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Copyright © 2013. Health Administration Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted
under U.S. or applicable copyright law.
I NTRODUCTION
H EALTHCARE
QUALITY
to
M A NAG E M E N T
SECOND EDITION
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Copyright © 2013. Health Administration Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted
under U.S. or applicable copyright law.
AUPHA/HAP Editorial Board for Undergraduate Studies
Eric S. Williams, PhD, Chairman
University of Alabama
Steven D. Berkshire, EdD, FACHE
Central Michigan University
Stephanie L. Bernell, PhD
Oregon State University
Rosemary Caron, PhD
University of New Hampshire
Susan P. Casciani, FACHE
Towson University
David E. Cockley, DrPH
James Madison University
Tracy J. Farnsworth
Idaho State University
Riaz Ferdaus, PhD
Our Lady of the Lake College
Mary K. Madsen, PhD, RN
University of Wisconsin–Milwaukee
Lydia Middleton
AUPHA
John J. Newhouse, PhD
St. Joseph’s University
Rubini Pasupathy, PhD
Texas Tech University
Jacqueline Sharpe
Old Dominion University
Daniel J. West, Jr., PhD, FACHE
University of Scranton
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I NTRODUCTION
H EALTHCARE
QUALITY
to
M A NAG E M E N T
SECOND EDITION
Health Administration Press, Chicago, Illinois
AUPHA Press, Arlington, Virginia
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Copyright © 2013. Health Administration Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted
under U.S. or applicable copyright law.
Your board, staff, or clients may also benefit from this book’s insight. For more information on quantity
discounts, contact the Health Administration Press Marketing Manager at (312) 424-9470.
This publication is intended to provide accurate and authoritative information in regard to
the subject matter covered. It is sold, or otherwise provided, with the understanding that the
publisher is not engaged in rendering professional services. If professional advice or other expert
assistance is required, the services of a competent professional should be sought.
The statements and opinions contained in this book are strictly those of the author and do not
represent the official positions of the American College of Healthcare Executives, the Foundation
of the American College of Healthcare Executives, or the Association of University Programs in
Health Administration.
Copyright © 2013 by the Foundation of the American College of Healthcare Executives. Printed in
the United States of America. All rights reserved. This book or parts thereof may not be reproduced in
any form without written permission of the publisher.
18
17
16
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4
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1
Library of Congress Cataloging-in-Publication Data
Spath, Patrice.
Introduction to healthcare quality management / Patrice Spath. – Second edition.
pages cm
Includes index.
ISBN 978-1-56793-593-6 (alk. paper)
1. Medical care–Quality control. 2. Quality assurance. 3. Medical care–Quality control–
Measurement. 4. Quality assurance–Measurement. I. Title.
RA399.A1S64 2014
362.1–dc23
2013005277
The paper used in this publication meets the minimum requirements of American National Standard
for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984. ™
Acquisitions editor: Carrie A. McDonald; Project manager: Joyce Dunne; Cover design: Marisa Jackson;
Layout: Fine Print, Ltd.
Found an error or a typo? We want to know! Please e-mail it to [email protected], and write
“Book Error” in the subject line.
For photocopying and copyright information, please contact Copyright Clearance Center at
www.copyright.com or (978) 750-8400.
Health Administration Press
A division of the Foundation of the American
College of Healthcare Executives
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(312) 424-2800
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in Health Administration
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This book is dedicated to all the health profession students who have taken
one of the university courses I teach in healthcare quality management.
While these students are learning from me, I am also learning a lot from them.
I thank all of my students for helping me to appreciate how best
to explain complex topics in understandable ways
and how not to overwhelm them with jargon.
Each book I write gets a little better because of what I learn
from practitioners and students of healthcare quality management.
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Copyright © 2013. Health Administration Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted
under U.S. or applicable copyright law.
Copyright © 2013. Health Administration Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted
under U.S. or applicable copyright law.
BRIEF CONTENTS
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Chapter 1: Focus on Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 2: Quality Management Building Blocks . . . . . . . . . . . . . . . . . . . . . . . . . 13
Chapter 3: Measuring Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Chapter 4: Evaluating Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Chapter 5: Continuous Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Chapter 6: Performance Improvement Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Chapter 7: Improvement Project Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Chapter 8: Improving Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Chapter 9: Achieving Reliable Quality and Safety . . . . . . . . . . . . . . . . . . . . . . . . 210
Chapter 10: Managing the Use of Healthcare Resources . . . . . . . . . . . . . . . . . . . . 234
Chapter 11: Organizing for Quality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
vii
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AN: 643679 ; Spath, Patrice.; Introduction to Healthcare Quality Management
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Copyright © 2013. Health Administration Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted
under U.S. or applicable copyright law.
Copyright © 2013. Health Administration Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted
under U.S. or applicable copyright law.
DETAILED CONTENTS
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Content Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii
Supplemental and Instructional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xx
Chapter 1: Focus on Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.1 What Is Quality?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Healthcare Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ix
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x
Contents
Chapter 2: Quality Management Building Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1 Quality Management Activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2 Quality Management Milestones in Industry and Healthcare . . . . . . . . . . . . .
2.3 External Forces Affecting Healthcare Quality Management . . . . . . . . . . . . . .
2.4 Quality Management Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
14
15
16
23
27
28
28
29
Chapter 3: Measuring Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1 Measurement in Quality Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2 Measurement Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3 Measurement Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.4 Selecting Performance Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.5 Constructing Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.6 Measures of Clinical Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.7 Balanced Scorecard of Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32
33
34
35
37
40
44
51
63
66
68
68
69
Chapter 4: Evaluating Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
4.1 Assessment in Quality Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
4.2 Display Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.3 Compare Results with Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
4.4 Determine Need for Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
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Contents
Chapter 5: Continuous Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1 Improvement in Quality Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.2 Performance Improvement Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
111
112
113
113
116
128
128
129
Chapter 6: Performance Improvement Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.1 Qualitative Improvement Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
131
132
133
159
160
161
Chapter 7: Improvement Project Teams. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.1 Project Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.2 Team Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.3 Team Dynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
163
164
165
171
176
178
178
179
Chapter 8: Improving Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.1 Safety in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.2 Preventing Mistakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.3 Measuring Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.4 Improving Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.5 Patient Engagement in Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
180
181
182
184
187
192
203
205
206
206
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Contents
Chapter 9: Achieving Reliable Quality and Safety . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.1 Reliable Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.2 Applying Reliability Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.3 Monitoring Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.4 Realizing Sustained Improvements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
210
211
212
216
224
226
228
229
229
Chapter 10: Managing the Use of Healthcare Resources . . . . . . . . . . . . . . . . . . . . . 234
Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.1 Utilization Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.2 Defining Appropriate Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.3 Measurement and Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.4 Utilization Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.5 Discharge Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.6 Utilization Management Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
234
235
236
237
241
247
251
251
254
258
259
260
Chapter 11: Organizing for Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11.1 Quality Management System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11.2 Quality Management Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11.3 A Hospitable Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
264
265
267
274
278
282
283
284
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
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FOREWORD TO THE
SECOND EDITION
I
n my foreword to the first edition of this book, I commented on the number of Google
hits for the search term healthcare quality books—19.3 million—and the impressive
decrease by 98 percent when I refined the search term to healthcare quality textbooks. A
new Google exercise for this second edition foreword presented an astounding 202 million
hits for the broad term but a percentage decrease for the textbooks search similar to that
in 2009 (resulting in 2.24 million hits). Although I am no longer surprised by the magnitude of references on the web, I was pleased to note that Patrice Spath’s Introduction to
Healthcare Quality Management appeared third on the list of search results for textbooks.
If the first edition holds this, albeit subjective, ranking of prominence, what can we expect
from the second edition?
In health professions education, more so than in many other disciplines, textbook
content is dynamic. The “who, what, when, where, why, and how” of healthcare are driven
by technology innovations, policy and politics, economic models, and other societal and
regulatory influences. For this reason, healthcare textbooks are supplemented with journal
and news articles, research findings, and web-based resources to ensure that students are
provided with essential current knowledge. A healthcare textbook is considered “good”
if the foundational concepts remain sound and a significant amount of the application
content is relevant to current practice for a reasonable period of time—ideally, three or
more years. The tipping point when a new edition is warranted often is signaled by an
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xiv
Foreword to the Second Edition
increase in the amount or a diversity in the type of supplemental resources required or by
the emergence of important industry initiatives.
The first edition of Introduction to Healthcare Quality Management has maintained
its relevance by way of its conceptual framework and its utility related to the application
content. For this edition, the author reviewed each chapter and made appropriate revisions
to ensure that the content is up to date. The inclusion of a new chapter and several new
sections in the other chapters adds value for students and other purchasers.
Important additions to the conceptual base of this textbook are discussions of the
human factors and reliability sciences. These principles are applied by an increasing number
of healthcare organizations to improve the reliability of their performance. The criteria—and
the expectations—by which healthcare organizations are measured with regard to their ability to provide safe, effective, and high-quality patient care continue to evolve. The relationship between organizational performance and payment for services provided has become
tightly coupled. Some healthcare organizations achieve success under a single evaluation
framework but are unable to sustain their performance when regulatory or operational
environments change. Thus, clinicians and managers must create a culture conducive to
accountability, risk management, and corrective action that is effective and supports reliable, high-quality performance in a dynamic environment.
Spath’s discussion of new technologies throughout the book will aid managers and
leaders as they deploy technology-based services to improve the patient experience. Technologies supporting communication and information capture, management, and analysis are progressively sophisticated, keeping pace with advances in clinical technologies.
These rapidly evolving products enable patients, clinicians, and organizations to embrace
e-health applications at the individual, community, and global levels. From her extensive
knowledge in this area from a practice perspective, Spath demonstrates how new technologies are creating innovative opportunities for data collection and more reliable healthcare
performance.
Patients and their families are better informed than ever because of the communication and information technologies now available to the general population. As a result,
they are more confident in discussing their diagnoses and treatments with their healthcare
providers. When these discussions cover personal and family preferences and constraints,
clinicians are armed with information to guide patients in healthcare decision making.
Spath’s textbook reflects this shift toward patient engagement by including a section on
measuring a patient’s healthcare experience, adding an important component to the conceptual framework of healthcare quality.
As the knowledge in all domains of healthcare grows, so does the need to apply
the knowledge to solve complex organizational problems—ideally by using a proactive
(rather than reactive) approach and often by including teams of professionals from many
academic and professional disciplines. Diverse teams bring the diverse skills needed to
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Foreword to the Second Edition
select and apply appropriate analytical tools for improvement. As the team concept of
care delivery evolves, providers must emphasize the conceptual foundations of healthcare
quality and embrace a culture of accountability for the quality and safety of the patient
experience. This textbook provides health professions students with core knowledge that
will enable them to adapt to organization-specific models as informed, educated, and
valued employees.
Donna J. Slovensky, PhD, RHIA, FAHIMA
School of Health Professions
University of Alabama at Birmingham
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PREFACE
T
he old adage “The only constant is change” was true for the healthcare industry
when I started my career many years ago, and it is true today. The pace of change
has certainly picked up in the past few years, which brings unique challenges to
staying well informed about new regulations, patient care recommendations, new technologies, and innovations.
Mental overload is the new norm. How do individuals react when they are overwhelmed by too much information? Studies in the discipline of cognitive psychology
indicate that overload causes people to develop tunnel vision. They lose their view of the
big picture as their attention is narrowed to one issue or one task—seeing the world as if
through a soda straw. Tunnel vision is the mind’s biological response to encountering too
much information. Regardless of how good we presume ourselves to be at multitasking,
our working memory can only concentrate on one thing at a time. This book provides
readers with the opportunity to focus on one fundamental topic: how healthcare quality is measured, evaluated, and improved. Once this learning has been assimilated into
your long-term memory (your personal knowledge database), it will be there for retrieval
whenever you need it.
This second edition of Introduction to Healthcare Quality Management is a culmination of my more than 30 years of experience as a hospital quality director, trainer,
and consultant for other quality professionals and as an instructor of undergraduate- and
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xviii
Preface
graduate-level healthcare quality courses. Improvement fads, and the quality gurus who
advocate their use, have come and gone; the cycle will surely repeat itself long after I’ve
retired. In this book I’ve stuck to the basics—the foundational principles and techniques
common to any healthcare quality initiative. Once they have mastered these basics, students
of quality management will be able to adapt to whatever model of quality comes along. For
individuals seeking advanced degrees, this book is a starting place for expanded learning.
This book is directed to people with little or no clinical healthcare experience. The
case studies and illustrations focus primarily on the provision of health services rather
than the diagnosis and treatment of patients. Clinical discussions are accompanied by
explanatory text to clarify terminology or situations that may be unfamiliar to students.
The websites listed at the end of each chapter point readers to advanced learning resources
(up to date as of this writing), including additional clinical quality management examples.
Throughout my years of teaching quality management to beginners, I’ve found
that vocabulary can be a barrier to learning. Simple concepts, such as measuring patient
complication rates, may be tricky to understand if students have had little healthcare
experience. To help overcome this barrier, the textbook introduces many of the concepts
by using analogies from everyday life. Once students see the link between what they know
and do almost every day and the basic quality concepts, they begin to understand related
healthcare quality principles and techniques. While the analogies may seem simplistic,
they often help the novice unravel the vagaries of healthcare quality management.
CONTENT OVERVIEW
The book begins with a chapter on the attributes of quality and factors that affect consumer
perceptions of quality. The notion of value—quality at a reasonable cost—is introduced
with an explanation of how perceived value influences purchasing decisions. Students learn
the Institute of Medicine’s definition of healthcare quality and the quality characteristics
expected in high-performing healthcare organizations. How these quality characteristics are
measured and improved is reinforced throughout the remainder of the book.
Chapter 2 offers a description of the interrelated elements of quality management:
measurement, assessment, and improvement. This trilogy provides a framework on which
subsequent chapters build. The chapter continues with a discussion of the science of quality and its application in healthcare organizations. Students are introduced to the work
of Walter Shewhart, W. Edwards Deming, and other quality pioneers of the manufacturing industry. Healthcare organizations, which have been slow to adopt statistical process
control techniques, are beginning to rival those in other industries in their application of
quality management tools. The background behind these quality management advances
is presented to help students grasp subjects covered in later chapters. Chapter 2 concludes
with a summary of external forces that influence healthcare quality management activities.
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Preface
Chapters 3 through 7 provide step-by-step descriptions of how healthcare quality is
measured, assessed, and improved. Chapter 3 begins with an overview of quality measurement. The three measurement categories—structure, process, and outcome—are introduced and explained through numerous examples from a variety of healthcare settings.
Also covered are methods for choosing performance measures and constructing measures
that yield worthwhile information. Most important, this chapter introduces students to a
critical element of clinical quality management: measurement of clinical decision making
using evidence-based guidelines.
Measurement is only the first step in quality management. The measurement results
must be evaluated to determine whether performance is acceptable. Performance assessment,
the second component of quality management, is covered in Chapter 4. Methods for effective display and communication of data are introduced and two report formats—snapshot
and trend—are discussed. Appropriate uses for each type of report and evaluation of results
against performance expectations are demonstrated through case studies. Chapter 4 then
provides an overview of statistical process control techniques, which are gaining popularity
among healthcare organizations as a means of evaluating performance. The impact of unnecessary process variation on quality, methods of measuring variation, and ways measurement
can be used to control variation are also discussed. The chapter concludes with a discussion
of the factors involved in the next step of quality management—assessing whether to proceed
with an improvement initiative or to continue measuring.
The decision to improve performance sets in motion an improvement initiative.
The next step is to determine which improvement process to follow. No standard process exists for improving performance. Shewhart’s Plan-Do-Check-Act (PDCA) cycle of
improvement has been modified and adapted many times since its introduction in the
1920s. Chapter 5 acquaints students with the PDCA model and other frameworks commonly used in improvement initiatives. It describes the primary purpose of each model
and the differences between and similarities among them. Most important, this chapter
emphasizes the need for a systematic approach to healthcare quality initiatives. Several
project examples take students through the steps of methodical process improvement.
Throughout the steps of a process improvement initiative, many decisions must be
made. How wide is the gap between expected and actual performance? What factors are
causing undesirable performance? Which problems take priority? How can the process be
changed to improve performance? The answers to these questions are gathered through
the use of quality improvement tools. Some of these tools are quantitative—similar to the
graphs and displays discussed in Chapter 4—and some are qualitative—for example, nominal group technique, cause-and-effect diagrams, and flowcharts. Chapter 6 introduces 14
qualitative tools commonly used in improvement initiatives. Practical examples and case
studies provide students with the knowledge to apply these tools in real-life situations. In
Chapter 7, students learn how improvement teams are formed and managed.
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xx
Preface
Two characteristics of high-quality patient care—safety and effectiveness—are
particularly important in today’s performance-oriented, cost-conscious environment. A
complete chapter is devoted to each subject. Chapter 8 begins with a discussion of the
factors prompting increased public scrutiny of the safety of healthcare services. Using the
measurement, assessment, and improvement framework, the chapter demonstrates how
patient safety is evaluated and improved. Of particular importance are two safety improvement tools: (1) failure mode and effects analysis and (2) root cause analysis. Students of
quality management should remember that they, too, are recipients of healthcare services;
at the conclusion of this chapter, they discover what they can do as patients to protect
themselves from potentially harmful medical mistakes.
Chapter 9 provides more detail on how to accomplish the important goal of achieving
high-quality, reliable performance in healthcare. Because healthcare processes are not well
designed, people’s vigilance and hard work are often relied on to ensure good performance.
A better way to advance quality is to apply human factors and reliability science principles. In
this chapter, students are introduced to techniques for improving processes—used for years
in other industries and now being successfully applied in the healthcare environment—so
that failures can be reduced and reliable quality can be realized.
Quality improvement and cost control depend on the organization’s ability to reduce
underuse and overuse of healthcare services. Utilization management activities, described
in Chapter 10, are undertaken by healthcare organizations to determine whether they are
using resources appropriately. The chapter reveals tactics that purchasers and providers use
to prospectively, concurrently, and retrospectively ensure effective use of healthcare services.
A systematic approach is needed to control resource use without compromising the quality
of patient care. This structured approach is also covered in Chapter 10.
Healthcare quality is not produced in a vacuum. Organization-wide commitment
and an adequately supported infrastructure are essential to achieving performance excellence. Chapter 11 introduces the contributors vital to the success of a quality program,
and it details elements of a planned and systematic improvement approach. Most important, Chapter 11 emphasizes the role of a supportive organizational culture in the quality
process and concludes with a discussion of cultural factors that can advance or inhibit
achievement of quality goals.
SUPPLEMENTAL
AND
INSTRUCTIONAL RESOURCES
Each chapter concludes with student discussion questions. Some questions encourage contemplation and further dialogue on select topics, and some give students a chance to apply
the knowledge they have gained. Others promote continued learning through discovery
and use of information available on the Internet. I hope that, on completion of each chapter, students feel compelled to address the discussion questions to expand their learning.
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Preface
Additional resources are available to students and instructors on this book’s companion
website. For access information, visit www.ache.org/books/IntroHealthcareQuality2. The
book companion features test banks, a PowerPoint presentation, and, for instructors,
answers to discussion questions.
In keeping with my goal of sticking to the basics, some quality topics are not covered
in depth or not covered at all. My decision to omit them should not be taken as a signal
that they are unimportant to the study of healthcare quality management. Supplemental
learning materials may be needed depending on course prerequisites and program curricula.
The websites listed at the end of each chapter can be used to add topics or augment those
insufficiently covered in the book. The information I have included on rapidly changing
“hot topics,” such as pay for performance and meaningful use of information technology, is
purposefully high level; current journal articles are students’ best resource for these subjects.
A firm grasp of the basics—measurement, assessment, and improvement—better prepares
students to address any quality management topic they encounter.
Patrice L. Spath, RHIT
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CHAPTER 1
FOCUS ON QUALITY
LEARNING OBJECTIVES
After reading this chapter, you will be able to
➤ recognize factors that influence consumers’ perception of quality products and
services;
➤ explain the relationship between cost and quality;
➤ recognize the quality characteristics important to healthcare consumers,
purchasers, and providers; and
➤ demonstrate an understanding of the varied dimensions of healthcare quality.
1
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2
Introduction to Healthcare Quality Management
KEY WORDS
➤ Cost-effectiveness
➤ Defensive medicine
➤ Healthcare quality
➤ High-value healthcare
➤ Institute for Healthcare Improvement (IHI)
➤ Institute of Medicine (IOM)
➤ National Quality Strategy
➤ Providers
➤ Purchasers
➤ Quality
➤ Quality assurance
➤ Reliability
➤ Value
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Chapter 1: Focus on Quality
3
S
ince opening its first store in 1971, Starbucks Coffee Company has developed into
an international corporation with more than 19,000 locations in more than 55
countries. The company’s dedication to providing a quality customer experience
is a major contributor to its success. Starbucks’s customers expect to receive high-quality,
freshly brewed coffee in a comfortable, secure, and inviting atmosphere. In almost every
customer encounter, Starbucks meets or exceeds those expectations. This consistency
does not occur by chance. Starbucks puts a lot of behind-the-scenes work into its customer service. From selecting coffee beans that meet Starbucks’s exacting standards of
quality and flavor to ensuring baristas are properly trained to prepare espresso, every part
of the process is carefully managed.
Providing high-quality healthcare services also requires much work behind the
front lines. Every element in the complex process of healthcare delivery must be carefully
managed. This book explains how healthcare organizations manage the quality of their
care delivery to meet or exceed customers’ expectations. These expectations include delivering an excellent patient care experience, providing only necessary healthcare services, and
doing so at the lowest cost possible.
1.1
WHAT IS QUALITY?
In its broadest sense, quality is an attribute of a product or service. The perspective of the
person evaluating the product or service influences her judgment of the attribute. No universally accepted definition of quality exists; however, its definitions share common elements:
◆
Quality involves meeting or exceeding customer expectations.
◆
Quality is dynamic (i.e., what is
considered quality today may not be
good enough to be considered quality
tomorrow).
◆
*
Quality
Perceived degree of
excellence.
LEARNING POINT
Defining Quality
A quality product or service is one that meets or exceeds expectations. Expectations can change, so quality must be continuously improved.
Quality can be improved.
RELIABILITY
An important aspect of quality is reliability. From an engineering perspective, reliability
refers to the ability of a device, system, or process to perform its prescribed function without failure for a given time when operated correctly in a specified environment (Meeker
2002). Reliability ends when a failure occurs. For instance, your laptop computer is considered reliable when it functions properly during normal use. If it stops functioning—
fails—you have an unreliable computer.
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Reliability
The measurable capability of a process,
procedure, or health
service to perform
its intended function
in the required time
under commonly occurring conditions.
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4
Introduction to Healthcare Quality Management
Consumers want to experience quality that is reliable. Patrons of Starbucks pay a
premium to get the same taste, quality, and experience at every Starbucks location (Clark
2008). James Harrington, past president of the American Society for Quality, cautioned
manufacturers to focus on reliability more than they have in recent years to retain market share. First-time buyers of an automobile are
often influenced by features, cost, and perceived
LEARNING POINT
quality. Repeat buyers cite reliability as the priImportance of Reliability
mary reason for sticking with a particular brand
(Harrington 2009).
A necessary ingredient of quality is reliability, loosely defined as
Reliability can be measured. A reliable
the probability a system will perform properly over a defined
process performs as expected a high proportion
time span. It may be possible to achieve reliability without
of the time. An unreliable process performs as
quality (e.g., consistently poor service), but quality can never
expected a low proportion of the time. Unforbe achieved without reliability.
tunately, many healthcare processes fall into
the unreliable category (Amalberti et al. 2005).
Healthcare processes that fail to consistently perform as expected a high proportion of the time contribute to medical errors that cause up
to 98,000 annual deaths in the United States (Wachter 2010). Healthcare consumers are
no different from consumers of other products and services; they expect quality services
that are reliable.
*
C O S T −Q U A L I T Y C O N N E C T I O N
Value
A relative measure that
describes a product’s
or service’s worth, usefulness, or importance.
We expect to receive value when purchasing products or services. We do not want to find
broken or missing parts when we unwrap new merchandise. We are disheartened when
we receive poor service at a restaurant. We become downright irritated when our banks
fail to record a deposit and our checks bounce.
How you respond to disappointing situations depends on how you are affected by
them. With a product purchase, if the merchandise is expensive, you will likely contact
the store immediately to arrange an exchange or a refund. If the product is inexpensive,
you may chalk it up to experience and vow never to do business with the company again.
At a restaurant, your expectations increase as the price of the food goes up. Yet, if you
are adversely affected—for example, you get food poisoning—you will be an unhappy
customer no matter the cost of the meal. The same is true for banks that make mistakes.
No one wants the hassle of reversing a bank error, even if the checking account is free.
Unhappy clients tend move on to do business with another bank.
Cost and quality affect the customer experience in all industries. But in healthcare, these factors are harder for the average consumer to evaluate than in other types
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Chapter 1: Focus on Quality
5
of business. Tainted restaurant food is easier to recognize than an unskilled surgeon is.
As for cost, everyone agrees that healthcare is expensive, yet, if someone else is paying
for it—an insurance company, the government, or a relative—the cost factor becomes
less important to the consumer. If your surgery does not go well, however, you’ll be an
unhappy customer regardless of what it cost.
In all industries, multiple dynamics influence the cost and quality of products and
services. First, prices may be influenced by how much the consumer is willing to pay. For
example, one person may pay a premium to get the latest and most innovative electronic
gadget, whereas another person may wait until
the price comes down before buying it. If prices
LEARNING POINT
are set too high, potential buyers resist purchasing
Cost–Quality Connection
it, thus affecting sales. Apple Inc. experienced this
phenomenon in January 2007 with the launch of
The cost of a product or service is indirectly related to its perits newest iPhone. Within two months, lagging
ceived quality. A quality healthcare experience is one that
sales of this popular product led Apple to drop
meets a personal need or provides some benefit (either real
the price by $200 (Dalrymple 2007).
or perceived) and is provided at a reasonable cost.
Second, low quality–say, poor customer
service or inferior products—eventually causes
a company to lose sales. The US electronics and
automotive industries faced this outcome in the early 1980s when American consumers
started buying more Japanese products (Walton 1986). Business and government leaders
realized that an emphasis on quality was necessary to compete in a more demanding, and
expanding, world market.
*
Consumer−Supplier Relationship
The consumer–supplier relationship in healthcare is influenced by different dynamics.
For example, consumers may complain about rising healthcare costs, but most are not
in a position to delay healthcare services until the price comes down. If you break your
arm, you immediately go to a doctor or an emergency department to be treated. You are
not likely to shop around for the best price or postpone treatment if you are in severe
pain.
In most healthcare encounters, the insurance companies or government-sponsored
payment systems (such as Medicare and Medicaid) are the consumer’s agent. When healthcare costs are too high, they drive the resistance against rising rates. These groups act on
behalf of consumers in an attempt to keep healthcare costs down. They exert their buying
power by negotiating with healthcare providers for lower rates. In addition, they monitor
billing claims for overuse of services and will not pay the providers—the suppliers—for
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6
Introduction to Healthcare Quality Management
services considered medically unnecessary. If a doctor admits you to the hospital to put a
cast on your broken arm, your insurance company will question the doctor’s decision to
treat you in an inpatient setting. Your broken arm needs treatment, but the cast can be put
on in the doctor’s office or emergency department. Neither you nor the insurance company
should be charged for the higher costs of hospital care if a less expensive and reasonable
treatment alternative is available.
The connection between cost and quality is value. Most consumers purchase a
product or service because they will, or perceive they will, derive some personal benefit
from it. Healthcare consumers—whether patients or health plans—want providers to
meet their needs at a reasonable cost (in terms of money, time, ease of use, and so forth).
When customers believe they are receiving value for their dollars, they are more likely to
perceive their healthcare interactions as quality experiences.
Healthcare quality
Degree to which health
services for individuals and populations
increase the likelihood
of desired health
outcomes and are consistent with current professional knowledge.
Purchasers
Individuals and organizations that pay for
healthcare services
either directly or
indirectly.
Cost-effectiveness
The minimal expenditure of dollars, time,
and other elements
necessary to achieve
a desired healthcare
result.
Providers
Individuals and organizations licensed or
trained to give healthcare.
1.2
HEALTHCARE QUALITY
What is healthcare quality? Each group most affected by this question—consumers,
purchasers, and providers—may answer it differently. Most consumers expect quality in
the delivery of healthcare services: Patients want to receive the right treatments and experience good outcomes; everyone wants to have satisfactory interactions with caregivers; and
consumers want the physical facilities where care is provided to be clean and pleasant, and
they want their doctors to use the best technology available. Consumer expectations are
only part of the definition, however. Purchasers and providers may view quality in terms
of other attributes.
IDENTIFYING
THE
STAKEHOLDERS
IN
QUALITY CARE
Purchasers are individuals and organizations that pay for healthcare services either
directly or indirectly. If you pay out of pocket for healthcare services, you are both a
consumer and a purchaser. Purchaser organizations include government-funded health
insurance programs, private health insurance plans, and businesses that subsidize the cost
of employees’ health insurance. Purchasers are interested in the cost of healthcare and
many of the same quality characteristics that are important to consumers. People who are
financially responsible for some or all of their healthcare costs want to receive value for
the dollars they spend. Purchaser organizations are no different. Purchasers view quality
in terms of cost-effectiveness, meaning they want value in return for their healthcare
expenditures.
Providers are individuals and organizations that offer healthcare services. Provider individuals include doctors, nurses, technicians, and clinical support and clerical
staff. Provider organizations include hospitals, skilled nursing and rehabilitation facilities,
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Chapter 1: Focus on Quality
7
outpatient clinics, home health agencies, and all
? DID YOU KNOW?
other institutions that provide care.
In addition to the attributes important
to consumers and purchasers, providers are
In a consumer message to Congress in 1962, President John F.
concerned about legal liability—the risk that
Kennedy identified the right to be informed as one of four basic
unsatisfied consumers will bring suit against the
consumer rights. He said that a consumer has the right “to be
organization or individual. This concern can
protected against fraudulent, deceitful, or grossly misleading
influence how providers define quality. Suppose
information, advertising, labeling, and other practices, and to be
you have a migraine headache, and your doctor
given the facts he needs to make an informed choice” (Kennedy
orders a CT (computed tomography) scan of
1962). Consumers have come to expect this right as they purchase
your head to be 100 percent certain there are no
goods and services in the marketplace.
physical abnormalities. Your physician may have
no medical reason to order the test, but he is taking every possible measure to avert the possibility
Defensive medicine
that you will sue him for malpractice. In this scenario, your doctor is practicing defensive
Diagnostic or theramedicine—ordering or performing diagnostic or therapeutic interventions primarily to
peutic interventions
safeguard the provider against malpractice liability (Manner 2007). Because these interconducted primarily
ventions incur additional costs, providers’ desire to avoid lawsuits can be at odds with
as a safeguard against
malpractice liability.
purchasers’ desire for cost-effectiveness.
DEFINING HEALTHCARE QUALITY
Before efforts to improve healthcare quality can be undertaken, a common definition
of quality is needed to work from, one that encompasses the priorities of all stakeholder
groups—consumers, purchasers, and providers. The Institute of Medicine (IOM), a nonprofit organization that provides science-based advice on matters of medicine and health,
brought the stakeholder groups together to create a workable definition of healthcare quality. In 1990, the IOM committee charged with designing a strategy for healthcare quality
assurance published this definition:
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.
In 2001, the IOM Committee on Quality of Health Care in America further clarified the concept of healthcare quality in its report Crossing the Quality Chasm: A New Health
System for the 21st Century. The committee identified six dimensions of US healthcare quality
(listed in Critical Concept 1.1), which influence the improvement priorities of all stakeholder groups.
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Institute of Medicine
(IOM)
A private, nonprofit
organization created by
the federal government
to provide sciencebased advice on matters
of medicine and health.
Quality assurance
Evaluation activities
aimed at ensuring compliance with minimum
quality standards.
(Quality assurance and
quality control may be
used interchangeably
to describe actions performed to ensure the
quality of a product,
service, or process.)
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8
Introduction to Healthcare Quality Management
!
CRITICAL CONCEPT 1.1
Six Healthcare Quality Dimensions
• Safe—Care
Safety—Care
intended
intended
toto
help
help
patients
patients
should
should
not
not
harm
harm
them.
them.
• Effectiveness—Care
Effective—Care should
should
be based
be based
on scientific
on scientific
knowledge
knowledge
and provided
and provided
to patients
to
patients
who
could
who
benefit.
couldCare
benefit.
should
Care
not
should
be provided
not be to
provided
patientstounlikely
patientstounlikely
benefit to
from
benit.
efitother
In
fromwords,
it. In other
underuse
words,
and
underuse
overuseand
should
overuse
be avoided.
should be avoided.
• Patient
Patient-centeredness—Care
centered—Care should
should
be respectful
be respectful
of and of
responsive
and responsive
to individual
to individual
patient
patient preferences.
preferences,
needs, and values, and patient values should guide all clinical decisions.
Source: IOM (2001).
• Timely—Care should be provided promptly when the patient needs it.
• Efficient—Waste, including equipment, supplies, ideas, and energy, should be
avoided.
• Equitable—The best possible care should be provided to everyone, regardless of
age, sex, race, financial status, or any other demographic variable.
Source: IOM (2001).
Institute for Healthcare Improvement
(IHI)
An independent, notfor-profit organization driving efforts to
improve healthcare
throughout the world.
The IOM healthcare quality dimensions, together with the 1990 IOM quality-ofcare definition, encompass what are commonly considered attributes of healthcare quality.
Donald Berwick, MD (2005), then president of the Institute for Healthcare Improvement (IHI), put this description into consumer terms when he wrote about his upcoming
knee replacement and what he expected from his providers:
◆
Don’t kill me (no needless deaths).
◆
Do help me and don’t hurt me (no needless pain).
◆
Don’t make me feel helpless.
◆
Don’t keep me waiting.
◆
Don’t waste resources—mine or anyone else’s.
The attribute of reliability is also important in healthcare quality. It is not enough to
meet consumer expectations 90 percent of the time. Ideally, healthcare services consistently
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Chapter 1: Focus on Quality
9
meet expectations 100 percent of the time. Unfortunately, healthcare today does not maintain consistently high levels of quality over time and across all services and settings (Chassin
and Loeb 2011). Quality continues to vary greatly from provider to provider, and inconsistent levels of performance are still seen within organizations. In addition to the goal of
achieving ever-better performance, healthcare organizations must strive for reliable quality.
High-value healthcare
When consumers define healthcare quality, they include high-value healthcare that
Low-cost, high-quality
achieves good outcomes at reasonable prices. Currently, the cost–quality ratio is far from
healthcare.
ideal. Quality shortfalls exist in “areas as diverse as patient safety, the evidence basis for care,
care coordination, access to care, and health disparities” (Smith, Saunders, and Stuckhardt
2012, 92). Inefficiencies resulting from poorly
designed systems unnecessarily increase costs
LEARNING POINT
throughout the healthcare system. For example,
National Quality Strategy Priorities
when previous test results or health records are
not available to the doctor during a patient’s
appointment, duplicate testing can occur. In a
The 2012 Strategy focuses on six priorities:
recent survey, nearly one-quarter of patients said
1. Patient safety
their healthcare provider had to order a previ2. Person- and family-centered care
ously performed test to have accurate information
3. Communication and coordination of care
available for diagnosis (Stremikis, Schoen, and
4. Preventive care
Fryer 2011). Better value in healthcare cannot
5. Community health
be attained until the quality shortfalls are greatly
6. Making care affordable
reduced.
In April 2012, the US Department of
Health and Human Services released the 2012
National Quality
Annual Progress Report to Congress on the National Strategy for Quality Improvement in
Strategy
Health Care. This report details implementation of the National Quality Strategy, which
Document prepared
is designed to pursue three aims: better care, healthy people and communities, and affordby the US Department
able care.
of Health and Human
The National Priorities Partnership, a collaboration of 51 major national organizaServices that helps
tions with a shared vision to achieve a better healthcare system, assists in gathering public
healthcare stakeholders
across the country—
input into the annually updated National Quality Strategy.
*
CONCLUSION
Customers’ perceptions and needs determine whether a product or service is “excellent.”
Quality involves understanding customer expectations and creating a product or service
that reliably meets those expectations. Achieving high quality can be elusive because customer needs and expectations are always changing. To keep up with the changes, quality
must be constantly managed and continuously improved.
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patients; providers;
employers; health insurance companies; academic researchers; and
local, state, and federal
governments—prioritize
quality improvement
efforts, share lessons,
and measure collective
success.
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10
Introduction to Healthcare Quality Management
Healthcare organizations are being challenged to improve the quality, reliability,
and value of services. As shown in Chapter 2, they can achieve this goal through a systematic quality management process.
FOR DISCUSSION
1. In your opinion, which companies provide superior customer service? Which companies
provide average or mediocre customer service? Name the factors most important to you
when judging the quality of a company’s customer service.
2. Think about your most recent healthcare encounter. What aspects of the care or service
were you pleased with? What could have been done better?
3. Review the priorities in the current National Quality Strategy (www.ahrq.gov/working
forquality). Which priority is most important to you as a healthcare consumer, and why?
Which priority do you believe is most important to providers, and why?
4. How does the reliability of healthcare services affect the quality of care you receive?
What type of healthcare service do you find to be the least reliable in delivering a quality
product? What type do you find the most reliable?
WEBSITES
• Agency for Healthcare Research and Quality, Becoming a High Reliability Organization:
Operational Advice for Hospital Leaders
www.ahrq.gov/qual/hroadvice/
• American Society for Quality
www.asq.org
• Institute for Healthcare Improvement
www.ihi.org
• Institute of Medicine
http://iom.edu
• Joint Commission High Reliability Resource Center
www.jointcommission.org/highreliability.aspx
• National Priorities Partnership
www.qualityforum.org/npp/
• National Quality Strategy
www.ahrq.gov/workingforquality
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Chapter 1: Focus on Quality
REFERENCES
Amalberti, R., Y. Auroy, D. Berwick, and P. Barach. 2005. “Five System Barriers to Achieving
Ultrasafe Health Care.” Annals of Internal Medicine 142 (9): 756–64.
Berwick, D. M. 2005. “My Right Knee.” Annals of Internal Medicine 142 (2): 121–25.
Chassin, M. R., and J. M. Loeb. 2011. “The Ongoing Quality Improvement Journey: Next Stop,
High Reliability.” Health Affairs 30 (4): 559–68.
Clark, T. 2008. Starbucked: A Double Tall Tale of Caffeine, Commerce, and Culture. New
York: Back Bay Books.
Dalrymple, J. 2007. “Lessons Learned from the iPhone Price Cuts.” Published September 11.
www.pcworld.com/article/id,137046-c,iphone/article.html.
Harrington, H. J. 2009. “Nice Car . . . When It Runs.” Quality Digest 29 (2): 12.
Institute of Medicine (IOM). 2001. Crossing the Quality Chasm: A New Health System for the
21st Century. Washington, DC: National Academies Press.
———. 1990. Medicare: A Strategy for Quality Assurance: Volume I, edited by K. N. Lohr.
Washington, DC: National Academies Press.
Kennedy, J. F. 1962. “Special Message to the Congress on Protecting the Consumer Interest,
March 15, 1962.” Accessed February 20, 2009. www.jfklink.com/speeches/jfk/publicpapers/
1962/jfk93_62.html.
Manner, P. L. 2007. “Practicing Defensive Medicine—Not Good for Patients or Physicians.”
Accessed November 11, 2012. www.aaos.org/news/bulletin/janfeb07/clinical2.asp.
Meeker, W. Q. 2002. “Reliability: The Other Dimension of Quality.” ASQ Statistics Division
Newsletter 21 (2): 4–10.
Smith, M., R. Saunders, and L. Stuckhardt. 2012. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press.
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11
Copyright © 2013. Health Administration Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted
under U.S. or applicable copyright law.
12
Introduction to Healthcare Quality Management
Stremikis, K., C. Schoen, and A. K. Fryer. 2011. A Call for Change: The 2011 Commonwealth
Fund Survey of Public Views of the U.S. Health System. New York: Commonwealth Fund.
US Department of Health and Human Services. 2012. 2012 Annual Progress Report to Congress on the National Strategy for Quality Improvement in Health Care. Accessed November 1, 2012. www.ahrq.gov/workingforquality.
Wachter, R. 2010. “Patient Safety at Ten: Unmistakable Progress, Troubling Gaps.” Health
Affairs 29 (1): 165–73.
Walton, M. 1986. The Deming Management Method. New York: Putnam Publishing Group.
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CHAPTER 2
QUALITY MANAGEMENT
BUILDING BLOCKS
LEARNING OBJECTIVES
After reading this chapter, you will be able to
➤ describe the three primary quality management activities: measurement,
assessment, and improvement;
➤ recognize quality pioneers’ contributions to, and influence on, the manufacturing
industry;
➤ identify factors that prompted healthcare organizations to adopt quality
practices originally developed for use in other industries; and
➤ describe external forces that influence quality management activities in
healthcare organizations.
13
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14
Introduction to Healthcare Quality Management
KEY WORDS
➤ Accreditation
➤ Accreditation standards
➤ Assessment
➤ Baldrige National Quality Award
➤ Conditions of Participation
➤ Criteria
➤ Data
➤ Harm
➤ Health maintenance organization (HMO)
➤ High-reliability organizations (HROs)
➤ Improvement
➤ Measurement
➤ Misuse
➤ Overuse
➤ Performance expectations
➤ Quality assurance
➤ Quality circles
➤ Quality control
➤ Quality management
➤ Quality planning
➤ Statistical thinking
➤ Underuse
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Chapter 2: Quality Management Building Blocks
Q
uality does not develop on its own. For quality to be achieved, a systematic
evaluation and improvement process must be implemented. In the business
world, this process is known as quality management. Quality management is
a way of doing business that ensures continuous improvement of products and services
to achieve better performance. According to the American Society for Quality (2012),
the goal of quality management in any industry is to achieve maximum customer satisfaction at the lowest overall cost to the organization while continuing to improve the
process.
The authors of the 2001 Institute of Medicine (IOM) report Crossing the Quality Chasm recommend eliminating overuse, underuse, and misuse of services to achieve
maximum customer service in healthcare (Berwick 2002). Overuse occurs when a service is provided even though no evidence indicates it will help the patient—for example,
prescribing antibiotics for patients with viral infections. Underuse occurs when a service
that would have been medically beneficial to the patient is not provided—for example,
performing a necessary diagnostic test. Misuse occurs when a service is not carried out
properly—for example, operating on the wrong part of the patient’s body.
2.1
QUALITY MANAGEMENT ACTIVITIES
Quality management may appear to be a difficult and bewildering undertaking. While
the terminology used to describe the process can be puzzling at first, the basic principles
should be familiar to you. Quality management involves measurement, assessment, and
improvement—activities people perform almost every day.
Consider this example: Most people must manage their finances. You must
measure—that is, keep track of your bank deposits and debits—to know where you stand
financially. Occasionally, you have to assess your current financial situation—that is,
inquire about your account balance—to determine your financial “health.” Can you afford
to go out to dinner, or are you overdrawn? Periodically, you must make improvements—
that is, get a part-time job to earn extra cash or remember to record debit card withdrawals—
so that you do not incur unexpected overdraft charges.
The three primary quality management activities—measurement, assessment, and
improvement—evolve in a closely linked cycle (Exhibit 2.1). Healthcare organizations
track performance through various measurement activities to gather information about
the quality of patient care and support functions. Results are evaluated in the assessment
step by comparing measurement data with performance expectations. If expectations are
met, organizations continue to measure and assess performance. If expectations are not
met, they proceed to the improvement phase to investigate reasons for the performance
gap and implement changes on the basis of their findings. The quality management cycle
does not end at this point, however. Performance continues to be evaluated through measurement activities.
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15
Quality management
A way of doing business that continuously
improves products and
services to achieve
better performance.
Overuse
Provision of healthcare
services that do not
benefit the patient and
are not clearly indicated
or are provided in excessive amounts or in an
unnecessary setting.
Underuse
Failure to provide appropriate or necessary
services, or provision of
an inadequate quantity
or lower level of service
than that required.
Misuse
Incorrect diagnoses,
medical errors, and
other sources of avoidable complications.
Measurement
Collection of information for the purpose of
understanding current
performance and seeing how performance
changes or improves
over time.
Assessment
Use of performance
information to determine whether an
acceptable level of quality has been achieved.
Improvement
Planning and making
changes to current
practices to achieve
better performance.
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16
Introduction to Healthcare Quality Management
EXHIBIT 2.1.
Cycle of
Measurement,
Assessment, and
Improvement
Measurement
How are we doing?
Yes
Assessment
Are we meeting
expectations?
No
Improvement
How can we improve
performance?
Data
Numbers or facts that
are interpreted for the
purpose of drawing
conclusions.
Performance
expectations
Minimum acceptable or
desired level of quality.
The financial management example used earlier to explain quality management
vocabulary also may help clarify basic quality management techniques. For instance, when
you review your expenditures on leisure activities over the last six months, you are monitoring performance—looking for trends in your spending habits. If you decide to put 10 percent of your income into a savings account each month, you are setting a performance goal.
Occasionally, you check to see whether you have achieved your goal; in other words, you
are evaluating performance. If you need to save more money, you implement an improvement plan. You design a new savings strategy, implement that strategy, and periodically
check your progress. Application of these techniques to healthcare quality management is
covered in later chapters.
QUALITY MANAGEMENT MILESTONES
AND HEALTHCARE
2.2
Harm
An outcome that
negatively affects a
patient’s health or
quality of life.
IN
INDUSTRY
The concept of quality management is timeless. To stay in business, manufacturing and
service industries have long sought better ways of meeting customer expectations. Healthcare professionals live by the motto primum non nocere—first, do no harm. To fulfill this
promise, discovering better ways to care for patients has always been a priority. Although
the goal—quality products and services—is the same regardless of the industry, methods
for achieving this goal in healthcare have evolved differently than in other industries.
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Chapter 2: Quality Management Building Blocks
17
INDUSTRIAL QUALITY EVOLUTION
The contemporary quality movement in the manufacturing industry can be traced to the
work of three men in the 1920s at Western Electric Company in Cicero, Illinois. Walter
Shewhart, W. Edwards Deming, and Joseph Juran learned and applied the science of
quality improvement to the company’s production lines (ASQ 2012). Shewhart used statistical methods to measure variations in the telephone equipment manufacturing process.
Waste was reduced and product quality was improved by controlling undesirable process
variation. Shewhart is referred to as the father of statistical quality control, a method we
explore in Chapter 4.
Deming (1994) learned Shewhart’s methods and made measurement and control
of process variation a key element of his philosophy of quality management:
◆
Organizations are a set of interrelated
processes with a common aim.
◆
Process variation must be understood.
◆
How new knowledge is generated
must be understood.
consultant, transformed traditional industrial thinking about
How people are motivated and work
together must be understood.
mance feedback, and measurement-based quality management.
◆
?
DID YOU KNOW?
In the 1950s, W. Edwards Deming, a professor and management
quality control by emphasizing employee empowerment, perfor-
Following World War II, Japanese manufacturing companies invited Deming to
help them improve the quality of their products. Over a period of several years, as a result
of Deming’s advice, many low-quality Japanese products became world class. The Deming
model for continuous improvement is described in Chapter 5.
Juran combined the science of quality with its practical application, providing a
framework for linking finance and management. The components of that framework, the
Juran Quality Trilogy, are as follows (Uselac 1993):
◆
Quality planning—define customers and how to meet their needs
◆
Quality control—keep processes working well
◆
Quality improvement—learn, optimize, refine, and adapt
In the 1950s, Juran, like Deming, helped jump-start product improvements at
Japanese manufacturing companies. Whereas Deming focused on measuring and controlling process variation, Juran focused on developing the managerial aspects supporting
quality. One of Juran’s management principles—focusing improvements on the “vital
few” sources of the problems—is described in Chapter 4.
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Quality planning
Setting quality objectives and specifying
operational processes
and related resources
needed to fulfill the
objectives.
Quality control
Operational techniques
and activities used to
fulfill quality requirements. (Quality control
and quality assurance
may be used interchangeably to describe
actions performed to
ensure the quality of
a product, service, or
process.)
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18
Quality circles
Small groups of
employees organized
to solve work-related
problems.
Criteria
Standards or principles
by which something is
judged or evaluated.
Baldrige National
Quality Award
Recognition conferred
annually by the Baldrige National Quality
Program to US organizations demonstrating
performance excellence, including healthcare organizations.
Introduction to Healthcare Quality Management
Another individual who had a significant impact on contemporary quality practices in industry was Kaoru Ishikawa, a Japanese engineer who incorporated the science of
quality into Japanese culture. He was one of the first people to emphasize the importance
of involving all members of the organization rather than management-level employees
only. Ishikawa believed that top-down quality goals could be accomplished only through
bottom-up methods (Best and Neuhauser 2008). To support his belief, he introduced the
concept of quality circles—groups of 3 to 12 frontline employees that meet regularly to
analyze production-related problems and propose solutions (Ishikawa 1990).
Ishikawa stressed that employees should be trained to use data to measure and
improve processes that affect product quality. Several of the data collection and presentation techniques he recommended for process improvement purposes are covered in
chapters 4 and 6. The science of industrial quality focuses on improving the quality of
products by improving the production process. Improving the production process means
removing wasteful practices, standardizing production steps, and controlling variation
from expectations. These methods have been proven effective and remain fundamental to
industrial quality improvement. The work of Shewhart, Deming, and Ishikawa laid the
foundation for many of the modern quality philosophies that underlie the improvement
models described in Chapter 5.
Following World War II, US manufacturers were under considerable pressure to
meet production schedules, and product quality became a secondary consideration. Recognizing the consequences of these lags in quality, in the 1970s, US executives visited
Japan to discover ways to improve product quality. During these visits, Americans learned
about the quality philosophies of Deming, Juran, and Ishikawa; the science of industrial
quality; and the concept of quality control as a management tool. In 1980, NBC aired a
television program titled If Japan Can . . . Why Can’t We? which described how Japanese
manufacturers had adopted Deming’s approach to continuous improvement, most notably his focus on variation control (Butman 1997, 163). As a result, many US companies
began to emulate the Japanese approach. Several quality gurus emerged, each with his own
interpretation of quality management. During the 1980s, Juran, Deming, Philip Crosby,
Armand Feigenbaum, and others received widespread attention as philosophers of quality
in the manufacturing and service industries.
In 1987, President Ronald Reagan signed into law the Malcolm Baldrige National
Quality Improvement Act (NIST 2010). This national quality program, managed by the
US Commerce Department’s National Institute of Standards and Technology, established
criteria for performance excellence that organizations can use to evaluate and improve
their quality. Many of these criteria originated from the quality philosophies and practices
advanced by Shewhart, Deming, Juran, and Ishikawa. The annual Baldrige National
Quality Award was also created to recognize US companies that meet the program’s
stringent standards. For the first ten years of the award’s existence, eligible companies
were limited to three categories: manufacturing, service, and small business. In 1998, two
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Chapter 2: Quality Management Building Blocks
categories—education and healthcare—were added. The core values and concepts of the
Baldrige Health Care Criteria are described in Critical Concept 2.1. In 2002, SSM Health
Care, based in St. Louis, became the first healthcare organization to win the Baldrige
National Quality Award.
!
CRITICAL CONCEPT 2.1 Core Values and Concepts in the Baldrige
Health Care Criteria for Performance Excellence
• Safety—Care
Visionary
Leadership:
intended
Senior
to help
leaders
patients
set directions
should not
andharm
create
them.
a patient focus, clear and
visible values, and high expectations. The directions, values, and expectations should
• Effectiveness—Care should be based on scientific knowledge and provided to
balance the needs of all stakeholders. The leaders need to ensure the creation of stratepatients who could benefit. Care should not be provided to patients unlikely to bengies, systems, and methods for achieving excellence in health care, stimulating innovaefit from it. In other words, underuse and overuse should be avoided.
tion, and building knowledge and capabilities.
• Patient-centeredness—Care should be respectful of and responsive to individual
Patient Focus: The delivery of health care services must be patient focused. All attitudes
patient preferences.
of patient care delivery (medical and non-medical) factor into the judgment of satisfaction
and value. Satisfaction and value are key considerations for other customers too.
Source: IOM (2001).
Organizational and Personal Learning: Organizational learning refers to continuous
improvement of existing approaches and processes and adaptation to change, leading to
new goals and/or approaches. Learning is embedded in the operation of the organization.
Valuing Staff and Partners: An organization’s success depends increasingly on the
knowledge, skills, creativity, and motivation of its staff and partners. Valuing staff
means committing to their satisfaction, development, and well being.
Agility: A capacity for rapid change and flexibility [is] a necessity for success. Health care
providers face ever-shorter cycles for introductions of new and improved health care services. Faster and more flexible response to patients and other customers is critical.
Focus on Future: A strong future orientation includes a willingness to make long term
commitments to key stakeholders—patients and families, staff, communities, employers, payers, and health profession students. Important for an organization in the strategic planning process is the anticipation of changes in health care delivery, resource
availability, patient and other stakeholder expectations, technological developments,
new partnering opportunities, evolving regulatory requirements, community/societal
expectations, and new thrust by competitors.
(Continued)
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19
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20
Introduction to Healthcare Quality Management
!
CRITICAL CONCEPT 2.1 (Continued) Core Values and Concepts
in the Baldrige Health Care Criteria for Performance Excellence
• Safety—Care
Management
forintended
Innovation:
to help
Innovation
patientsisshould
making
notmeaningful
harm them.change to improve an
organization’s services and processes and create new value for the organization’s stake• Effectiveness—Care should be based on scientific knowledge and provided to
holders.
patients who could benefit. Care should not be provided to patients unlikely to benManagement
efit from it. by
In other
Fact:words,
Measurement
underuseand
andanalysis
overuse of
should
performance
be avoided.
[are] needed for
an effective health care and administrative management system. Measurements are
• Patient-centeredness—Care should be respectful of and responsive to individual
derived from the organization’s strategy and provide critical data and information about
patient preferences.
key processes, outputs, and results.
Source:
(2001).
PublicIOM
Responsibility
and Community Health: Leaders need to emphasize the responsi-
bility the organization has to the public and need to foster improved community health.
Focus on Results and Creating Value: An organization’s performance measurements
need to focus on key results. Results should focus on creating and balancing value for all
stakeholders—patients, their families, staff, the community, payers, businesses, health
profession students, suppliers and partners, stockholders, and the public.
Systems Perspective: Successful management of an organization requires synthesis
and alignment. Synthesis means looking at the organization as a whole and focusing on
what is important while alignment means concentrating on key organizational linkages
among the requirements in the Baldrige Criteria.
Source: Reprinted with permission from Spath, P. L. 2005. Leading Your Healthcare Organization to Excellence: A
Guide to Using the Baldrige Criteria. Chicago: Health Administration Press, 23–25. All rights reserved. Copyright 2005.
HEALTHCARE QUALITY EVOLUTION
Until the 1970s, the fundamental philosophy of healthcare quality management was based
on the pre–Industrial Revolution craft model: Train the craftspeople (e.g., physicians,
nurses, technicians), license or certify them, supply them with an adequate structure (e.g.,
facilities, equipment), and then let them provide health services (Merry 2003). In 1913,
the American College of Surgeons (ACS) was founded to address variations in the quality
of medical education. A few years later, it developed the hospital standardization program to address the quality of facilities in which physicians worked. Training improvement efforts were also under way in nursing; the National League for Nursing Education
released its first standard curriculum for schools of nursing in 1917.
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