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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Introduction to Health Care Quality explores the issues of quality management in today's health care environment, and provides clear guidance on new and perennial challenges in the field. The idea of 'quality' is examined in the context of a variety of health care situations, with practical emphasis on assessment, monitoring, analysis, and improvement. Students will learn how to utilize statistical tools, patient data, and more to understand new models of reimbursement, including pay for performance and value-based purchasing. They will also learn how to learn how to incorporate technology into everyday practice. Each chapter centers on an essential concept, but builds upon previous chapters to reinforce the material and equip students with a deeper understanding of the modern health care industry. Real-world situations are highlighted to show the intersection of theory and application, while cutting-edge methodologies and models prepare students for today's data-driven health care environment. Health care quality is defined and assessed according to setting, with factors such as standards, laws, regulations, accreditation, and consumerism impacting measurement and analysis in tremendous ways. This book provides an overview of this complex field, with insightful discussion and expert practical guidance. Health care today is worlds away from any other point in history. As the field grows ever more complex, quality management becomes increasingly critical for ensuring optimal patient care. Introduction to Health Care Quality helps students and professionals make sense of the issues, and provide top-notch service in today's rapidly changing health care environment.
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Seitenzahl: 595
Veröffentlichungsjahr: 2016
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Table of Contents
Title Page
Copyright
Dedication
List of Figures and Tables Preface
Preface
Acknowledgments
About the Author
Introduction
Part I: Quality Management Fundamentals
Chapter 1: Foundations of Health Care Quality
Defining Quality
Contributions of Quality Theorists—Nothing New under the Sun
Quality Management Methodologies
Organizations Making an Impact on Quality and Safety Standards
Centers for Medicare and Medicaid Services
Institute for Healthcare Improvement
Agency for Health Research and Quality
National Quality Forum
The Leapfrog Group
Data: The Foundation of Quality Management
Summary
Key Terms
Quality Concepts in Action
References
Suggestions for Further Reading
Useful Websites
Chapter 2: Understanding the Impact of Health Care Reform
The Affordable Care Act
New Models of Payment
New Models of Providing Care
New Models for Collecting Data
Improving Interpersonal Communication
Summary
Key Terms
Quality Concepts in Action
References
Suggestions for Further Reading
Useful Websites
Chapter 3: Making the Case for Change
What Is Involved in Change?
Managing and Measuring Quality in the Reform Environment
Who Is Involved in Change?
Changing Communication
The Role of Data in Promoting Change
Summary
Key Terms
Quality Concepts in Action
References
Suggestion for Further Reading
Useful Websites
Chapter 4: New Challenges for Health Care Professionals
Meeting Statistical Expectations for Standards of Care
Meeting Patient Expectations
Role of Dashboards
Role of Data Analysis
Understanding Different Kinds of Data
Managing Care for Chronic Illness across the Continuum
Managing Aggregated Patient Care Issues
Improving Communication
Summary
Key Terms
Quality Concepts in Action
References
Suggestions for Further Reading
Useful Websites
Chapter 5: Improving Patient Safety
Understanding Medical Errors and Adverse Events
High-Reliability Organizations
The Role of Quality Management in Promoting a Safety Culture
Prioritizing Improvements
Expanding Data Sources: Partnerships to Develop Best Practice
Leading Organizational Improvements
The Role of Nursing Leaders in Promoting Safety
The Role of the Medical Staff in Promoting Safety
Promoting Safety through Effective Communication
Summary
Key Terms
Quality Concepts in Action
References
Suggestions for Further Reading
Useful Websites
Part II: Applying Quality Tools and Techniques
Chapter 6: Working with Quality Tools and Methods
Identifying a Problem
Describing Information
Variability
Making Use of Data
Using Quality Tools and Techniques to Improve Safety
Clinical Pathways or Care Maps
Improving Performance: Plan-Do-Study-Act
Summary
Key Terms
Quality Concepts in Action
Suggestions for Further Reading
Useful Websites
Chapter 7: Working with Quality Data
Working with Measurements
Understanding Issues in Data Collection
Using Data to Understand Appropriateness of Care
The Value of Aggregated Data in Performance Improvement
The Role of Data in Managing Chronic Disease
Using Data to Monitor Variability
Publicly Reported Data
Interpreting and Making Use of Data
Quality Management in the Future
Summary
Key Terms
Quality Concepts in Action
References
Suggestions for Further Reading
Useful Websites
Chapter 8: Working with Quality and Safety Measures
Commitment to Quality
Using Measures to Understand Care
Defining the Measure
Process Measures
Pay for Performance
Patient Satisfaction Measures
Monitoring Measures
Safety and Environment of Care Measures
Summary
Key Terms
Quality Concepts in Action
References
Suggestions for Further Reading
Useful Websites
Chapter 9: Translating Information into Action
Maximizing Efficiency
Determining Appropriate Levels of Care
End-of-Life Care/Advanced Illness
Understanding Mortality
Improving ICU Care
Analyzing Readmission
Using Data for Improvements
Patient-Centered Care
Delivering the Message
Summary
Key Terms
Quality Concepts in Action
References
Suggestions for Further Reading
Useful Websites
Chapter 10: Preparing for the Future
The New Quality Management
The Business of Health Care
Measurements Are the Nuts and Bolts of Quality
Getting Everyone on Board
Challenges for the Future
Summary
Key Terms
Quality Concepts in Action
Suggestions for Further Reading
Useful Websites
Index
End User License Agreement
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Guide
Table of Contents
Begin Reading
List of Illustrations
Chapter 1: Foundations of Health Care Quality
Figure 1.1: Causes of Patient Mortality Pie Chart
Figure 1.2: Causes of Patient Mortality Histogram
Figure 1.3: Medication Error Rate Pareto Chart, January 2011–June 2011
Figure 1.4: Hospital Compare Webpage for Unplanned Readmissions
Figure 1.5: Hospital Compare for Waiting Times
Figure 1.6: Quality Indicator
Chapter 2: Understanding the Impact of Health Care Reform
Figure 2.1: Value‐Based Performance at a Community Hospital
Figure 2.2: Value‐Based Performance at a Tertiary Hospital
Chapter 3: Making the Case for Change
Figure 3.1: Screening Tool to Identify Advanced Illness
Figure 3.2: Dimensions of Care
Figure 3.3: Lines of Communication
Figure 3.4: JCPAC Communication
Chapter 4: New Challenges for Health Care Professionals
Figure 4.1: Inpatient Likelihood to Recommend
Figure 4.2: Quality and Safety Vector of Measures Dashboard
Figure 4.3: Hospital Comparison Dashboard
Figure 4.4: Raw Heart Failure Readmission Rate
Figure 4.5: Tactics and Team Responsibilities
Figure 4.6: Patient Friendly Care Map for Hip Replacement Surgery
Figure 4.7: Preoperative Continuum of Care
Figure 4.8: Postoperative Continuum of Care
Chapter 5: Improving Patient Safety
Figure 5.1: Falls with Injury
Figure 5.2: Analytics and Interpretation
Figure 5.3: Monthly Emergency Department Data
Figure 5.4: Raw Sepsis and Severe Sepsis/Septic Shock Mortality Rate, January 2008–September 2014
Figure 5.5: Discharge Follow‐up Information Heart Failure
Figure 5.6: Prioritization Matrix
Figure 5.7: Serum Lactate Order to Result within 90 Minutes for Severe Sepsis/Septic Shock in the Emergency Department
Figure 5.8: Integrating Data/Generating Reports
Figure 5.9: Patient Outcome Monitoring Tool
Figure 5.10: Communication across the Care Continuum
Chapter 6: Working with Quality Tools and Methods
Figure 6.1: Falls Cause‐and‐Effect Diagram
Figure 6.2: Flowchart
Figure 6.3: Time‐Out Checklist
Figure 6.4: Newborn Deliveries Run Chart
Figure 6.5: Waiting Time for Emergency Department Triage
Figure 6.6: Standard Deviation Formula
Figure 6.7: Blood Pressure Bell Curve
Figure 6.8: Comparing RCA and FMEA
Figure 6.9: Transfusion Flowchart
Figure 6.10: Hip Replacement Care Map
Figure 6.11: Variance Analysis: CAP Chart
Figure 6.12: Variance Analysis: CAP Outcome Bar Chart
Figure 6.13: Quality Improvement through Care Pathways
Figure 6.14: Improved Efficiency and Throughput
Figure 6.15: Clinical Guidelines Creation Methodology
Figure 6.16: PDSA Cycle
Chapter 7: Working with Quality Data
Figure 7.1: Hospital‐Acquired Pressure Injury Index
Figure 7.2: Mortality Surveillance Tool Summary Report
Figure 7.3: Kidney Transplant Data Input
Figure 7.4: Wound Infection Rate
Figure 7.5: 30-Day Observed Readmission Rate for Heart Failure Analysis
Figure 7.6: Heart Failure Readmission by Age
Figure 7.7: Heart Failure Readmission Analysis: HF Discharges by Discharge Disposition
Figure 7.8: Know Your Heart Failure Zones
Figure 7.9: Control Chart of
Clostridium difficile
Figure 7.10: Hospital Compare Benchmark Report: Inpatient Clinical Measures—Inpatient Surgical Infection Prevention
Figure 7.11: Timely Heart Attack Care
Chapter 8: Working with Quality and Safety Measures
Figure 8.1: Hospital Medication Administration Process
Figure 8.2: Medication Error Measures
Figure 8.3: Executive Summary Medication Measures
Figure 8.4: Medication Safety Alert
Figure 8.5: Mammography Rate
Figure 8.6: Independent Variables
Figure 8.7: Non‐ICU Central Line–Associated BSI Control Chart
Figure 8.8: Public Reporting Scores
Figure 8.9: Executive Summary
Figure 8.10: Risk‐Adjusted Mortality Index
Figure 8.11: Non‐ICU Central Line‐Associated BSI Index
Figure 8.12: Non‐ICU Central Line‐Associated BSI Index Pivot View
Figure 8.13: Safety Services Quarterly Report
Chapter 9: Translating Information into Action
Figure 9.1: Throughput
Figure 9.2: Ambulatory Surgery Log Tracking
Figure 9.3: Advanced Illness
Figure 9.4: APACHE Reports
Figure 9.5: Bariatric Preoperative Checklist
Figure 9.6: SF‐36 Physical and Mental Health Component Analysis by Time Point
Chapter 10: Preparing for the Future
Figure 10.1: Data Overload
List of Tables
Chapter 3: Making the Case for Change
Figure 3.1: Inpatient Quality Indicators
Figure 3.2: Table of Measures for Ambulatory Services
Chapter 7: Working with Quality Data
Figure 7.1: Kidney Transplant Table of Measures
Chapter 9: Translating Information into Action
Figure 9.1: Bariatric Table of Measures
INTRODUCTION TOHEALTH CARE QUALITY
Theory, Methods, and Tools
Yosef D. Dlugacz
Copyright © 2017 by John Wiley & Sons, Inc. All rights reserved.
Published by Jossey-Bass
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Library of Congress Cataloging-in-Publication Data
Names: Dlugacz, Yosef D., 1947- author.
Title: Introduction to health care quality : theory, methods, and tools / Yosef D. Dlugacz.
Description: First edition. | Hoboken, New Jersey : Jossey-Bass & Pfeiffer Imprints, Wiley, [2017] | Includes bibliographical references and index.
Identifiers: LCCN 2016020039 (print) | LCCN 2016020736 (ebook) | ISBN 9781118777916 (pbk.) | ISBN 9781118779576 (epdf) | ISBN 9781118779590 (epub)
Subjects: | MESH: Quality of Health Care— organization & administration | Health Care Reform— methods | Patient Safety | Quality Control | Health Information Management— methods | United States
Classification: LCC RA971 (print) | LCC RA971 (ebook) | NLM W 84.4 AA1 | DDC 362.1068— dc23
LC record available at https://lccn.loc.gov/2016020039
Cover Design: Wiley
Cover Images: © duncan1890/iStockphoto, © Tsyhun/iStockphoto, © sturti/iStockphoto
To Doris, whose love, intelligence, compassion, and humor have accompanied me for the past 45 remarkable years
LIST OF FIGURES AND TABLES
Figures
1.1 Causes of Patient Mortality Pie Chart
1.2 Causes of Patient Mortality Histogram
1.3 Medication Error Rate Pareto Chart, January 2011–June 2011
1.4 Hospital Compare Webpage for Unplanned Readmissions
1.5 Hospital Compare for Waiting Times
1.6 Quality Indicator
2.1 Value‐Based Performance at a Community Hospital
2.2 Value‐Based Performance at a Tertiary Hospital
3.1 Screening Tool to Identify Advanced Illness
3.2 Dimensions of Care
3.3 Lines of Communication
3.4 JCPAC Communication
4.1 Inpatient Likelihood to Recommend
4.2 Quality and Safety Vector of Measures Dashboard
4.3 Hospital Comparison Dashboard
4.4 Raw Heart Failure Readmission Rate
4.5 Tactics and Team Responsibilities
4.6 Patient Friendly Care Map for Hip Replacement Surgery
4.7 Preoperative Continuum of Care
4.8 Postoperative Continuum of Care
5.1 Falls with Injury
5.2 Analytics and Interpretation
5.3 Monthly Emergency Department Data
5.4 Raw Sepsis and Severe Sepsis/Septic Shock Mortality Rate, January 2008–September 2014
5.5 Discharge Follow‐up Information Heart Failure
5.6 Prioritization Matrix
5.7 Serum Lactate Order to Result within 90 Minutes for Severe Sepsis/Septic Shock in the Emergency Department
5.8 Integrating Data/Generating Reports
5.9 Patient Outcome Monitoring Tool
5.10 Communication across the Care Continuum
6.1 Falls Cause‐and‐Effect Diagram
6.2 Flowchart
6.3 Time‐Out Checklist
6.4 Newborn Deliveries Run Chart
6.5 Waiting Time for Emergency Department Triage
6.6 Standard Deviation Formula
6.7 Blood Pressure Bell Curve
6.8 Comparing RCA and FMEA
6.9 Transfusion Flowchart
6.10 Hip Replacement Care Map
6.11 Variance Analysis: CAP Chart
6.12 Variance Analysis: CAP Outcome Bar Chart
6.13 Quality Improvement through Care Pathways
6.14 Improved Efficiency and Throughput
6.15 Clinical Guidelines Creation Methodology
6.16 PDSA Cycle
7.1 Hospital‐Acquired Pressure Injury Index
7.2 Mortality Surveillance Tool Summary Report
7.3 Kidney Transplant Data Input
7.4 Wound Infection Rate
7.5 30-Day Observed Readmission Rate for Heart Failure Analysis
7.6 Heart Failure Readmission by Age
7.7 Heart Failure Readmission Analysis: HF Discharges by Discharge Disposition
7.8 Know Your Heart Failure Zones
7.9 Control Chart of Clostridium difficile
7.10 Hospital Compare Benchmark Report: Inpatient Clinical Measures—Inpatient Surgical Infection Prevention
7.11 Timely Heart Attack Care
8.1 Hospital Medication Administration Process
8.2 Medication Error Measures
8.3 Executive Summary Medication Measures
8.4 Medication Safety Alert
8.5 Mammography Rate
8.6 Independent Variables
8.7 Non‐ICU Central Line–Associated BSI Control Chart
8.8 Public Reporting Scores
8.9 Executive Summary
8.10 Risk‐Adjusted Mortality Index
8.11 Non‐ICU Central Line‐Associated BSI Index
8.12 Non‐ICU Central Line‐Associated BSI Index Pivot View
8.13 Safety Services Quarterly Report
9.1 Throughput
9.2 Ambulatory Surgery Log Tracking
9.3 Advanced Illness
9.4 APACHE Reports
9.5 Bariatric Preoperative Checklist
9.6 SF‐36 Physical and Mental Health Component Analysis by Time Point
10.1 Data Overload
Tables
3.1 Inpatient Quality Indicators
3.2 Table of Measures for Ambulatory Services
7.1 Kidney Transplant Table of Measures
9.1 Bariatric Table of Measures
PREFACE
When I began to think about revising the outdated Quality Handbook for Health Care Organizations: A Manager's Guide to Tools and Programs (Jossey‐Bass, 2004), my goal was to introduce and explore the many changes that have made an impact on health care in the last decade. I quickly realized that I couldn't simply revise the book for a second edition; too much had changed. An entirely new book introducing quality management was needed if I wanted it to be of value to health care professionals and students. This Introduction to Health Care Quality: Theory, Methods, and Tools seemed necessary.
Even the change in titles is revealing. Quality is no longer the sole purview of managers. To the contrary, now everyone—clinicians, administrators, executives, patients—involved in health care services needs to work within a quality framework and be familiar with quality management processes. Students who hope to work in health care, whether in the clinical, administrative, or policy‐making roles, need to know the fundamentals of quality management to succeed. Physicians, nurses, pharmacists, and public health policy makers all need to involve themselves in performance improvement activities and understand how to transform data into useful information in order to take action. Administrators and executives have to meet the goals of specific quality measures set by government agencies in order to be reimbursed for the delivery of care and medical services.
My books are designed to be of practical use to students and professionals and are based on my experience working in the field of quality management for decades and teaching fundamentals of quality all over the world. I have the good fortune of being part of a vast health care system that encompasses the entire spectrum of health care services—21 hospitals, the Feinstein Institute for Medical Research, the Krasnoff Quality Management Institute, the Center for Learning and Innovation, rehabilitation and skilled nursing facilities, a home care network, a hospice network, and progressive care centers—offering a range of outpatient services; ambulatory facilities; psychiatric care; long‐term nursing care; and children's organizations. Thus I have direct and immediate access to the issues that most concern administrators and executives, floor and unit managers, clinicians, policy makers, IT professionals, and others. Writing from personal experience gives me the opportunity to share practical issues of quality in action and relay the direct application of quality management theory, methods, and tools.
I have always been a champion of quality and I like to think an advocate for patients' rights and patient safety. I have worked diligently to ferret out gaps in care and potential gaps in safety to improve performance, and further communication and accountability across the hospital and the continuum of care. I followed this path because I believe in the tenets of quality management; I believe in the objectivity of data to make a case for good or poor care. I believe in numbers, in measurements, in tracking improvements and interventions over time using reliable and valid data.
But it was not until I myself became a patient that my theoretical expertise quickly became of immediate and practical concern. As a patient, I found myself vulnerable to issues of safety and communication failures that I had written about and spoken about but had never directly experienced. Although I had always understood the importance of patient identification, for example, until I was receiving chemotherapy and the nurses made absolutely sure that I was getting the correct dose of the correct medications in the correct manner, and asked me multiple times to confirm my name, I didn't realize how reassuring it was to know that the procedures developed to ensure proper patient identification were in place and being followed. When I needed my MRI results to be transmitted to my oncologist in a timely fashion, I didn't want any failures of communication to take place. Ensuring quality care became deeply personal.
And although I am probably better educated than most about dealing with health care data, I found that when I was confronted with three very different plans of care from three very highly regarded physicians, I needed to understand mortality rates and complications from treatment, numbers, variation, and evidence in a new way. How many patients with my particular very rare cancer had each doctor treated and with what outcome? I realized how valuable my experience as a quality professional was. I knew what questions to ask. Quality care is, of course, a goal for organizations to strive for, but it is also for everyone. I realized that everyone—health care professionals, patients, and potential patients—should be quality managers. This book, then, is for everyone.
New models of health care are so‐called patient‐centered, making patients central to the care plan and treatment process. Again, to me, this is no longer theory. It is in fact critical that patients understand what is happening to them, why they are having the treatment they are having, what the predicted outcomes will be, and what complications might occur. All these issues, basic to quality management, were now basic to me. All patients should indeed be treated holistically. We are not defined by our disease or our illness; we are people with psychosocial experiences and needs, some of us more capable than others or simply luckier than others in being able to take good care of ourselves.
Everyone should be a quality manager. Everyone will have occasion to interact with a health care delivery system of one kind or another, either for themselves or for family and loved ones. Everyone needs to be schooled about quality, how to assess care, what to look for, what is expected, what should not be tolerated. Everyone should be an advocate for quality care. I hope this book will be useful to professionals and nonprofessionals alike.
ACKNOWLEDGMENTS
I want to thank the many people who have made this book possible. Thanks to Dr. William Tap, and the extraordinary team of health professionals at Memorial Sloan Kettering, where I received good care: the intelligence and compassion, professionalism and expertise that every patient deserves and so few receive. I can't thank you enough. And thanks to Dr. Samuel Kenan, of Northwell Health, whose surgery skills and oncology knowledge saved my life.
Thanks to the many people, present and past, who have worked to make the North Shore–LIJ Health System, now Northwell Health, excel in quality. Abraham Krasnoff, John Gallagher, and Lawrence Scherr believed in quality management and in me. The chair of the board of trustees, Mark Claster, has been a champion of quality for many years and has been instrumental in shaping quality concepts for the board and for the health system. Michael Dowling, the CEO of Northwell Health, has trusted me and supported me in establishing the Krasnoff Quality Management Institute and is committed to building the best‐quality health system possible. His executive team of Mark Solazzo, David Battinelli, MD, Gene Tangney, and others have made quality a priority and have recognized its importance in establishing and maintaining outstanding care.
To the entire Krasnoff team, especially Debi Baker for her support with graphics and careful perusal of the manuscript; Megan Smith for her constant support with everything; Marcella De Geronimo, Kevin Masick, Eric Hamilton, Rosemarie Linton, Larry Lutsky, Anne Marie Fried, and the rest of the group for their generous willingness to offer their expertise; and everyone else who has shared their professional smarts with me in the writing of this book, many many thanks. Thanks also to my friend and colleague Alice Greenwood for her commitment and support and editorial prowess, whose contributions have made a real difference in this book. Her capacity to translate complex ideas into accessible language for a broad audience has helped to make my books not only successful but a pleasure to write.
Thanks to the wonderful folks at Jossey‐Bass, including the late Andy Pasternack, who encouraged this new volume; to Seth Schwartz and Melinda Noack for their intelligence, good humor, and support; to the people at Wiley, Patricia Rossi, Monica Rogers, Jeevarekha Babu, and the copyeditor, Debra Manette, for shepherding the book into publication; and to the rest of the team: You made the production of this book a real pleasure.
And as always to my wonderful family—my children, Adam, Stefanie, Hillel, Stacey, James, and Stacy—and my extraordinary grandchildren—Kylie, Lila, Jack, Nico, and Amber—your love carried me through this chapter of my life, and your faith in me has been inspiring.
To my wife, Doris, to whom I owe everything!
ABOUT THE AUTHOR
Yosef D. Dlugacz, Ph.D., is the Senior Vice President and Chief of Clinical Quality, Education, and Research of the Krasnoff Quality Management Institute of the Northwell Health system. The goal of the institute is to bridge the gap between theoretical knowledge learned in the academic setting and the realities of applying quality management methods in today's health care reform environment. Dr. Dlugacz's research focuses on developing models that link quality, safety, good clinical outcomes, and financial success for increased value and improved efficiencies.
Dr. Dlugacz's methodologies have been praised nationally and internationally, and he has appeared in numerous teleconferences promoting quality and safety. Many of the best practices that have resulted from the quality management performance improvement process he has established have been published by The Joint Commission as standards for the entire industry.
His academic appointments have included: Associate Professor of Science Education at the Northwell Hofstra School of Medicine; Adjunct Professor of Information Technology and Quantitative Methods at the Hofstra University Frank G. Zarb School of Business; Visiting Professor to Beijing University's MBA Program; and Professor at Baruch Mt. Sinai, MBA program, City University of New York.
Dr. Dlugacz has published widely in health care and quality management journals on a variety of clinical care and quality topics. The Healthcare Financial Management Association published his article “High‐Quality Care Reaps Financial Rewards” in its Strategic Financial Planning publication. His book The Quality Handbook for Health Care Organizations: A Manager's Guide to Tools and Programs (Jossey‐Bass, 2004) has been praised as a valuable text for new quality professionals. His book Measuring Health Care: Using Quality Data for Operational, Financial, and Clinical Improvement (Jossey‐Bass, 2006) helps to educate professionals about the relationship between quality care and financial success. Value‐Based Health Care: Linking Finance and Quality (Jossey‐Bass, 2010), which explores the relationship between quality care and organizational efficiency, was selected for a 2010 Bugbee‐Falk Award from the Association of University Professionals in Health Administration and nominated for the ACHE/Hamilton Book of the Year Award. Dr. Dlugacz was invited to write two chapters for Error Reduction in Health Care: A System's Approach to Improving Patient Safety, edited by Patrice Spath (Jossey‐Bass, 2011).
Dr. Dlugacz received his PhD in sociology from the Graduate Center of the City University of New York.
INTRODUCTION
Health care is changing—its delivery, its structures, even its underlying philosophy. Wellness, rather than sickness, is now the focus of government concern. The patient experience of health and well‐being, rather than the physician's interpretation, is now central, and patient expectations are measured, communicated, and meaningful for financial success. Smaller health care organizations are banding together to become larger health care systems because financial efficiencies dictate such collaborations. Data are abundantly available to track various aspects of care. All these changes encourage new ways of thinking about health care and the organizations that deliver that care; those professionals who hope to understand and thrive in this new environment require quality tools, techniques, information, and education.
Introduction to Health Care Quality: Theory, Methods, and Tools is designed to familiarize health care professionals and students, administrative and clinical leaders, and policy makers with contemporary issues in quality management in the new health care reform environment. In addition, due to the rapidly changing technology for tracking medical information, such as the electronic health record, quality managers and health professionals will need to have increased familiarity with database development, data analytics and statistics, the role of measurements in monitoring quality, and performance improvement methodologies if health organizations are to succeed in the increasingly competitive marketplace. Because government agencies are linking quality variables to financial success, health professionals today are required to communicate information accurately and transparently and meet newly established benchmarks for the delivery of care. This book is designed to help professionals meet these needs.
Quality professionals, indeed all health care professionals, are required to work within new models of health care delivery, such as the patient‐centered medical home, accountable care organizations, value‐based purchasing, bundled payments, and pay for performance. Community programs that encourage wellness and prevention are now reimbursed whereas under the older models, hospital services and patient volume controlled financial outcomes. It is a new health care world, and those involved in it require new information and new skills.
The purpose of this book is to provide just that: to give professionals and students the tools they need to work effectively within the increasingly data‐driven health care environment. Quality data provide the foundation of care decisions, performance improvement initiatives, prioritization of resources, documentation about meeting expectations, analyzing market competition, and understanding the patient experience. Physicians and other clinicians are expected to work within the quality framework, collect data, report outcomes, collaborate in multidisciplinary teams, and develop communication strategies as never before. Inpatient hospital, ambulatory centers, and health care system leadership have to become involved in quality data and measurements in order to administer effectively and maximize reimbursements. Patients, who are the health care consumers, are more able than ever before to access comparative information about different care facilities and providers and make informed choices about where they spend their health care dollars.
This book addresses these quality issues from the point of view of my personal experience as a quality professional for the past 30 years. It offers experiential, practical, and applied examples of hands‐on implementation of how the fundamentals of quality management can improve efficiency and effectiveness of organizational and clinical processes, based on my career as the Senior Vice President of Quality Management and as the Executive Director of the Krasnoff Quality Management Institute, for Northwell Health (formerly the North Shore‐LIJ Health System), one of the largest integrated health systems in the United States. My goal is to show quality management in action, offering theoretical information and practical examples within each chapter. The exercises at the end of each chapter, “Quality Concepts in Action,” are designed to reinforce the quality concepts discussed in that chapter in applied situations. The references, suggestions for further reading, and useful websites at the end of each chapter provide students of health care quality with rich resource material for further exploration of the quality concepts and ideas in the chapter.
The material in the chapters not only exposes interested professionals to quality management fundamentals but also attempts to provoke creative ways of thinking about the provision of care. In addition to offering new material, each chapter reinforces and integrates previous discussions. I have taken examples from my experience, and although for privacy issues they are hypothetical, the examples are entirely realistic. The first five chapters review quality management theory and fundamentals and the changes necessary to the new reform environment. Chapters 6 through 9 show the application of quality theory with the tools and techniques used for performance improvement. Chapter 10 reviews and concludes the issues highlighted in the previous chapters.
Chapter 1 outlines the basics or fundamentals of quality management, introducing the most influential quality theorists, from Nightingale through Donabedian, and organizations concerned with quality, among them The Joint Commission, the Centers of Medicare and Medicaid Services, and the Institute of Medicine. A discussion of how to develop quality indicators for performance improvement is offered.
Chapter 2 highlights the changes and new models of care required by the health care reform bill, the Accountable Care Act, such as accountable care organizations, bundled payments, pay for performance, value‐based purchasing, the patient‐centered medical home, and so on. In this chapter the role of health information technology is discussed, including the pros and cons of electronic health records. Improving communication between physician and patient, encouraged in the health care reform environment, has led to innovative practices, such as narrative medicine, which is being taught in medical schools to increase professional awareness of how to elicit information.
Chapter 3 introduces in general terms the changing paradigms involved in providing safe quality care in different settings, such as the inpatient hospital and the community. It also stresses the importance of quality measurements in the reform environment and of effective leadership in making productive change. Various techniques to improve multidisciplinary communication, such as huddles, are outlined. The importance of health literacy in improving patient safety is also discussed in this chapter. An example of developing effective structures for moving information throughout a health system is offered, as is the role of quality data and measurements in promoting change for performance improvement.
Chapter 4 examines new challenges for health professionals that the reform environment promotes, such as the importance of statistical information and quality measurements in monitoring quality of care and patient satisfaction. Dashboards of measurements are discussed for their value in assessing care and improving processes, especially for issues involved in chronic disease management. Health information technology and various data sources are also reviewed for appropriateness in monitoring care. Improving communication across the continuum, using microsystems, macrosystems, Lean, TeamSTEPPS, SBAR, and checklists, is discussed.
Chapter 5 stresses the role of administrative and clinical leaders in improving patient safety and how metrics and measurements should be used by leaders to monitor the processes of care and patient safety. Principles of High Reliability Organizations are shown to address patient safety issues in a proactive paradigm. The role of quality management, nursing leaders, and the medical staff in promoting a safety culture is outlined. Examples of effective ways to report data for business intelligence and for decision making are presented. Prioritization issues and the role of dashboards in determining priorities are discussed, as well as how to interpret gaps in care, errors, and leaders' role in monitoring adverse events.
Chapter 6 shows how to work with quality tools and methods to manage problems, identify gaps in care, and target errors with such quality management tools as root cause analysis, failure mode, effects analysis, cause‐and‐effect diagrams, flowcharts, and other graphical displays of information. Basic statistical concepts involved in using data for analysis and quality research are presented. The value of using clinical pathways to improve communication and standardize the process of disease management is argued. Improving performance methodologies, such as the Plan‐Do‐Study‐Act cycle, is defined.
Chapter 7 continues the discussion of the role and challenges of working with quality data to evaluate care and the difference between using data for regulatory compliance and for performance improvement. Issues involved in extracting data from the electronic health record are discussed. Case studies are offered to show the application of data to real‐life hospital situations, such as the appropriate assignment of end‐of‐life patients, chronic disease management, readmission, and working with aggregated data to make improvements. Examples offered include variation from the standard of care and variance analysis, which are monitored by control charts.
Chapter 8 discusses issues involved in using quality measurements to understand and improve care from the points of view of the clinician, administrator, and patient. Process and outcomes measures are used as examples. Measures used for the value‐based purchasing or pay‐for‐performance paradigms as well as patient satisfaction measures are presented. Examples of dashboards of measures, developed so that leaders have ready access to importance quality information, are offered. This chapter also includes using safety and environment of care measures to improve patient safety.
Chapter 9 shows how to use the quality tools, such as throughput, queuing theory, and APACHE data for ICU efficiency, to manage efficiencies, and explains how to develop protocols and algorithms of care to optimize efficiency and safety for various procedures, such as bariatric surgery and more global issues, such as understanding mortality, from a clinical and administrative point of view. This chapter delves into the complex problems attached to patient‐centered care, working in teams, and delivering the message of change throughout the organization.
Chapter 10 concludes with the challenges health care professionals will face in the future, regardless of the composition of staff or distinctions among health care organizations, since quality metrics and principles of teamwork and performance improvement underlie all levels of care. The chapter summarizes the previous chapters' exploration of the role of leaders, the use of quality data and measurements in performance improvements, and identifying barriers to effective change.
PART ONEQUALITY MANAGEMENT FUNDAMENTALS
CHAPTER ONEFOUNDATIONS OF HEALTH CARE QUALITY
Chapter Outline
Defining Quality
Contributions of Quality Theorists—Nothing New under the Sun
Quality Management Methodologies
Organizations Making an Impact on Quality and Safety Standards
Centers for Medicare and Medicaid Services
Institute for Healthcare Improvement
Agency for Health Research and Quality
National Quality Forum
The Leapfrog Group
Data: The Foundation of Quality Management
Summary
Key Terms
Quality Concepts in Action
References
Suggestions for Further Reading
Useful Websites
Key Concepts
Understand issues involved in defining the concept of quality in health care.
Introduce important quality theorists.
Describe quality methodologies.
Explain the role of agencies and groups that have an impact on health care quality.
Review the role of data as the foundation of quality management.
Quality, which is easily recognized—and even more easily recognized in its absence—is surprisingly hard to define. One knows it when one experiences it, be it in a car, a restaurant, or a health care organization, and one knows when it is missing. It can be considered an attitude or orientation, a dedication of individuals in an organization to strive for excellence, or quality can be based on an individual's perception and his or her value system.
Perhaps the least controversial definition of quality was proposed in 1990 by the Institute of Medicine (IOM), an independent, nonprofit organization that advises decision makers and the public about health care issues: “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Lohr, 4). It should be noted that “desired health outcomes” are difficult to define and measure, and may be dependent on knowing the population and the community served. To understand quality, it is useful to know the history of how quality management has evolved, the significant thinkers and theorists who have contributed to defining quality, and the organizations that have influenced how health care is delivered in the United States.
Defining Quality
Quality standards are not fixed entities but rather should be thought of as a moving target, going between better quality or worse quality, defined by the expectations of customers. If customer expectations are met, quality is considered to be high. However, meeting customer expectations is complicated because customers themselves may not even be aware of or able to articulate their expectations regarding quality. For this reason, many organizations conduct satisfaction surveys and analyze complaints in order to better understand what customers want from their health care experience.
In fact, health care quality has to meet the expectations of many groups of customers: patients and their families, physicians, organizations, regulators, payers, and communities. Each of these customers may have different expectations of quality, such as access to care (do customers/patients get the care they need?) and effectiveness of care (are they better?). Medical outcome expectations, or effectiveness, are usually set through professional organizations and adopted as standards of care. Today, patients and payers have information and opinions about their care that is eroding the primacy of physicians to be the sole setters of expectations. Patients, communities, governmental agencies, and payers are setting standards in addition to physicians.
Contributions of Quality Theorists—Nothing New under the Sun
Many of the early quality theorists defined methods, tools, and techniques that are still being used today in health care settings. Many of the problems identified by these quality thinkers still exist today. Many of the solutions they proposed are still being discussed today. Each of these prominent theorists contributed something to our understanding of what quality means and how to provide quality outcomes. A brief introduction to some of the highlights of their work in quality follows.
Florence Nightingale
In thinking about medical quality, the place to start is with Florence Nightingale (1820–1910), an English social reformer and statistician. She is considered to be the founder of modern nursing and became famous for her nursing skills with wounded soldiers during the Crimean War. However, her work encompassed more than improving nursing practice and broadening nursing education. In addition, she was an advocate for health care reform and wrote works to educate laypeople about medical knowledge. Nightingale was also a social reformer, especially of women's rights and hunger relief. She had the good fortune to be born into a wealthy family to a progressive‐thinking father who encouraged her education, especially her exceptional mathematical and analytic skills.
Nightingale can be credited with creating the framework for quality management, using data as the bases for graphics about monthly improvements in mortality associated with her sanitary reforms. She understood the association among overcrowding, sanitation, infection, and mortality. In this way, she linked cause with effect. She pioneered the visual representation of statistical information, using the pie chart (see Figure 1.1) and the histogram (see Figure 1.2) to illustrate sources of patient mortality.
Figure 1.1 Causes of Patient Mortality Pie Chart
Figure 1.2 Causes of Patient Mortality Histogram
These figures reveal the same information in different formats. Both, however, make it clear at a glance that the majority of deaths (60 percent) were the result of poor hygiene and sanitation, double the number of deaths from battle wounds. Graphical displays are powerful representations of information.
Nightingale's comprehensive statistical analysis of rural India's sanitation was instrumental in reform. In 1873, she reported that mortality among the soldiers in India had declined from 69 to 18 per 1,000. She knew that “statistics of a hospital ought to include not only the nominal list of the dead, but the cause of death” as well (Joint Commission on Accreditation of Healthcare Organizations [JCAHO] 1999, 146). Today, 150 years after her work, the health care community sees the value of using outcomes measurements (data describing a patient's health state) in identifying quality care and cost effectiveness. Nightingale “realized that if judgments of outcomes were to matter, it would require attention to accurate data collection and accurately defined measures” (Batalden and Mohr 1999, 11).
In addition to understanding and exposing cause and effects and promoting outcomes measurements based on creditable data, Nightingale also understood that problems could be caused not by individuals alone but by systems. She understood the structures, processes, and waste in health care organizations; she set standards for staffing. All these ideas are still being discussed in quality management departments today. Many people think they are discovering new ideas, but Nightingale was using these ideas, and most productively, long ago.
Ernest A. Codman
Like Nightingale, Ernest Amory Codman (1869–1940) was a medical reformer who sought to improve medical care by analyzing outcomes, or what he called end results. He tracked his patients on end‐results cards, noting demographic data, diagnosis, treatment, and outcomes—data that health care organizations are still attempting to accurately collect and analyze today. Codman worked to standardize care and reduce variation in order to create efficiency as well as good outcomes. He was the first physician to promote the study of outcomes and evidence‐based medicine (making judicious use of the most current research and information to make medical decisions); before Codman, only Florence Nightingale had concerned herself with these ideas.
Codman believed that physicians should be held accountable for the success of their care, and if their patients did not have good outcomes, physicians should question why not and change their practice accordingly. Codman's idea was straightforward: “The common sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire, ‘If not, why not?’ with a view to preventing similar failures in the future” (Codman 1934, Preface).
The surgeons who were his colleagues at Massachusetts General Hospital were not eager to embrace this level of accountability, and in frustration Codman quit and opened up his own End Result Hospital, where he was able to practice what he preached, using performance measurements to evaluate care and make improvements. This concept of end results was a forerunner of what is today termed evidence‐based medicine. At his hospital, between 1911 and 1916, of the 337 patients who were discharged, Codman recorded 123 errors. Not only did he record these results but he published them to promote what we now call transparency (access to reliable accurate information about care). Codman believed physicians should admit to and learn from their mistakes.
Codman was concerned with the types of medical errors that might prevent good results and developed a classification system for errors: lack of technical skill, poor surgical judgment, and lack of diagnostic skill or failures in equipment. Today we talk about “waste” and “value,” concepts that Codman was concerned with decades ago. Today we think of waste as overuse, underuse, misuse of medical services, failure of care coordination, administrative complexity, and fraud (Health Policy Brief 2012). Codman's concept of waste involved unnecessary deaths caused by ill‐judged operations or poor diagnoses, functions associated with surgeons. He wanted to use the data accompanying the evaluations to publicly rank surgeons. Unsurprisingly, he was not popular with his peers. Even today, physicians are reluctant to work from standards, claiming that it impinges on their individual judgment and promotes “cookbook” medicine. They prefer the evidence of their experience rather than the recorded experience of others.
A tireless crusader for quality, Codman was instrumental in founding the American College of Surgeons and its Hospital Standardization Program, which later became the Joint Commission on Accreditation of Healthcare Organizations (now called The Joint Commission, TJC), a not‐for‐profit accrediting agency that evaluates quality of care and patient safety. Codman's ideas are promoted today by government and regulatory agencies (such as the Centers for Medicare and Medicaid Services [CMS] and TJC), as well as private professional groups (e.g., Institute for Healthcare Improvement [IHI] and the Leapfrog Group). Remarkably, a century later, Codman's commonsense approach to the evaluation of care is still not universally accepted by the medical establishment.
William Andrew Shewhart
William Andrew Shewhart (1891–1967), a physicist, engineer, and statistician, is another pioneering quality theorist, known for developing statistical quality control (using statistical methods to assess and improve quality) and the Shewhart improvement cycle of Plan‐Do‐Study‐Act (PDSA). Employed in industry for Western Electric and Bell Telephone, among others, his work highlighted the importance of reducing variation (i.e., changes) in a process and continuously monitoring that process. What now seems obvious, that variation leads to poor quality, was a new idea with Shewhart.
An example of the importance of standardization could be taken from any arena, not just manufacturing or health care. Think of building a house. If the roof is too small, the rain and snow will come in; if a door is too big, it won't close. We expect no variation in our products, not some of the time but all of the time. We want standardization. But health care quality management professionals today are unable to convince clinicians of the importance of standardization and lack of variation. As Dr. Donald Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement and the former administrator of the Centers for Medicare and Medicaid Services, admonished many years after standardization was first proposed by Shewhart: “Professionals need to embrace the scientific control of variation in the service of their patients and themselves” (1991, 1212).
Shewhart described how lack of standardization increased variation and degraded quality, and he framed variation as the result of one of two causes, either assignable (or special) cause variation or chance (or common) cause variation. Significantly, in 1924 he described the first control chart for distinguishing between the two (see Chapter 7). Control charts launched the idea of statistical process control and quality improvement. Shewhart said that data contained both signal and noise, and it was important to separate the two. He realized that bringing a process into statistical control where there is only a chance cause of variation would enable accurate predictions of future outcomes as well as be efficient economically; in other words, control would reduce waste and improve quality.
Among Shewhart's goals was to help management make good decisions, based on data rather than subjective experience. To combine creative management with statistical analysis, he developed what he called the Learning and Improvement cycle, now known as the PDSA cycle of quality improvement (see Chapter 6). Shewhart believed that constant (re)evaluation of practice would lead to successful outcomes. He worked with and influenced the thinking of Edward Deming and Joseph Juran, and his concept of statistical control led to the development of the Six Sigma improvement process (a data‐driven methodology to identify and eliminate defects in a process) later adopted by General Electric under Jack Welch, which transformed that organization.
William Edwards Deming
W. Edwards Deming (1900–1993) was also an engineer and statistician who worked with Shewhart and is often associated with his teachings. He was also a proponent of the PDSA cycle of performance improvement (which Deming called the Shewhart cycle and others call the Deming cycle). He worked in Japan after World War II and had a significant impact on improving that country's devastated manufacturing process.
The Japanese had studied Shewhart's techniques, and after the war, as part of their reconstruction efforts, they looked for an expert to teach them about statistical control. Deming trained Japanese managers and business executives in concepts of quality as well as statistical control. His message was that improving quality would result in decreased costs. He believed that variation caused waste. When Japanese businesses applied Deming's philosophy, they were enormously successful. The result of this success was an international demand for Japanese products. Although Deming never used the term, he is credited with developing Total Quality Management.
Deming encouraged business leaders to think about manufacturing as an interrelated system with a common aim rather than as a series of individual pieces. His philosophy was that when the focus of the organization and top leaders was on quality, quality increased, costs were reduced, and market share increased, but when the focus was primarily on costs, over time, costs would rise and quality would suffer.
According to his obituary published in The New York Times (Holusha 1993), when he was brought in to Ford to help explain why the sales numbers of Hondas and Toyotas were superior to Ford's, he said: “Can you blame your competitor for your woes? No. Can you blame the Japanese? No. You did it yourself.” He exhorted managers to treat workers like partners and encourage them to identify problems in the workplace without fear of reprisals. Today, in the health care setting, we are still wrestling with issues of fear, reprisals, and problem‐solving methods.
DEMING'S PHILOSOPHY OF QUALITY
Deming's philosophy of quality is summarized in what he called a System of Profound Knowledge, which is comprised of four key ideas:
Appreciation of a system
Understanding variation
A theory of knowledge
Understanding human behavior and psychology
When Deming was hospitalized and he received inefficient care, he realized that health care organizations had serious problems: There were many treatment delays, the showers didn't work, and so on. He blamed leaders. He saw how hard nurses worked and realized that “the design of this system to reduce unwanted variation in care could only be improved by a leadership that was obviously lacking” (Best and Neuhauser 2005, 311). He wanted organizations to be customer‐focused and for leaders to be aware of and meet customer expectations. Today, the CMS has developed patient surveys (Hospital Consumer Assessment of Healthcare Providers and Systems [HCHAPS]) to determine whether customer expectations were met or not.
Avedis Donabedian
Avedis Donabedian (1919–2000) was born in Lebanon to Armenian parents who fled to an Arab village north of Jerusalem. He trained as a physician there before moving to America and teaching in medical schools, among them Harvard and the University of Michigan. Often called the father of health care quality, he was very interested in health services research, especially in assessing quality of care. In Evaluating the Quality of Medical Care (written in 1966), Donabedian discusses the importance of evaluating quality through examining structure, process, and outcome, referred to as the Donabedian model of patient safety. The structure, process, and outcome model remains today the dominant paradigm for evaluating health care quality.
Donabedian adopted and adapted the systems approach of industrial quality theorists to the delivery of health care services. His writings lay out seven “pillars” of quality health care: efficacy, efficiency, optimality, acceptability, legitimacy, equity, and cost. Every one of Donabedian's pillars is being discussed today, sometimes as if it was a novel idea.
Donabedian had modern and sophisticated ideas about how to assess quality, discussing in his writings issues related to access to care, the importance of measuring and evaluating quality, the completeness and accuracy of medical records, observer bias, patient satisfaction, and cultural preferences in health care, all still relevant today. However, his thinking about quality in health care was also quite personal. He said:
Systems awareness and systems design are important for health professionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system's success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system. (Mullan 2001, 137)
An excellent quality management program includes internalized caring and compassion for the patient.
Joseph M. Juran
Joseph M. Juran (1904–2008), another influential quality theorist, was an engineer and management consultant who also worked in post–World War II Japan, helping to rebuild the country's economy through improved manufacturing practices. Along with Shewhart and Deming, Juran is considered among the three founders of modern quality improvement. His philosophy involves three managerial processes, sometimes referred to as the “Juran trilogy”:
Quality planning to meet customer expectations
Quality control to ensure that processes are working efficiently
Quality improvement to optimize results.
Juran was also the first to apply the Pareto principle, developed by the Italian economist Vilfredo Pareto, to quality—the idea that 80 percent of a problem is caused by 20 percent of the causes. Therefore, if improvements were focused on the 20 percent, the results would have big effects.
A Pareto chart is basically a bar chart with the highest bar, representing the largest amount of defects or problems, on the left and the shortest bar, representing the fewest problems, on the right (see Figure 1.3). The left vertical axis shows the frequency of the occurrence and the right vertical axis shows the cumulative percentage which is tracked by a line graph.
Figure 1.3 Medication Error Rate Pareto Chart, January 2011–June 2011
Figure 1.3 shows that the vast majority of medication errors, in fact 80 percent, occur during the administrative and prescribing phases of the medication use process. Juran was at the forefront of linking quality and cost. One might say that, with a Pareto chart, you know where your buck will return the biggest bang. The chart is useful in prioritizing issues for resource expenditure, in this case improving processes related to medication administration and prescription.
Among Juran's greatest contributions to quality theory was his realization that organizational culture is responsible for the inertia that must be overcome in order to implement change. Juran credited his insight to Margaret Mead's Cultural Patterns and Technical Change (1955) (Best & Neuhauser, 2006), which convinced him that only by understanding an organization's cultural barriers to change could change be implemented; change had to conform to the organization's values. Today quality management professionals are still struggling to implement methods to change health care culture to encourage staff to accept and adopt changed practices.
Philip Crosby
Philip Crosby (1926–2001) was a business management expert who contributed to quality theory. His work became popular in the 1970s when American manufactured goods were losing market share to Japanese products because they were superior in quality to American‐made products. Crosby is best known for promoting the concept of zero defects in a process. In 1979 he published a book, Quality Is Free, in which he said that to improve quality, “do it right the first time” (DIRFT), an approach that is surprisingly difficult to implement, as evidenced by unresolved gaps in safety that haunt hospitals today. His writings were popular with the public, especially when he described the cost of poor quality. Crosby, like his contemporary quality theorists, realized that poor quality or good quality was dependent on leaders setting up expectations for quality.
Crosby promoted four fundamental principles of quality:
Quality is defined as conformance to product/customer requirements.
Quality should involve prevention of errors.
The performance standard for quality is zero defects.
Quality can be quantified by the price of nonconformance (the cost of nonvalued activities).
Issues of conforming to requirements, focus on prevention, zero defects, and understanding the cost of poor quality are still discussed in health care improvement efforts (Creech 1994, 478).
CONTRIBUTIONS OF QUALITY THEORISTS
Florence Nightingale
Link causes with effects.
Use data to understand outcomes.
