality management purposes it must be accurate, useful, easy to interpret, and consistently reported. Accuracy relates to the correctness of the numbers.
For example, in the above case study, the time the patient entered the clinic must be precisely recorded on the registration sign-in sheet. Otherwise, the wait time calculation will be wrong. Accuracy also relates to the validity of the measure. Valid Relevant, meaningful, and correct; appropriate to the task at hand Usefulness Performance measures must be useful.
Measurement information must tell people something they want to know. For instance, the computerized billing system of a health clinic contains patient demographic information e. The number or statistic used to report the data can influence the interpretation of the measurement information. For the measures to be used effectively, they must be accurate, useful, easy to interpret, and reported consistently. Line graph A graph in which trends are highlighted by lines connecting data points See figures 3.
Ease of Interpretation Performance measures must be easy to interpret. Suppose the clinic manager in the case study reported the wait times for each patient on each day of the week. An excerpt from the report for one day is shown in Table 3.
The purpose of performance measurement is to provide information, not to make people sort through lots of data to find what they want to know.
Having to read through several pages of wait time data to identify improvement opportunities would be tedious. A much better way to report the patient wait time data is illustrated in Figure 3. Using a line graph, the clinic manager displays the average wait times for the morning and afternoon of each day of the week. Consistent Reporting Performance measures must be uniformly reported to make meaningful comparisons between the results from one period and the results from another period.
For example, Table 3. Period suppose the clinic manager starts calculating patient wait time information differently. He changes the wait time end point from the time the patient leaves the reception area to the time the patient is seen by a care provider. This slight change in the way wait times are calculated could dramatically affect performance results.
The care providers would see an increase in average wait times and interpret it as a problem when in fact the increase was caused by the different measurement criteria, not a change in performance. This new measure can be used, but it should be reported separately, as shown in Figure 3. Period These measurement categories were first conceptualized in by Dr. Avedis Donabedian His research in quality assessment resulted in a widely accepted healthcare measurement model that is still used today.
Donabedian contended that the three measurement categories—structure, process, and outcome—represent different characteristics of healthcare service. To fully evaluate healthcare performance, Donabedian recommended that performance in each dimension be measured. The structure of healthcare is measured to judge the adequacy of the environment in which patient care is provided. The process of healthcare is measured to judge whether patient care and support functions are properly performed.
Healthcare outcomes are measured to judge the results of patient care and support functions. Performance measures for most products and services would fall into these same categories. Table 3. As such, measures of structure are indirect measures of performance.
For example, although a restaurant maintains all food at proper storage temperatures, the possibility of serving spoiled food still exists. To ensure quality, measures of process and outcome also must be taken. Process Measurement Measures of process evaluate whether activities performed during the delivery of healthcare services are delivered satisfactorily.
For instance, if an emergency department has a policy that all patients with confirmed pneumonia receive an antibiotic within two hours of arrival, we would measure caregiver compliance with the policy to determine whether their performance is acceptable. In healthcare quality management, process measures are most commonly used. Process measures provide important information about performance at all levels in the organization. However, good performance does not automatically translate to good results.
In the previous example, even if all patients with pneumonia receive antibiotics within two hours of arrival in the emergency department, some may not recover. For this reason, another dimension of healthcare quality—outcome—must be measured.
O u t c om e M e a s u r e m e n t Measures of outcome evaluate the results of healthcare services—the effects of structure and process.
A common outcome measure is patient satisfaction, an indicator of how well a healthcare facility is meeting customer expectations. Healthcare facilities also measure patient mortality death and complication rates to identify opportunities for improvement. Outcome measures are also used to evaluate the use of healthcare services. Average length of hospital stay and average cost of treatment are two examples of outcome measures that examine the use of services.
Process measures are used to assess whether services are delivered properly. Outcome measures are used to assess the final product or end results. For example, patient mortality rates at one hospital may be higher than rates at other hospitals because the hospital cares for more terminally ill cancer patients. This healthcare organization may do all the right things but appear to be an underperformer because of the population it serves.
When evaluating measurement data, many factors affecting patient outcomes must be considered. This measure is a snapOutcome: What is the rate of patient pain reduction following shot of overall clinic performance.
Because many therapy? The percentage of time reception staff telephones patients to remind them of upcoming clinic appointments is an example of an System-level measure activity-level measure. Data describing the Consider how the performance of an automobile is evaluated.
A common meaoverall performance of several interdependent sure of car performance is the number of miles it can travel per gallon of gasoline. Activity-level measures can be used to evaluate these actions. For example, average time between engine tune-ups is Activity-level measure Data describing the an activity-level measure of an action that affects car performance.
By using a combination performance of one of system- and activity-level measures, the owner can judge not only overall fuel economy process or activity but also actions or lack thereof that might be adversely affecting it.
A mix of system- and activity-level measures allows a healthcare organization to judge whether overall performance goals are being met and where frontline improvements may be needed. On the external side, numerous government regulations, accreditation standards, and purchaser requirements directly affect measurement activities.
The number and type of measures used to evaluate performance vary in proportion to the number of external requirements the organization must meet. Critical Concept 3. The performance measurement requirements of the federal government, the largest purchaser of healthcare services, continue to increase in response to quality improvement and cost-containment efforts. The measures of performance required of healthcare organizations help purchasers assess value in terms of the six Institute of Medicine IOM quality aims described in Chapter 1: Healthcare should be safe, effective, patient centered, timely, efficient, and equitable.
State licensing regulations often require healthcare organizations to evaluate structural issues, such as compliance with building safety and sanitation codes. Licensing regu- Chapter 3: Measuring Performance lations may also include specific requirements for process and outcome measures.
A list of performance data that must be collected by ambulatory surgical treatment centers in Illinois is shown in Critical Concept 3. Certain state and federal regulations apply only to specific healthcare units, such as radiology and laboratory departments.
These regulations contain many quality control requirements with corresponding system- and activity-level performance measurement obligations. For instance, any facility that performs laboratory testing on human specimens must adhere to the quality standards of the Clinical Laboratory Improvement Amendments, passed by Congress in to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test is performed U.
Food and Drug Administration Accreditation standards may duplicate those mandated by government regulations and purchasers. However, some measurement requirements found in accreditation standards are unique. They also must participate in the core measure project, which involves gathering and sharing measurement results with The Joint Commission. As much as possible, The Joint Commission coordinates its core measurement requirements with the measurement activities mandated by CMS to lighten the workload for organizations subject to both groups.
Learning Point A growing number of external groups are Choosing Measures mandating that healthcare organizations gather specific performance measures for quality manHealthcare organizations measure many aspects of perforagement purposes. When selecting performance measures, organizations must consider the most mance. Some of the measures are mandated by external current measurement directives of relevant govregulatory, licensing, and accreditation groups.
Some of the ernment regulations, accreditation bodies, and measures are chosen to evaluate performance issues imporpurchasers. Consider a home health agency with a particularly large hospice patient population. Hospice patients have a limited life expectancy and require comprehensive clinical and psychosocial support as they enter the terminal stage of an illness or a condition. The measures required of Medicare-certified home health agencies do not address some of the performance issues unique to hospice patients and their families.
Consequently, the home health agency will need to identify and gather its own performance measures of hospice services in addition to collecting the measures required to maintain Medicare certification. These steps can be time consuming but are essential to ensuring the measures are useful for quality management purposes. Identify Topic of Interest The first step to constructing a performance measure is to determine what you want to know. Consider just one function—for example, taking patient X-rays in the radiology department.
This function involves several steps: Chapter 3: Measuring Performance 45 1. Answers to these questions can help the radiology department gauge its performance in each quality dimension. Factors the radiology manager will take into consideration when selecting performance measures for the department are summarized in Table 3.
Aspects of service that will be measured to answer performance questions must be stated explicitly. Without this knowledge, measures cannot be developed. D e v e lo p the Measure Once performance questions have been identified, the next step is to define the measures that will be used to answer the questions.
To turn the question into a performance measure, the manager decides to use the percentage of results communicated to doctors within 48 hours of completion of an outpatient X-ray exam. The top number in the fraction is the numerator, and the bottom number is the denominator.
To calculate the percentage of results communicated to the doctor within 48 hours of exam completion, the top number is divided by the bottom number and then multiplied by Examples of performance measures, along with the numerators and denominators that would help answer some of the questions in Table 3.
Some performance measures, typically structure measures, do not have denominators. For instance, health plans usually want to know whether a hospital is accredited. Evidence of accreditation is a structure measure.
This measure is an absolute number; a denominator is not necessary. Cancel Delete. Cancel Overwrite Save. Don't wait! Try Yumpu. Start using Yumpu now! Terms of service. Privacy policy. Cookie policy. Change language. As before, this textbook will be useful to a wide variety of students and programs. Undergraduate students in health care management, nursing, public health, nutrition, athletic training, and allied health programs will find the writing to be engaging.
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