Quality Management Integration in Long-Term Care (Bradley Excerpt)

CONTENTS

Chapter 1 Key Concepts in Quality Management Integration . . . . . . . . . .1Guidelines For Excellence in Care and Service . . . . . . . . . . . . . . . . .2Core Concept 1: Customer Focus . . . . . . . . . . . . . . . . . . . . . . . . . .3Core Concept 2: Continual Learning . . . . . . . . . . . . . . . . . . . . . . . .4Core Concept 3: Employee Involvement . . . . . . . . . . . . . . . . . . . . . .5Core Concept 4: Systems Orientation . . . . . . . . . . . . . . . . . . . . . . .7Core Concept 5: Continuous Process Improvement . . . . . . . . . . . . . .8Core Concept 6: Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Critical Issues and Future Trends in QMI . . . . . . . . . . . . . . . . . . . .12Reaching for Excellence Through QMI . . . . . . . . . . . . . . . . . . . . .14The 3-Phase Quality Management Integration Process . . . . . . . . . .14Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Chapter 2 The Evolution of QMI: History,Tools, and Techniques . . . . . .19Examining the Historical Roots of TQM and CQI . . . . . . . . . . . . .19Implementing TQM and CQI in the Service Industries . . . . . . . . . .21Implementing TQM and CQI in the Health Care Industry . . . . . . .23Examining QMI Implementation and Results:

Two Mini-Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Chapter 3 Implementing QMI in the Nursing Facility . . . . . . . . . . . . . . .33Foundation of QMI: Knowing Who Is the Customer . . . . . . . . . . .34Implementation of QMI Project Plans: 3-Phase

Quality Management Integration Process . . . . . . . . . . . . . . . . .36Phase 1: Priorities, Strategies, and Objectives . . . . . . . . . . . . . . . . .37Phase 2: Implementation of the Quality ImprovementProcess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Phase 3: Continuous Improvement of the QualityManagement Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Chapter 4 Internal Critical Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55QMI Factors Unique to Health Care . . . . . . . . . . . . . . . . . . . . . . .56Internal Organizational Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . .57Management Perceptions of Barriers to QMI . . . . . . . . . . . . . . . . .70Other Critical Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71Quality Management from the Corporate Perspective . . . . . . . . . . .73Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

Chapter 5 External Critical Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79Financial Reimbursement Systems . . . . . . . . . . . . . . . . . . . . . . . . .79Regulatory Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82A Picture of the Future: Integrated Delivery Systems . . . . . . . . . . .85Barriers and Critical Issues (Internal and External) . . . . . . . . . . . . .87Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

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Chapter 6 Management by Fact: Data Collection and Analysis Are the Foundations of Decisions . . . . . . . . . . . . . . . . . . . . . . .91Common Cause Analysis of Care Delivery Systemsand Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92

Uses of Data in QMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93Data Collected During the Woodland Care Center Project:Methods, Results, and Evaluations . . . . . . . . . . . . . . . . . . . . . . .105

Use of Survey Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106Process Factors to Track QMI Implementation . . . . . . . . . . . . . . .111Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113

Chapter 7 Pathway to Success: Strategic Approaches toImplementing QMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115New Roles for Management and Employees, FollowingQMI Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118

Working with Internal and External Consultants . . . . . . . . . . . . . .118Assessing the Breadth and Depth of QMI Deploymentin an Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123

Woodland Care Center:A Postscript . . . . . . . . . . . . . . . . . . . . . . .123Five Great Reasons to Implement QMI . . . . . . . . . . . . . . . . . . . .124Status of QMI Implementations: Questions Remain . . . . . . . . . . .125Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126

AppendixesA: The 3-Phase Quality Management Integration Process . . . . . .129B: Executives and Managers Guide to Integration of New

Quality Management Culture . . . . . . . . . . . . . . . . . . . . . . . .130C: Health Care Criteria for Performance Excellence1999:

A Framework for Organization Self-Assessment . . . . . . . . . . .131D: Data-Driven QMI:A Mini-Handbook . . . . . . . . . . . . . . . . . .132E: QMI Survey Results:Woodland Care Center: Pre- and

Postevaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138F: Family Satisfaction Surveys . . . . . . . . . . . . . . . . . . . . . . . . . .141G: Preliminary Strategic Planning for QMI (Sample) . . . . . . . . . .151H: Omnibus Budget Reconciliation Act of 1987 (OBRA) . . . . . .152I: QMI Needs Assessment Interview on Current

Status of Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153J: For Further Reading and ViewingQMI at the Library . . . . .154

K: Accelerators and Inhibitors Require Quality Councils Attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159

L: Quality Management Plan (Sample) . . . . . . . . . . . . . . . . . . . .160M: Assessment Tool for QMI Deployment: Strategic

Planning for Organizational Development . . . . . . . . . . . . . . .164

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .167

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LIST OF EXHIBITSQMI Implementation Guidelines

Customer Focus Implementation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Continual Learning Implementation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . .5Employee Involvement Implementation Guidelines . . . . . . . . . . . . . . . . . . . . . . . .6Systems Orientation Implementation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . .7Transforming Inputs (Resources) into Outputs (Services and Products) . . . . . . . . . . . . .9Continuous Process Improvement Implementation Guidelines . . . . . . . . . . . . . . . .9Processes and Systems: Doing Your Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Leadership Implementation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Jurans Quality Trilogy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21The PlanDoStudyAct Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Making Customer Service More than a Slogan . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Data versus Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Quality Assurance versus Quality Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Leadership Roles in QMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40Multifacility Organization Quality Council Infrastructure (Sample) . . . . . . . . . . . . .41Quality Improvement Projects in the Departments . . . . . . . . . . . . . . . . . . . . . . . . . .46To Team or Not to Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47Assessing QMI Training Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51A Systematic Approach to Process Improvement

Counteracts Politics/Turf Battles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65Indicator Priority Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6811 Barriers to QMI ImplementationManagements Perceptions . . . . . . . . . . . . . .71Strategic Quality Planning Begins with the Board of Directors

and Flows Through the Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76Maintaining Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83Organizational Impact of Vertically Integrated Systems

on Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86Process Improvement in the Meal-Delivery Process (Using the QMI Tools) . . . . . . . .93

Pareto Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94Run Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94Process Flow Diagram (Flowchart) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95Cause-and-Effect Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96

Monitoring Organizational Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99Clinical Data: Indicators that Track Process Outcomes . . . . . . . . . . . . . . . . . . . . . .101Quality Indicators Focus Process Management/Quality Improvement Efforts . . . . .104Using Charts to Analyze Data and Communicate Results . . . . . . . . . . . . . . . . . . . .107

Pareto Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108Run Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109

Indicator Selection Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112Continuing Education for Quality Leaders: Certified Quality

Manager (CQM) Body of Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121

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PREFACEPrior to the late 1980s, long-term care was primarily a range of services that wereoffered to frail older adults living in institutions that provided health care, personal care,and rehabilitation services, usually for extended periods of time. The contemporaryemphasis on health restoration and returning elders to noninstitutional settings (e.g., indi-viduals home, board and care home) forces facilities to respond to the growing expecta-tions of health care professionals, regulatory and payer groups, family members, andresidents.Quality management practices allow long-term care facilities to respond to envi-ronmental and industry changes, while enhancing responsiveness to customers. Thisresponsiveness to change is a key factor in any facilitys success.

The term total quality management (TQM) represents organization-wide qualityimprovement and quality management for all employees and managers in all departmentsand processes. Some organizations call the TQM process continuous quality improvement(CQI), referring to the steady changes in work processes that improve resident care andan organizations bottom line.The focus of both CQI and TQM is providing service toan organizations customers by meeting their needs and requirements, delighting themwith the services provided, and anticipating future needs. Because long-term care facili-ties vary widely in designating their quality management processes as TQM or CQI, wefelt the need for a single designationquality management integration, or QMIthatcombines both philosophies and builds on their foundation.

QUALITY MANAGEMENT INTEGRATION (QMI)QMI combines the concepts of TQM and CQI

Continuous quality improvement (CQI)Continuously improving the excellence of process outcomes/results tooptimize customer satisfaction

Total quality management (TQM)Involving all parts of the organization and all of the employees incontinuous process improvement

QMI addresses quality management issues such as

Who is involved in QMI and in what areas of the organization? When and how does an organization implement QMI practices? What is the best way to improve an organizations work processes? What is the intended effect on customers? How does an organization set priorities?

The two primary questions that are addressed in this book are

1. How can we improve long-term care for each resident, while simultaneouslybecoming more effective throughout the facility as a whole?

2. How can we be more efficient and reduce the risk of error, yet maintain our focuson the customer satisfaction of each resident and his or her family?

Because the concepts and outcomes of TQM and CQI are so closely related, wedeveloped the QMI model and its six core concepts. Each of the six concepts is founded

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on data collection and analysis, as described in Chapter 1 (see the QMI model at thebeginning of each chapter).We stress integration in QMI because the core concepts andtheir reliance on data are integrated into the daily work of the entire organization and donot stand alone as a separate quality project.

Applying the six core concepts of QMI is vital for successful strategic planning, train-ing/education, and implementation. Because we take a realistic approach to implementa-tion, barriers and critical issues are identified and defined clearly, as are real-worldsuggestions on working through obstacles. Powerful QMI tools and techniques are de-tailed to ensure that teams and individual employees or managers will be successful,whether initiating strategic planning for quality improvement or improving an establishedprocess.The 3-phase quality management integration process (p. 15 and Chapter 3 showthis process in detail) ensures that leadership activities, such as the organizations qualitycouncil, are effective.

An actual case study in long-term careWoodland Care Center at the beginning ofits quality journeyis introduced and followed through the book. (Woodland Care Cen-ter is a pseudonym that is used to protect the true identity of the facility.Most of the othermini-cases are synthesized from the authors combined experiences in long-term care.)Woodlands journey reflects many critical issues and barriers that must be faced by otherLTC organizations and illustrates the QMI process.

Each chapter contains displays that highlight the human or practical aspects of QMIimplementation in long-term care facilities. There are numerous illustrations of imple-mentation procedures and various case materials are included.

Chapter 1 provides an overview of the six core concepts that are involved in imple-menting an effective QMI process and illustrates their reliance on data-driven decisionmaking.These six concepts make up what we call the QMI model. Each core concept isdescribed in detail and is accompanied by practical implementation guidelines for theirintegration in daily work.A number of key terms and techniques are introduced, includ-ing the 3-phase quality management integration process.This process is a guide throughthe quality journey.

Next, we describe the issues that are faced by the long-term care industry within thebroader history of TQM and CQI. Chapter 2 examines the roots of quality managementand its development in other service industries and in the health care industry. Successfultechniques as well as potential pitfalls in introducing QMI to a facility are highlighted.Issues such as customer service; managements role in implementing quality managementprocesses; and data collection and analysis, or management by fact, are discussed. Weinclude two mini-cases that demonstrate the implementation of QMI principles.The casesillustrate both the impressive cost savings and the customer satisfaction improvements thatare possible through QMI.

In Chapter 3, we describe the application of the 3-phase quality management inte-gration process at Woodland Care Center.The Woodland case also demonstrates the useof a number of successful techniques and tools that are critical to QMI implementation.Detailed examples are drawn from activities at Woodland. Instead of adding complex worksystems, we explore how QMI can make work processes more efficient for staff, whileimproving resident and family satisfaction.

Chapters 4 and 5 are central to our discussion of quality management in long-termcare:They help address the question, what barriers and critical issues within the facility

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and in the broader long-term care environment might you face as your organization im-plements QMI? Chapter 4 explores in detail the potential barriers and critical issues thatare internal to long-term care facilities and strongly affect the success of QMI implemen-tation in them.The potential roadblocks to implementing QMI range from short-termfocus and resource limitations to turf wars and ineffective communication.The issues thatare critical to successful implementation of QMI include the pivotal role of management,how to gain support from physicians, the family as a system, and the corporate or multi-facility viewpoint about QMI.

Chapter 5 explores potential barriers and critical issues that are external to the long-term care facility.We examine powerful drawbacks of the current system, in particular theregulatory requirements and financial reimbursement structures in long-term care. Webelieve that the contemporary emphasis on meeting standards rather than exceeding thempromotes quality assurance, not quality improvement, and inhibits cost-containment effortsunintentionally. In addition, we explore the decisive impact of financial reimbursementsystems and regulatory requirements on policy and proposed process changes in healthcare.

A section in Chapter 5 focuses on integrated delivery systems (IDSs; e.g., networks,mergers, managed care organizations) and addresses the complexity of future health caresystems.In many facilities IDSs have forced profound changes in systems and care processes.If problems exist in free-standing local facilities, imagine how those problems can be com-pounded in merged networks.The six core concepts of QMI and the tools of data col-lection and analysis enable managed care organizations to

Limit risk Provide cost-effective services Measure customer satisfaction Track the success of residents long-term clinical outcomes Provide residents continuum of care across an integrated health care system

Chapter 6 covers the crucial role that data collection and analysis play in QMI andconsiders the data collected during Woodlands quality project and in several mini-cases.Tracking levels and trends in long-term care data and measuring both your work processesand your results are fundamental to management-by-fact QMI processes. Sets of keyquality indicators and several mini-cases illustrate the application of QMI tools and con-cepts to everyday issues in long-term care facilities.There is an emphasis on analyzing andstudying long-term data across multiple resident groups as well as on studying individualresidents to monitor changes in clinical and functional effectiveness.The usefulness andinterpretation of satisfaction survey data for both customers and employees also areconsidered.

Finally, Chapter 7 pulls together the quality management principles and issues thatmust be addressed to integrate QMI successfully into your organizations daily work. Issuesto be addressed by QMI leaders are detailed, and the training and certification of qualitymanagers are discussed.Working with both internal and external quality consultants alsois examined. Appendixes AM provide QMI implementation tools and other referencematerials.

We have combined two voices in this book, an internal and an external consultant.One of the authors is a vice president of organizational performance who works full time

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in a large, multifacility organization; the other author is an external consultant who sup-ports long-term care organizations for a specific project or for a specified period of time,bringing an outsiders fresh viewpoint and breadth of experience to the issues that sur-round a QMI process. Our tasks are very similar, even if our daily professional lives appeardifferent:We both provide support and consultation to organizations that are strugglingwith the communication problems and critical issues that surround every QMI implemen-tation in long-term care.Thus, our visions of the outcomes of successful QMI processesare parallel in most applications.

The variety of our professional experiences comes into use during each QMI imple-mentation project as management and staff groups face QMIs culture changes, the needfor enhanced communication, and the shifts in job roles.We communicate the win-winbenefits for every individual.Our confidence in QMI derives from seeing successful orga-nizations transformed as they provide better service to their customers and clients andfrom working with organization leaders to develop efficient work processes and ever-improving employee satisfaction.

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Quality Management Integration in Long-Term Care (Bradley Excerpt)

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