Improving Quality in Health Care Organizations

Improving Quality in Health Care Organizations ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Improving Quality in Health Care Organizations Chapter 9 Improving Quality in Health Care Organizations (HCOs) Jennifer L. Hefner and Ann Scheck McAlearney CHAPTER OUTLINE t Quality Improvement in Health Care t Approaches to Quality Improvement t Performance Measurement in Quality Improvement t Getting to Higher Quality and Quality Improvement t Applying Quality Improvement Frameworks LEARNING OBJECTIVES After completing this chapter, the reader should be able to: Explain the importance of quality improvement (QI) in health care Define quality and performance measures for organizations Differentiate the important issues in using quality and performance measures Identify the challenges of undertaking QI and implementing QI in health care organizations (HCOs) Distinguish among QI frameworks Describe opportunities to apply QI tactics and strategies to support QI in HCOs Assess conditions for QI change Justify the need to manage for QI in health care Explain the importance of people and focusing on people issues in QI efforts Describe management roles to create high-performance, quality-focused organizations KEY TERMS Access 1FSGPSNBODF.FBTVSFT Benchmarking 1MBOo%Po4UVEZo”DU 1%4? .FUIPEImproving Quality in Health Care Organizations $MJOJDBM1SBDUJDF(VJEFMJOFT 1SPDFTT.FBTVSFTPG1FSGPSNBODF $POUJOVPVT2VBMJUZ*NQSPWFNFOU $2* 2VBMJUZ*NQSPWFNFOU 2* )JHI1FSGPSNBODF8PSL1SBDUJDFT )181T 2VBMJUZ*NQSPWFNFOU 2* *OUFSWFOUJPOT *NQMFNFOUBUJPO 4JY4JHNB Lean 4USVDUVSBM.FBTVSFTPG1FSGPSNBODF 0VUDPNF.FBTVSFTPG1FSGPSNBODF 5SBOTBDUJPOBM-FBEFSTIJQ 1BUJFOU&YQFSJFODF.FBTVSFT 5SBOTGPSNBUJPOBM-FBEFSTIJQ 1FSGPSNBODF*NQSPWFNFOU 214 PART 2 r MICRO PERSPECTIVE rrr*/13?$5*$& 4IBSQ)FBMUI$BSFBOE*UT2VBMJUZ*NQSPWFNFOU+PVSOFZ Sharp HealthCare is a large, not-for-profit health system based in San Diego, California. With over 14,000 employees and 2,600 physician affiliates, the system is comprised of four acute-care hospitals, three specialty hospitals, and two medical groups, and includes a wide range of other facilities and services. Given its location in a highly regulated state, Sharp faces particular challenges associated with corporate practice of medicine laws and the laws regulating nurse-staff ratios as they impact Sharp’s abilities to employ and deploy health care professionals throughout their organization. Yet despite these challenges, Sharp HealthCare has received increased attention over the past decade as it has received national recognition for Magnet designation for nursing excellence at two of its acute-care hospitals, national designation as a Planetree hospital at another acute-care hospital, and the prestigious 2007 Malcolm Baldrige Award for Quality for the system as a whole. Sharp’s self-described quality improvement “journey” has been multifaceted and has touched the entire health system. In the late 1990s, Sharp had a solid reputation in the San Diego area, and patient satisfaction scores collected by the organization were high, indicating that there was not much to worry about. A change in system leadership, Improving Quality in Health Care Organizations however, created an opportunity to focus on quality and quality improvement in a new way. Curious about how they were doing, Sharp decided to convene some focus groups to find out how patients felt about their health care experience. Much to the surprise and chagrin of health system leaders, Sharp’s patients told them the experience was not all that good, and health care in general left much to be desired from a customer perspective. Instead of confirming their belief that Sharp was well regarded by satisfied patients, these focus groups indicated many opportunities for improvement. The health system began to benchmark data against other health systems and contracted with Press Ganey for patient satisfaction measurement. Patient satisfaction scores as measured by the new scale were in the lowest quartile. Sharp’s leaders used these data to spark employee interest in quality and performance improvement and to motivate employees to address needed changes. Over the course of the next decade, Sharp made a substantial investment in Lean and Six Sigma methods as its selected approaches to QFSGPSNBODFJNQSPWFNFOU and built a QI focus into the culture of the organization. In addition, as an organizing framework for the QI journey, Sharp designed The Sharp Experience as a performance improvement initiative designed to help Sharp realize its mission-driven goal to be the best place to work, the best place to practice medicine, and the best place to receive care. Sharp’s receipt of the coveted Baldrige Award for Quality in 2007 provided public recognition of Sharp’s success in its QI journey. Now beyond Baldrige, Sharp continues to capitalize on opportunities for QI and is currently driving improvements in patient safety, including “just culture,” transparency, team training, standardized communication processes, handoff standardization, and design change to improve quality of care and patient safety throughout the health system. Most recently, Sharp HealthCare was recognized as “Most Wired” in 2016, was ranked 16th Best Employer in America by Forbes out of 500 large employers, and was recognized as a 2017 World’s Most Ethical Company. SOURCE: Nancy G. Pratt, RN, MS, Senior Vice President, Clinical Effectiveness, Sharp HealthCare; Sharp HealthCare website (http://www.sharp.com) CHAPTER PURPOSE With the release of the Institute of Medicine’s (IOM’s) report, To Err Is Human: Building a Safer Health System (2000), quality and patient safety reemerged as sentinel issues in health care delivery. Improving Quality in Health Care Organizations The Institute’s report prompted renewed effort to identify and implement RVBMJUZ JNQSPWFNFOU 2* JOUFSWFOUJPOT, interventions designed to decrease medical errors and enhance patient safety. It also rekindled attempts to hold health care organizations (HCOs) accountable for quality. Government agencies, accrediting bodies, employer groups, and other organizations have developed an ever-growing number of performance measures and patient safety goals against which they intend to measure a health care organization’s quality performance and improvement over time. Table 9.1 presents a sample of two types of these metrics—organizational measures and clinical measures. One five-hospital Academic Medical Center recently claimed that it reports 1,600 unique measures to 49 different sources (Murray et al., 2017). In many cases these measures are publicly reported, on websites such as the Centers for Medicare and Medicaid Services (CMS) Hospital Compare, and they are also used by groups such as Healthgrades, Leapfrog, and U.S. News and World Report to rank top performers on domains such as clinical processes, patient outcomes, and patient experience ratings. This chapter outlines how HCOs can CHAPTER 9 r Improving Quality in Health Care Organizations (HCOs) 215 5BCMF Examples of Quality Measures 0SHBOJ[BUJPOBM.FUSJDT $MJOJDBM.FUSJDT *OTUJUVUFPG.FEJDJOFT”JNTGPS *NQSPWFNFOU‡*0. Quality of Work Life t Perceptions of work–life balance t Often derived from organizational survey Safe t Standardized mortality rate for unit, for organization t Adverse drug events per doses (1,000) administered Employee Satisfaction with the Organization t Willingness to refer a friend or relative to the organization t Willingness to seek care within the organization t Employee turnover rates Effective t Lost days of work per employee t Growth in market share for organization t Statistics related to patient safety t Perceptions about quality of care within organizational culture Financial Metrics t Margins, etc. t Bed days per 1,000 t Market share Patient-Centered t Patient satisfaction with unit, with organization t Drill down into patient education statistics Patient Satisfaction tImproving Quality in Health Care Organizations With care, safety, providers t Willingness to refer friend/relative for care Timely t Access to care as measured by waiting times, other process measures t Measurement of delays in care Achievement of Strategic Goals t Alignment with balanced scorecard goals t Achievement of national patient safety goals t Participation in Institute for Healthcare Improvement (IHI) campaigns Efficient t Cost per adjusted hospital admission t Operating margin as measured by cash from operations Equitable t Disparities in care access t Disparities in utilization t Disparities in referrals made improve quality and patient safety through QI efforts and describes the challenges and strategies for changing organizational systems to ensure that QI is an accepted part of organizational behavior. QUALITY IMPROVEMENT IN HEALTH CARE Almost everyone agrees that high quality is an important and desirable characteristic of health care services. However, quality can be a difficult concept to define. Donabedian (2005) observed that although quality can be very broadly defined, it usually reflects the values and goals of the current medical system and of the larger society of which it is a part. According to Donabedian (1988), there are three major elements of quality: structure, process, and outcomes. Structure pertains to having the necessary resources to provide adequate health care; process focuses on how care is provided, delivered, and managed; and outcomes refers to changes in a patient’s health status as a result of medical care. Another definition of quality that is commonly used and widely accepted in health care is contained in the influential report from the Institute of Medicine (IOM), Crossing the Quality Chasm: A New Health System for the 21st Century. This report defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Institute of Medicine Committee on Quality of Health Care, 2001). The report also discussed the six major aims for improvement in health care, which emphasize the need for care to be safe, effective, patient-centered, timely, efficient, and equitable. HCOs, then, are challenged to provide care, or support the microsystems that deliver care, in a manner that achieves these aims (Berwick, Nolan, and Whittington, 2008). The current consensus in the scientific literature is that quality is a multidimensional concept including both patient experiences of care as well as clinical quality measures such as readmission and adverse events (Lehrman et al., 2010; Price et al., 2014). The CMS acknowledges 216 PART 2 r MICRO PERSPECTIVE this by linking value-based purchasing penalties to a variety of performance measures across these dimensions. Measures include Donabedian’s elements of structure, process, and outcomes.Improving Quality in Health Care Organizations Recently, there has been a move toward public reporting of these measures and ranking hospitals to identify top performers. However, there is a lack of consensus around how to define quality in order to achieve this goal. Healthgrades, the Leapfrog Group, U.S. News and World Report, Press Ganey, and CMS Hospital Compare all publish a yearly list of top performers in which they score hospitals using different methodologies and, by extension, different definitions of quality. Pressure from this public reporting, as well as given the spread of payer reimbursement incentives and penalties, is driving HCOs to focus on improving their scores across measures and dimensions of quality. The key to success in this effort is quality improvement. 2VBMJUZ*NQSPWFNFOU 2VBMJUZJNQSPWFNFOU 2* is an organized approach to planning and implementing processes driving continuous improvement in performance. QI emphasizes continuous examination and improvement of work processes by teams of organizational members trained in basic statistical techniques and problem-solving tools, and who are empowered to make decisions based on their analysis of the data. Typically, QI efforts are strongly rooted in evidence-based procedures and rely extensively on data collected about the processes and outcomes experienced by patients in organizations. Table 9.2 presents a glossary of common terms and programs associated with QI in Health Care. Similar to other systems-based approaches, QI stresses that quality depends foremost on the processes by which services are designed and delivered. The systemic focus of QI complements a growing recognition in the field that the quality of the care delivered by clinicians depends substantially on the performance capability of the organizational systems in which they work. While individual clinician competence remains important, many increasingly see that the capability of organizational systems to prevent errors, to coordinate care among settings and practitioners, and to ensure that relevant, accurate information is available when needed is critical in providing high-quality care (Elder et al., 2008). Improving Quality in Health Care Organizations This systems-based perspective on QI emphasizes organization-wide commitment and involvement because most, if not all, vital work processes span many individuals, disciplines, and departments in all clinical settings. 5BCMF Glossary of Common Terms and Programs Associated with QI in Health Care AIDET: A communication tool espoused by the Studer Group, designed to help clinicians establish trust with patients in order to improve compliance and clinical outcomes. AIDET is an acronym that stands for Acknowledge, Introduce, Duration, Explanation, and Thank You (http://www.studergroup.com/dotCMS/ detailProduct?inode=110454). Baldrige Award: A prestigious national award to companies in several categories, including health care that recognizes demonstrated excellence in seven categories: leadership; strategic planning; customer and market focus; measurement, analysis, and knowledge management; workforce focus; process management; and results. Applications are reviewed by an independent Board of Examiners (http://www.baldrige.nist.gov/). Benchmarking: A key feature of many QI approaches, benchmarking is the process of comparing an organization’s performance metrics (e.g., quality, cost, operational efficiency) to those of other “best practice” or peer organizations. Business Process Reengineering (BPR) Term used to describe efforts to radically review and reorganize existing work processes, or adopt new and innovative work processes, designed to improve customer value, organizational efficiency, and market competitiveness. A key to BPR is the development of organizational and management structures to effectively support the redesign (e.g., information technology) (see Hammer, 1990). Clinical Practice Guidelines Typically developed by expert panels, DMJOJDBMQSBDUJDFHVJEFMJOFT synthesize evidence from the literature and make recommendations regarding treatment for specific clinical conditions (see IOM, 2001). The National Guideline Clearinghouse (http://www.guideline.gov) is a publicly available resource for evidence-based guidelines covering a full range of clinical conditions. Continuous Quality Improvement (CQI) A participative, systematic approach to planning and implementing a continuous organizational improvement process. CHAPTER 9 r Improving Quality in Health Care Organizations (HCOs) 217 5BCMF Glossary of Common Terms and Programs Associated with QI in Health Care (Continued) Crew Resource Management (CRM): A technique from the aviation field that addresses errors resulting from communication and decision making in dynamic environments, such as teams, that has been adopted in the health care field to improve patient safety. CRM is among the evidence-based safety practices included in the Agency for Healthcare Research and Quality’s document entitled “Making Health Care SaferImproving Quality in Health Care Organizations : A Critical Analysis of Patient Safety Practices Evidence Report/Technology Assessment, No. 43.” (http://www.ncbi.nlm.nih.gov/ bookshelf/br.fcgi?book=erta43&part=A64100). Crucial Conversations Refers to concepts and techniques articulated in Patterson et al. (2002). Fortune “Best Places to Work”: Fortune magazine’s annual ranking of U.S. companies with greater than 1,000 FTEs that have been nominated as a “great place to work.” Awards are based on results of employee surveys (in 2009, 81,000 employees surveyed across 353 companies) and a “culture audit” conducted in each company (http://www.greatplacetowork.com/). High-Reliability Organizations High-reliability organizations (HROs) are those that have incorporated a culture and processes to “radically reduce system failures and effectively respond when failures occur” (http://www.ahrq.gov/ qual/hroadvice/hroadviceexecsum.htm). High-Performance Work Practices (HPWPs) Workforce or human resource practices that have been shown to improve an organization’s capacity to effectively attract, select, hire, develop, and retain high-performing employees. Just Culture/Just Safety Culture: Term used to describe an organizational culture that encourages open dialogue to facilitate patient safety practices; often described in contrast to a “blame” culture (that focus on individuals, rather than systems, as the source of safety infractions). A just culture gives some “leeway to individuals, but is still premised on . . . accountability and bureaucratic control.” More recently, scholars are advocating that just culture focus on organizational learning in the areas of quality and safety (Khatri, Brown, and Hicks, 2009). LeanA management and operations improvement approach, often described as a “transformation” that focuses on eliminating waste across “value streams” that flow horizontally across technologies, assets, and departments (as opposed to improving within each). The intent of a Lean approach is cost-effectiveness, error reduction, and improved service to customers. The term “Lean” was originally coined by Jim Womack, PhD, to describe innovations in Toyota’s manufacturing processes (http://www.lean.org). Magnet Status: A prestigious external designation from the “Magnet” program, this status recognizes hospitals that demonstrate 14 characteristics that comprise an excellent working environment for nurses (e.g., nursing leadership, quality of patient care, level of nursing autonomy, staffing ratios, professional development) (http://www.nursecredentialing.org/Magnet). Pay-for-Performance (P4P) Reimbursement for health care services which is designed to link payment incentives to quality and performance outcomes. Improving Quality in Health Care Organizations Demonstration programs to test various approaches have been under way through the Centers for Medicare and Medicaid Services (see IOM, 2007). Pebble Project: An initiative through the Center for Health Design, which works with partners to develop facilities that incorporate “evidence-based design” features that have been demonstrated to reduce errors, improve quality and efficiency, and improve work experience (https://www.healthdesign.org/research-services/pebble-project). Performance Improvement International A consulting company that espouses a system-oriented, engineering-based performance improvement methodology, which uses performance indicators and root cause analysis to reduce errors and improve performance (http://www.errorfree.com). Planetree: The Planetree Institute has developed a model of care that is a “patient-centered, holistic approach to healthcare, promoting mental, emotional, spiritual, social, and physical healing. It empowers patients and families through the exchange of information and encourages healing partnerships with caregivers. It seeks to maximize positive healthcare outcomes by integrating optimal medical therapies and incorporating art and nature into the healing environment.” Planetree partners adapt the model to fit their unique circumstances (http://www .planetree.org/). 218 PART 2 r MICRO PERSPECTIVE 5BCMF Glossary of Common Terms and Programs Assoc … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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