Introduction to Health Care Management

Chap 7. Quality improvement basics

Buchbinder, S. B. & Shanks, N. H.

林育秀, Ph.D.2021

Learning objectives

1. Contrast prior definitions of health care quality with current ones

2. Investigate the importance of quality in health care settings

3. Apply key quality concepts

4. Describe the Baldrige criteria

5. Assess the leading models of quality of improvement

6. Apply tools used in quality improvement

IOM Report on Medical Errors

▪ Established a baseline of information on the current state of the system and made a shocking yet convincing cases for high levels of concern for the safety of patients seeking care within the system.

▪ The report presented these errors as a serious health threat, one that could be compared with the lethality of breast cancer, motor vehicle accidents, and acquired immunodeficiency syndrome.

To Error is Human

▪ Preventable Medical Errors and How We Count Them

▪ Doctors make mistakes. Can we talk about that?

▪【醫界麻醉科風暴】麻醉科醫師人力不足微小疏忽釀悲劇單元1

▪「用藥安全」你不能不重視的潛在醫療危機

Quality

▪ The degree to which health services for individuals and patient populations increase the likelihood of desirable health outcomes and are consistent with current professional knowledge.

▪ Health care quality may be defined in various ways, with differing implications for health care providers, patients, third-party payers, policy makers, and other stakeholders.

Donabedian model

▪ Structural element: the material and human resources of an organization and the facility itself.

▪ The quality of personnel is documented in their numbers, skill level, and various certifications.

▪ The quality of facilities lies in accreditation and/or certification.

▪ Process: the actual delivery of care as well as its management.

▪ The quality of basic care including cleanliness, feeding, hydration, delivery of treatments, and keeping patients safe from falls and errors.

▪ Outcomes: the resulting health status of the patients and organizations.

▪ Mortality, morbidity, length of stay, function status

▪ Turnover of staff, cost outcomes

Donabedian model…cont.

結構面(structure)

• 長照機構或其服務的固

定特徵

• 長期照護機構或服務的

政策、經營理念、工作

組織、機構設施、器材

裝備、人員資格與經驗、

人事安排、工作人員住

民比例等

過程面(process)

• 長照服務提供者與失能

者、家屬間所發生的活

動

• 技術的操作與人際互動

的過程

• 診斷和治療的程序

• 轉介資源能有效運用

• 照顧人員提供服務的態

度

結果面(outcomes)

• 經長照提供者的處置，

而對失能者的健康及功

能狀況所產生的影響

• 泛指失能者的身體功能、

心理功能、自我照顧能

力、生活品質及滿意度

等狀況

參考資料： 高銘南(2006)。護理之家照護品質探討-以高雄地區某連鎖型護理之家為例。高雄：義守大學碩士論文。

Donabedian model…cont.

▪ Quality as having at least 4 components:

1. The technical management of health and illness

▪ Focus on the clinical performance of health care providers

2. The management of the interpersonal relationship between the providers of care and their clients

▪ The coproduction of care by both providers and patients

3. The amenities of care

▪ The patient’s interest in being treated in comfortable, clean surroundings

4. The ethical principles that govern the conduct of affairs in general and the health care enterprise in particular

▪ The provider’s ethical conduct in delivering care and his/her interest in furthering societal and organizational well-being (or effectiveness)

Donabedian model…cont.

Quality

▪ View of quality represents two fundamental questions:

1. Are the right things done?

▪ Assesses the effectiveness of clinical care

▪ Effectiveness: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse)

2. Are things done right?

▪ Considers the efficiency of care services

▪ Efficiency: avoiding waste, in particular waste of equipment, supplied, ideas, and energy

Why is quality important?

▪ Underuse: the failure to provide a service whose benefit is greater than its risk.

▪ Overuse: occurs when a health service is provided when its risk outweighs its benefits or it simply has no added benefit, as with overuse of certain diagnostic tests.

▪ Misuse: occurs when the right service is provided badly and an avoidable complication reduces the benefit the patient receives

Underuse

▪ It’s a problem since clinical research has produced a large number of effective treatments that are not widely used.

▪ Example:

▪ It takes an average of 17 years for evidence-based practices to reach clinical practice. Even when these practice reach clinicians, evidence-based recommended treatments may not be consistently used.

▪ Nearly 10,000 deaths from pneumonia could be prevented each year with a one time vaccination. Yet in 2005 only 56 out of 100 adults age 65 and older received the shot.

Overuse

▪ As certain treatments are provided despite evidence that the treatment is ineffective or even dangerous.

▪ Example:

▪ It includes treating people with antibiotics for simple infections – or failing to follow effective options that cost less or cause fewer side effects.

▪ when used appropriately, MRI’s and other imaging exams are valuable. But MRI’s often don’t change the treatments prescribed or a patient’s outcome, in which case the technology is an unnecessary cost.

Misuse

▪ Caught the public’s attention with the publication of the first IOM report on patient safety, which examined the high rate of medical errors in hospitals that thousands of patients die every year from preventable adverse events and another million are injured.

▪ Example:

▪ Misuse includes avoidable medical errors like prescribing a drug the patient is allergic to, for example a patient who gets a rash after receiving penicillin for strep throat, despite having a known allergy to that antibiotic.

The relevance of health information technology in quality improvement

▪ Health informatics: the multidisciplinary field in which information technology is brought to bear on our health care system wit a goal to improve quality, raise efficiency and lower costs.

▪ Analytics: the systematic use of data and related business insights developed through applied analytical disciplines (e.g., statistical, contextual, quantitative, predictive, cognitive, other models) to drive fact-based decision making for planning, management, measurement, and learning.

Small data vs. Big data

▪ Data sources: electronic medical records, medical claims data, pharmaceutical records, and medical imaging. ➔ small data analytics, predictive modeling, and real-time analytics.

▪ Data mining: is commonly referred to as big data

▪ Using the same repositories of data mentioned above, analysts attempt to predictive treatment outcomes or forecast future medical costs and utilization.

Quality of care

▪ It may the point of highest concern for all who have any role in or interaction with provision of health care.

▪ However, it seems that quality was not first on everyone’s list until pressure for cost containment as well as efficiency of care began and then steadily increased.

▪ Quality gap: the area between what research tells us are the optimal processes and outcomes for each portion of health care delivery and the processes and outcomes actually in place.

5-point agenda for bridging the quality gap

▪ All health care constituencies, including policymakers, purchasers, regulators, health professionals, health care trustees and management, and consumers, commit to a national statement of purpose for the health care system as a whole and to a shared agenda of six aims for improvement that can raise the quality of care to unprecedented levels.

▪ Clinicians and patients, and the health care organizations that support care delivery, adopt a new set of principles to guide the redesign of care processes.

▪ The Department of Health and Human Services identify a set of priority conditions upon which to focus initial efforts, provide resources to stimulate innovation, and initiate the change process.

5-point agenda for bridging the quality gap…cont.

▪ Health care organizations design and implement more effective organizational support processes to make change in the delivery of care possible.

▪ Purchasers, regulators, health professions, educational institutions, and the Department of Health and Human Services create an environment that fosters and rewards improvement by

1. creating an infrastructure to support evidence-based practice

2. facilitating the use of information technology

3. aligning payment incentives

4. preparing the workforce to better serve patients in a world of expanding knowledge and rapid change

https://www.youtube.com/watch?v=QexTk38euzY

Leaders of the quality movement: Plan-Do-Check-Act (PDCA)

• Introduced by Shewhart, 1939

• Statistical Method from the Viewpoint of Quality Control

• Nickname: Deming Cycle; Shewhart Cycle

Leaders of the quality movement: Pareto principle (80/20 Rule/principle)

• From economics, focusing attention and resources on those important quality problems that are attributable to a small number of factors

Baldrige Award Criteria: a strategic framework for quality improvement

▪ Effective quality improvement programs operate both at the top (strategic) level and the the operational (tactical) level of the organization.

▪ Quality improvement programs outline both an overall strategy (philosophy, framework) and a asset of tactical processes and tools for quality improvement.

▪ Baldrige Award Criteria: using a structure-process-results framework. These dimensions of quality have been continually refined and expanded from heir original manufacturing base to include health care organization.

25Reproduced from: Baldrige National Quality Award Brochure, National Institute of Standards and Technology. 2010.

Structural variables: Integration of customer needs (broadly defined) within the organization’s leadership and strategic planning process is necessary fro creating the conditions for quality

Process variables: quality improvement is recognized as an organization-wide responsibility.• Engaging staff in process management is

another necessary condition for quality.

Common elements of quality improvement: Measurement

▪ Measurement and the metrics associated with it: the most basic concept in quality improvement.

▪ Measurement: translation of observable events into quantitative terms.

▪ Metrics: the means actually used to record these observable.

▪ All quality improvement efforts require numerical data because“you can’t manage what you can’t measure.” ➔ quality improvement is riven by data-based evidence rather than subjective judgments or opinion.

Common elements of quality improvement: Measurement…cont.

▪ Good measurement begins with the rigorous definition of the concept to be measured.

▪ Should be written and should include the unit of measure.

▪ It requires the use of a measurement methodology that yields reliable (e.g., consistent) and valid (e.g., accurate) measures of the concept.

▪ Measurement reliability: if a measure is taken at several points over time or by various people, the measure will generally be consistent (not vary too much).

▪ Validity: depends on the accuracy of the measure, and extents to which the measure used actually measure the concept.

Common elements of quality improvement: Process variation

▪ Process variation: the range of values that a quality metric can take as a result of different causes within the process.

▪ Special-cause variation: due to unusual, infrequent, or unique events that cause the quality metric to deviate from its average by a statistically significant degree.

➔detecting and eliminating special-cause variation in a process

▪ Common-cause variation: due to the usual or natural cause of variation within a process.

➔detecting and reducing, whenever feasible, common-cause variation within a process.

Common elements of quality improvement: Statistical process control (SPC)

▪ Statistical process control: a method by which process variation is measured tracked, and controlled in an effort to improve the quality of the process.

▪ SPC is a branch of statistics that involves time-series analysis with graphic data display.

▪ Advantage: intuitive for most decision makers, because it lies I the use of a visual display.

▪ Limitation: the range of variation where the process is thought to be “in control” ➔ set at plus/minus 3 standard deviations from the mean.

Quality improvement approaches: 1. Continuous quality improvement (CQI)

▪ An organizational process in which employee teams identify and address problems in their work processes.

▪ CQI promotes the view that understanding and addressing the factors that create variation in an administrative or clinical process (e.g., long wait times, high hospital readmission rates) will produce superior patient care quality and organizational performance.

▪ Quality improvement should not be a one-time activity; rather, it should be a normal activity, resulting in a continual flow of improvements.

Continuous quality improvement (CQI)…cont.

▪ 5 dimensions:

1. Process focus

▪ Underpinning this approach are the concepts and tools of statistical process control (SPC).

2. Customer focus: in order to “delight the customer”

▪ A person, group, or organization that is impacted by a process at any point

3. Data-based decision making

▪ The foundation of SPC rests on the collection, analysis, and use of data to improve processes and monitor the success of process interventions.

Continuous quality improvement (CQI)…cont.

4. Employee empowerment

▪ Manifested by the widespread use of quality improvement teams composed of the individuals who have the most intimate knowledge of how the system works (the front line providers).

5. Organization-wide impact

▪ Its strategic use across the organization, accomplished through the coordinated and continuous improvement of various operational processes across organizational levels.

Continuous quality improvement (CQI): FOCUS-PDCA framework

▪ Modified by the Hospital Corporation of American (HCA), based on PDCA cycle.

▪ Became the most commonly used quality improvement framework in the health care industry.

FOCUS-PDCA framework: FOCUS

▪ Find: identify a process problem, preferably a “high-pain” one , to address.

▪ Organize: put together a team of people who work on the process. These people would then be trained on process improvement skills and tools.

▪ Clarify: results in the team moving to clarify the process problem through some type of process mapping (flowcharting).

▪ Understanding: involves measurement and data collection of key metrics to document the dimensions of the process problem and to provide a benchmark for goal setting.

▪ Select: identify a set of process improvements and then select rom them for implementation.

FOCUS-PDCA framework: PDCA

▪ Plan: take the process improvement from the S phase of FOCUS and create a plan for its implementation.

▪ Do: actually implement the process improvement.

▪ Check: study whether the process is improving, using the measures identified and measured in the U phase of FOCUS.

▪ Act: determine whether the process improvement was successful.

Quality improvement approaches: 2. Six Sigma

▪ A data-driven quality methodology that seeks to eliminate variation from a process.

▪ Like CQI, it is a resource-intensive tool requiring substantial up-front training in quality improvement tools and concepts, time and personnel resources to carry out quality improvement projects, and long-term management commitment.

▪ It employs a structured process: DMAIC

Six Sigma: DMAIC

▪ Define: delimiting the scope of work, determining due dates, and mapping the future state of the process, including improvements.

▪ Measure: both the creation of measure or metrics and their application to determine how well a process is performing.

▪ Analyze: breaks down the understanding of the process and often includes flowcharting the process.

▪ Improve: the steps that will be taken to meet the goals outlined during the define step.

▪ Control: ensuring that the improvements are permanent rater than temporary.

Quality improvement approaches: 3. Toyota Production System/Lean

Toyota Production System/Lean…cont.

▪ Lean as applied to the health care industry views waste as coming in the following categories:

1. Overproduction: production that is in excess, early, and faster than is needed.

▪ E.g., overuse of pre-operative bloodwork which research suggests as not being medically necessary in most surgical situation.

2. Motions: wasted when patients, inventory, and personnel moe inefficiently around a facility.

3. Overprocessing: when the product provided to the customer is complex or confusing.

▪ Both hospitals and physicians bill for services that are presented to the patient and insurer at different time

4. Defects: medical mistakes and delays in treatment.

▪ E.g., waiting is a feature of the US. Health care system, from waiting for a doctor’s appointment t waiting for the insurance company and hospital to settle a claim.

5. Underutilization of staff: not using staff time efficiently, such as failing to se staff knowledge, skills, and abilities in an optimal fashion.

▪ E.g., due to clinical policies and/or regulatory constraints, nurse practitioners and physician assistants are often underutilized in hospital and ambulatory setting.

Toyota Production System/Lean…cont.

▪ Six principles of Lean in health care:

1. Attitude of continues improvement

2. Value creation

3. Unity of purpose

4. Respect for people who do the work

5. Visualization

6. Flexible regimentation

Toyota Production System/Lean…cont.

Quality improvement tools: 1. Mapping processes/Flowcharting/Process mapping

Quality improvement tools: 2. Data collection: (1) check sheet

• Occurrence of some event or behavior is tallied.

Quality improvement tools: 2. Data collection: (1) chart abstractions/chart audits

• To collect information from a patient’s medical record.

Quality improvement tools: 2. Data collection: (1) Geographic mapping

• A pictorial check sheet in which an event or problem is plotted on a map.

Quality improvement tools: 3. Analyzing processes: (1) Cause-and-effect diagram

• Fishbone diagram or Ishikawa diagram

Quality improvement tools: 3. Analyzing processes: (1) Pareto chart

Significant few

Insignificant many

80% Line

Identify the correct Pareto chart

7 QC Tools

7 QC Tools…cont.

7 QC Tools…cont.

7 QC Tools…cont.

Q & A