BHM 320 Quality Management and Accountability

QUALITY MANAGEMENT AND ACCOUNTABILITY
Case Assignment
Please read the following article:

A physical examination of health care’s readiness for a total quality management program: A case study by Weeks, Helms, and Ettkin. Once you have finished the article, read the following case: Quality Improvement Program Intervention.

Using the information you gleaned from both articles, please discuss the following issues:

Provide a brief overview of the quality improvement process. Be sure to give examples and to specifically discuss what quality improvement teams are.
The article you read indicated that there needs to be an agreement and understanding between employees and managers for successful quality programs. Discuss this aspect of the case study (e.g. did this occur, what understanding do you think each group had, etc).
What steps did the manager take to implement the improvement process? What steps did he do correctly? Which ones did not work?
What recommendation do you think Joe made? Do you agree?
If you were the manager of this unit, what would you have done differently to implement the process

Module Overview
Introduction: Quality Management & Accountability

Outside of the healthcare industry, quality is defined as exceeding customer expectations. In applying Total Quality Management (TQM) and Continuous Quality Improvement (CQI) in healthcare, experts have viewed customer satisfaction as one dimension of quality. TQM and CQI have emerged in Europe over the last ten years as a distinct approach to improving quality which may be more cost-effective than other approaches. Accountability is critical in evaluating the effectiveness of healthcare programs. In today’s current healthcare system, accountability must be determined to ensure quality and economically feasible healthcare services are available.

In this module, we will discuss the general concepts and mechanics of TQM and CQI and how these apply to the assessment of quality and accountability in today’s healthcare delivery system. Several examples of TQM implementation will be provided throughout this module. Accountability in healthcare programs and healthcare service organizations to ensure the provision of quality patient-centered services will be discussed.

Quality Management and Accountability

Outside of the healthcare industry, quality is defined as exceeding customer expectations. In applying TQM in healthcare, experts have viewed customer satisfaction as one dimension of quality:

Patient Quality: whether the service gives patients what they want;
Professional Quality: professionals’ views of whether the service meets patients’ needs as assessed by professionals (outcome is one measure), and, whether personnel correctly select and carry out procedures which are believed to be necessary to meet patient’s needs, (process);
Management Quality: the most efficient and productive use of resources to meet client needs, without waste and within limits and directives set by higher authorities. (Ovretveit,1992)
TQM and CQI have emerged in Europe over the last ten years as a distinct approach to improving quality which may be more cost-effective than other approaches. It is useful to distinguish between two aspects of TQM:

TQM as an organization-wide approach and philosophy with a strategy for organization and personnel development, a quality management and information structure. An example of this aspect of TQM is the “Baldridge” Quality Award Framework and its many variations (i.e., EFQM, SUK, QUL, NKP, and FQA).
Quality team methods and frameworks for process improvement.
In European healthcare many different activities are carried out under the name of total quality management. Two definitions distinguish TQM from other approaches. TQM is has been defined as, “A comprehensive strategy of organizational and attitude change, for enabling personnel to learn and use quality methods, in order to reduce costs and meet the requirements of patients and other “customers” (Ovretveit, 1996).

A definition given by US theorists emphasizes that TQM is a management method: “TQM/CQI is simultaneously two things: a management philosophy and a management method”. They propose four “distinguishing characteristics or functions”, which are “often defined as the essence of good management:

empowering clinicians and managers to analyze and improve process;
adopting a norm that customer preferences are the primary determinants of quality and the term “customer ” includes both the patients and providers in the process;
developing a multidisciplinary approach which goes beyond conventional departmental and professional lines; and
providing motivation for a rational, data-based cooperative approach to process analysis and change” (McLaughlin and Kalunzny (1992).
Main components of TQM – Another way to define TQM is in terms of different “components”, and this type of definition can help to assess the degree to which an organization has adopted TQM:

Customer focus- internal and external
Process analysis
Quality project teams
Simple methods used in a systematic way to analyze quality problems, plan change, and evaluate the results.
Data to identify and analyze problems and to evaluate the results of change
Change implementation (i.e., the most difficult of these components to carry out in healthcare, because of complexity and because of the power and autonomy of many professions)
Some theorists take the view that TQM should also involve a system perspective, working to control unwanted variation in process performance using statistical process control methods (SPC), as well as Quality Function Deployment to match customer needs to organizational capability (Ishikawa, 1992)

TQM and Diversity

One cannot discuss quality and satisfaction within the context of any healthcare institution and/or the services it renders to staff and patients, without being aware to and address diversity issues.

Through the doors of the establishment pass a multitude of people each coming from a different and unique background. It is common today to see signs in more than one language, to have paperwork and informed consent forms in multiple languages, and to have a diverse workforce that can communicate with patients, customers, and visitors, and tend to their unique needs.

Therefore, in any operation carried out in a healthcare environment, one should plan ahead to ensure that process and procedure should be understandable to all participants, and that resources could be fully utilized by everyone in a safe and efficient manner.

Example of a TQM project

This project illustrates a simple 9 phase sequence which a team worked through to analyze and implement a solution to a quality problem (the T-QIS framework). An anesthetist working in a Norwegian hospital believed that the number of cancelled and delayed elective surgical operations was unnecessarily high. He had attended a course on TQM methods and the hospital had recently started a quality program. He got support from the managers of surgery and the operating room to start a team project. A team was formed which met every two weeks.

The team specified the problem and investigated the possible causes of delays. They did this by listing possible causes and then collecting data over three months about the different causes, for example, “patient too unwell for surgery”, “surgeon unavailable”, and “patient records unavailable”.

The “change intervention” which they made was simply to present the data about the number of cancellations and delays to meetings of the personnel who managed and worked in the operating room. They described the measurement system they had developed and how it would continue to be used to collect the data.

The table below shows how the number of cancelled operations was reduced. Collecting and presenting data to the personnel had motivated them to make changes.

1st March to 30th May 1997
1st January to 31st March 1998
Total elective procedures
1045
1125
Canceled operations
100 (9.6%)
83 (7.4%)
Avoidable cancellations
78 (7.5%)
54 (4.8%)
This work laid the basis for further work by the team to describe and analyze the operating room process. This was necessary because, over time, the simple problems which caused cancellations and delays had been solved by personnel and the more deep-seated problems then needed a more detailed analysis and change program (Ovretveit & Aslaksen 1999).

Example of a hospital wide TQM program

Probably one of the most successful TQM hospital programs has been that of in the Reiner de Graaf Gasthuis, in The Netherlands. The hospital director describes the decision to introduce TQM methods and culture in 1992 as being due to the lack of success in solving chronic problems characteristic of hospitals in general, such as long waiting times, lost X-Ray pictures and records, poor service attitudes towards patients, “blame-shifting” between departments and between employees and doctors, and inefficiencies. There were also gradually reducing budgets, and a need to cut costs. The hospital started with 7 demonstration projects, which were only partially successful.

In 1994, they started a strategic quality planning process to concentrate on key strategic areas, and focused on 8 key processes in the hospital. The project teams used a twelve-step TQM approach within the four phases of, “project definition and organization, diagnosis, planning, and holding the gains”. The following lessons emerged from this experience.

Cooperation between specialists and departments does not come naturally or as a result of exhortation.
Process analysis by a multidisciplinary team develops specialists understanding of how their work interrelates, and of where the problems occur. If the specialists take part in mapping the process and then in redesigning it, it makes it easier for them to agree changes which they would otherwise find “inconvenient”.
A structured team improvement process makes it possible to work methodically through the necessary stages to achieve measurable improvements.
Team facilitation by an expert is important if the team is to follow the steps and to use the methods correctly.
Reflecting on four years of the TQM program, the hospital director emphasized the following lessons.

Earlier project teams failed because they did not have trained facilitators or good team leaders, they met infrequently rather than for 1 hour every week, they did not follow the structured methods and jumped to conclusions too early, and doctors did not attend.
Each project team must have a “sponsor” from the high-level quality council, who supervises the team and helps with problems.
It is important to develop quality measures, for the projects and also as routine indicators.
Developing good training materials in your own language is important.
Source: Dr. John Ovretveit, Professor of Health Policy and Management, The Nordic School of Public Health, Box 12133, Goteborg, 40242, Sweden and Faculty of Medicine, Bergen University, Norway.

Steps to TQM

Deming has outlined 14 steps that managers can take to implement a Total Quality Management program:

Constancy of Purpose
Create a constancy of purpose for improvement of products and services
This requires
Innovation
Investment in research and education
Continuous improvement of products and services
Maintenance of equipment
New Philosophy
Adopt a new philosophy
Management must undergo a transformation and begin to believe in quality
products and services
Inspections
Cease dependence on mass inspections
Inspections should help identify ways to improve processes
Price Tag
Avoid awarding business on price tag alone
Lowest priced goods are not always the highest quality
Decide on suppliers based on record of improvements and commitment
Constant Improvement
Constantly improve the system of product and service
Improvement is not a one-time effort
Lead the organization into a practice of continuous improvement
Training
Institute training and retraining
Teach new skills to employees
Help employees recognize how to do their jobs correctly
Leadership
Institute leadership
Discover barriers to performance
Help employees take pride in work
Fear
Drive out fear
People should not fear reprisal or if they create waves; should feel free to take risks
Create an environment where workers can express concerns confidentially
Barriers
Break down barriers between staff
Promote teamwork
Foster interrelationships among departments
Exhortations
Avoid slogans, exhortations and targets
Employees may be offended
Discover and learn real ways of motivating employees
Quotas
Eliminate numerical quotas
Quotas impede quality
Quotas do not leave room for improvement
Workers need flexibility
Workmanship
Remove barriers to pride of workmanship
Employees should receive respect and feedback
Vigorous Program
Institute a vigorous program of education and training
With continuous improvement job descriptions may change
Employees should be trained for new responsibilities
Transformation
Take action to accomplish transformation
Management must work as a team to carry out the previous 13 steps
The Cost of Quality

Measuring the Costs of Quality

Cost Control
Cut-backs threaten quality
Costs can be saved by improving quality
Improved quality generates increased volume
Improved quality reduces costs of patient care
What is Considered Quality?
Products that meet consumer expectations
Expectations vary
Products that meet performance standards?
Good Value for Money
In healthcare everyone wants the best
We must distinguish between product quality and service quality
Product Quality
Design Quality
Higher design quality means higher cost
Lower design quality means lower cost
Conformance Quality
Meeting design standards
Service Quality
Generally, healthcare organizations provide services rather than products
Objective measurement of service quality is difficult
Can one measure the bedside manner of a nurse?
Is quality limited to outcomes?
Dimensions of Service Quality
Reliability
Tangibles
Responsiveness
Assurance
Empathy
Costs of Quality
Internal Failure Costs
External Failure Costs
Appraisal Costs
Prevention Costs
Internal Failure Costs
Costs that result from failing to meet specifications
Example: Inpatient is returned to the radiology department for repeat x-rays
Failure costs include:
Extra x-ray film
Additional power
Time of x-ray technologist
Extra transport
External Failure Costs
Similar to internal failure costs, they are the costs that result from failure to meet specifications
Example: Surgical patient is discharged and must return from home for follow-up/corrective surgery
Failure costs include:
Extra OR time
Extra salaries
Extra supplies
Malpractice
Appraisal Costs
Money spent to uncover failure or defects
Example: Testing a batch of x-ray film to ensure quality before use with patients
Prevention Costs
Money spent on preventing failure
Example: Monthly service of equipment
Example: Paying for continuing education or professional training
Total Costs Related to Quality
Quality costs will never be zero because:
Errors are common and cost $$
Prevention of errors costs $$
Organizations can only strive to minimize the costs related to quality
One dollar spent on prevention is worth more in terms of saving failure costs

Required Readings

Kennedy, D., Caselli, R., Berry, L., & Mishra, P.. (2011). A Roadmap for Improving Healthcare Service Quality/PRACTITIONER APPLICATION. Journal of Healthcare Management, 56(6), 385-400; discussion 400-2.

James, B., & Savitz, L.. (2011). How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts. Health Affairs, 30(6), 1185-1191.

Chassin, M., Loeb, J., Schmaltz, S., & Wachter, R.. (2010). Accountability Measures — Using Measurement to Promote Quality Improvement. The New England Journal of Medicine, 363(7), 683-8.

Larson, J. S. & Muller, A. (2002). Managing the Quality of Healthcare. Journal of Health and Human Services Administration. Harrisburg: Winter 2002/2003. Vol. 25, Iss. 3/4; p. 261.

Miller, N. (2000). Seeking accountability. Nursing Economics; Pitman; Mar/Apr 2000.

Nat Natarajan, R. (2006). Transferring best practices to healthcare: opportunities and challenges. The TQM Magazine. Bedford: 2006. Vol. 18, Iss. 6; p. 572.

Robinson, P. (2004). Master the steps to performance improvement. Nursing Management.Chicago: May 2004. Vol. 35, Iss. 5.

Scott, G. (2001). Accountability for service excellence. Journal of Healthcare Management; Chicago; May/Jun 2001.

Weeks, Brenda, Helms, Marilyn M, & Ettkin, Lawrence P. (1995). A physical examination of health care’s readiness for a total quality management program: A case study. Hospital Materiel Management Quarterly, 17(2), 68.
Required Readings
Kennedy, D., Caselli, R., Berry, L., & Mishra, P.. (2011). A Roadmap for Improving Healthcare Service Quality/PRACTITIONER APPLICATION. Journal of Healthcare Management, 56(6), 385-400; discussion 400-2.