Healthcare Quality Concepts

8/14/2019 Healthcare Quality Concepts

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CPHQ

Preparation Course



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Quality Management Trilogy

Quality Planning

Quality Control

Quality Improvement



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The Quality Management Trilogy

Quality Planning includes:– Identifying and tracking customers, their needs and

expectations.

– Designing new or redesigning systems, services, or

functions based on customer needs and expectations.– Identifying function and process issues critical to

effective outcomes; and developing new processescapable of achieving the desired outcome.

– Setting quality improvement objectives based onstrategic goals.



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The Quality Management Trilogy

Quality Improvement includes:– Collaboratively studying and improving selected

existing processes and outcomes in governance,management, clinical, and support activities;

– Analyzing causes of process failure, dysfunction,and/or inefficiency;

– Systematically developing optimal solutions to chronicproblems;

– Analyzing data/information for better or best practice.



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The Quality Management Cycle, based on Juran's QualityTrilogy (quality planning, quality control, quality improvement)

a. excludes the lab's activities to monitor equipment.

b. requires a departmentalized approach to quality

management.

c. encompasses only the non clinical aspects of QM.

d. incorporates information from strategic planning.



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That function in the Juran Quality Management Cycle that includesthe initial analysis of data/information is

a. quality planning.

b. quality initiatives.

c. quality control/measurement.

d. quality improvement.



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Quality Management Principles

Leadership commitment is the Key.

Focus on systems not on individuals.

All decisions are based on information derived fromreliable data.

Quality is what is perceived by the customer as quality.

Quality management is preventive and proactive notreactive or a quick fix.



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Quality empowers people; it does not police them.

The modern approach to quality is thoroughly

grounded in scientific and statistical thinking.

Total employee involvement is critical.

Sound customer-supplier relationships are absolutelynecessary for sound quality management.



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Productive work is accomplished through effectivestructure and efficient processes.

Defects in quality come from problems in

processes. Understanding the variability ofprocesses is a key to improving quality.

Quality measurement should focus on the most

vital processes.

Poor quality is costly.



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The major difference between traditional "quality assurance" activitiesand the expanded quality improvement/performance improvementactivities is the QI/PI focus on

a. people and competency.

b. analysis of data.

c. performance measures.

d. systems and processes.



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In the transition from quality assurance to qualitymanagement/quality improvement, which of the following emphaseshas resulted in the most significant benefit?

a. Focusing primarily on process rather than individualperformance

b. Focusing on organizationwide rather than clinicalprocesses

c. Organizing activities around patient flow rather thandepartment or discipline

d. Initiating more prospective rather than retrospectiveimprovement efforts



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Structure, Process, and Outcome

Structure

leads to

Process

leads to

Outcome



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Structure: is the arrangement of parts of a care system orelements that facilitate care; the care environment;evidence of the organization's ability to provide care topatients, e.g.:

• Resources

• Equipment

• Numbers of staff

• Qualifications/credentials of staff

• Work space



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Process: refers to the procedures, methods, means, orsequence of steps for providing or delivering care andproducing outcomes. In other words, processes areactivities that act on an "input" from a "supplier" to

produce an "output" for a "customer" e.g.- Clinical Processes

- Care Delivery Processes

- Administrative and Management Processes



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Outcome: refers to the results of care, adverse orbeneficial e.g.

Clinical:

- Short-term results of specific treatments andprocedures

- Complications - Adverse events - Mortality

Functional:

- Long-term health status

- Activities of daily living (ADL) status

Perceived:

- Patient/family satisfaction



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Monitoring the specific organization and content requirementsof a medical record system is a review of which focus?

a. Outcome of care

b. Process of care

c. Structure of care

d. Administration of care



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Monitoring phlebitis associated with IV insertions by nursesin the Surgical Intensive Care Unit addresses which focus?

a. Outcome of care

b. Process of care

c. Structure of care

d. Administrative procedure

Whi h f th f ll i b t d ib th f l



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Which of the following best describes the successfuloutcome of the quality improvement process?

a. Customer satisfaction

b. Enhanced communication

c. Employee empowerment

d. Improved statistical data



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What is the most important relationship between structure,process, and outcome as types of indicators of quality?

a. Interdependent: Structure directly affects both processand outcome.

b. Causal: Structure leads to process and process leads to

outcome.

c. Relational: Useful for comparisons, but not causal

d. There is no relationship; they are categories used to

group indicators.



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The Concept of Process Variation

Variation is "change or deviation in form, condition,appearance, extent, etc., from a former or usual state, orfrom an assumed standard." "Variation" generallyrefers to the whole process or a step in the process.

Variance is "a changing or tendency to change; degree ofchange or difference; divergence; discrepancy." Thisterm generally refers to specific data or information.



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Clinical Variation

Variation in clinical practice has been defended in thepast as the "art" of medicine.

In fact, variation can be either positive or negative.

In healthcare quality, we tend to think of variation as

negative or adverse, based on the quality assurancecase-specific review tradition.

Sometimes the art of medicine creates a "best practice,"which we now try to capture and replicate as part of

quality improvement process.

P V i ti



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Process Variation1. Common Causes

Random or common cause:– Intrinsic to the process itself;

– naturally occurring inliers.

" Example: patient response to medication will always vary,

within the cohort of patients and even for one patient overtime.“

Common causes" refer to situations, usually withinpatient care systems and processes (within the normal,bell-shaped curve) that are more ongoing, chronic, and

persistent.These common causes contribute to the "normal range of

variation" within a process.

P V i ti



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Process Variation1. Common Causes Cont.

The goal of quality improvement is not to eliminate, butto reduce variation in a process enough to produce andsustain "stability.“

Common causes may also contribute to what are

considered to be the less than desirable parts of a process.

Usually finding and resolving common causes ofproblems or variation is more time-consuming and maybe more difficult for departments, services,

The resolution of common causes of problems is oftenconsidered to be key, however, to continuous, incrementalimprovement of the quality of care and services renderedto patients

P V i ti



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Process Variation2. Special Cause

Special cause:

– Extrinsic to the usual process;

– related to identifiable patient or clinical characteristics,

– idiosyncratic practice patterns, or other factors that can be tracked("assigned") to root causes.

"Special causes" refer to sentinel events, one-time occurrences, orother unique, out-of-the-ordinary circumstances that give rise to avariation from what is normally expected.

Special causes are usually more easily identified and resolved,either by departments or QI teams.

Special causes account for the majority of what we call "outliers"-those problems that occur in the "tails" of a normal, bell-shapedcurve representing a particular process.



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Statistical Process Control

Walter Shewhart's causes of variation led him to develop a

methodology to chart the process and quickly determine when aprocess is "out of control.

This ongoing measurement and analysis is known as "statisticalprocess control (SPC)."

As long as assignable or special causes of variation exist, we cannot

make accurate predictions about process performance and probableoutcome.

Once assignable causes are eliminated, we can call the process"stable" and can measure the "capability of the process" by rates ofdeficiencies or rates of achievement of desired outcomes.

At this point we have the data we need to perform the in-depthanalysis that leads to improvement. [See also "Statistical ProcessControl" and Control Chart in "Graphic Representations ofComparison Data,"



Examples of application of the Pareto



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Examples of application of the ParetoPrinciple

20% of the possible reasons for dissatisfaction with an

ambulatory clinic are responsible for 80% of the recordeddissatisfaction on the survey, enabling the QI team toprioritize improvement efforts..

80% of a physician's practice or a hospital's admissions isaccounted for by 20% of the classes of diagnosesproviding a focus for practice guidelines and diseasemanagement..

20% of a healthcare organization's patients account for80% of the case managers' time, again providing data forprioritizing the development of clinical paths anddisease management protocols.

"Common causes" of problems in processes



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Common causes of problems in processesrefer to

a. one-time situations.

b. temporary situations.

c. acute situations.

d. chronic situations.

Applying the Pareto Principle in quality



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Applying the Pareto Principle in qualityimprovement is

a. prioritizing process issues.b. tracking and measuring process effectiveness.

c. providing meaningful data to support strategicobjectives.

d. prioritizing patient outcome issues.



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Special cause variation is to the process

a. random, extrinsic, outlier.

b. assignable, intrinsic, noise.

c. random, inlier, identifiable.

d. assignable, extrinsic, outlier.

When common cause process variation is



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When common cause process variation isidentified, the goal of quality improvement is to

a. promote compliance with established procedure orprotocol.

b. eliminate the variation.

c. improve practitioner competency.d. reduce variation sufficiently to produce stability.



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In statistical process control, it is important to first

a. eliminate assignable causes of variation.b. eliminate random causes of variation.

c. prioritize causes of variation.

d. eliminate all causes of variation.

Th C t f O t M t



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The Concept of Outcomes Management

“Outcomes Management" refers to a "technology of patient experience designed to help patients, payers, and providers make rational medical care-related choicesbased on better insight into the effect of these choices onthe patient's life" [Ellwood, 1988].

The resulting data, called outcome measures, aremeasures of performance.

O t t h ld i t f



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Outcomes management should consist of

A common language of health outcomes, understoodby patients;.

A national reference database containing informationand analysis on clinical, financial, and healthoutcomes, estimating:-

– Relationships between medical interventions andhealth outcomes –

– Relationships between health outcomes and moneyspent.

– Opportunity for decision-makers to access analysisrelevant in making choices.

Outcomes management depends on the



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Outcomes management depends on thefollowing four developing techniques

1. Practitioner reliance on standards and guidelines in

selecting appropriate interventions

2. Routine and systematic measurement of thefunctioning and well-being of patients, along with

disease-specific clinical outcomes, at appropriate timeintervals

3. Pooling of clinical and outcome data on a massive

scale

4. Analysis and dissemination of results (outcomes) fromthe segment of the database pertinent to the concerns

of each decision maker

The task of setting up an ambulatory care setting QM/QI



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g p y gprogram that focuses on "outcomes" as a measure of treatmenteffectiveness is difficult because:

a. the patient remains in control of treatment.b. patient care outcomes are determined by the payer.

c. there are no required medical records.

d. expected outcomes for ambulatory conditions are tooobvious.

The centerpiece of "outcomes management" in



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The centerpiece of outcomes management inhealthcare is

a. the measurement of the patient's functionalityand quality of life.

b. morbidity and mortality.

c. data reliability.

d. financial impact.

S i i



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System Thinking

A body of principles, methods, and tools focused on

the interrelatedness of forces in systems operating fora common purpose.-

The belief that the behavior of all systems followscertain common principles, the nature of which canbe discovered, articulated, understood, and used tomake change.

According to David Mc Camus, former chairman and

CEO of Xerox Canada, systems thinking "requires'peripheral vision': the ability to pay attention to theworld as if through a wide-angle, not a telephotolens, so you can see how your actions interrelate withother areas of activity"

D fi iti



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Definitions

System: perceived whole whose elements 'hang together' because they

continually affect each other over time and operate towarda

common purpose"

Systemic structure: Not just the organizational chart, but the patternof interrelationships among all key components of the system:

– Process flows-

– Attitudes and perceptions-

– Quality of products and services –

– Ways in which decisions are made –

– Hierarchy, and

Systemic structures may be visible or invisible, built consciously orunconsciously based on choices and decisions made over time.

Interrelationships are discovered by asking the question: "What

happens if it (process, perception, attitude, task, etc.) changes?"

S i S Thi ki



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Steps in Systems Thinking

1. Describe the problem (one that is chronic, limited in

scope, with a known history) as accurately as possible,without jumping to conclusions.

2. Tell the story; build the model, providing as many

divergent ideas as possible.

3. Ask the question: "How did we-through our thinking,processes, practices, procedures-contribute to or createthe circumstances, good and bad, that we now face?“

4. Look for causality:-causal relationships betweenevents or patterns of behavior



C t S ti f ti



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Customer Satisfaction

Customer/supplier Relationships

Customer needs & expectations

Measurable characteristics of the process agreed to

Guiding principles of good customer service

Id tif C t



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External

– Patients

– Physicians– Community

– Regulatory

– Payers

Identify Customers

Internal

– Nursing

– Pharmacy

– Laboratory

Tools Used To Identify Customers &



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Tools Used To Identify Customers &Their Needs

Identify Customers: – Wheel & Spoke” “Sundial”

– Customer lists by type e.g. internal & external

– Customer lists by categories e.g.:

• Patients & families

• Practitioners / clinicians

• Suppliers / Vendors

• Provider organizations ….etc

Tools Used To Identify Customers & Their



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oo s Used o de t y Custo e s & eNeeds (Cont.)

Identify Customer needs:

– Surveys

– Assigned interviews – Focus groups

– Research – Brainstorming

Guiding Principles of Good Customer



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Guiding Principles of Good CustomerService

Pay attention to your customer's needs; a successful,long-term relationship with your customer is built dayby day

Own your customer's problem as if it were yourproblem

Be courteous to your customer



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Gu d g c p es o Good Cus o eService

Turn a loss into a win by providing prompt andcourteous attention to your customer when your productor service fails; remedy the situation through effectiveservice

Look at all situations through the eyes of your customer,see your product or service as if for the first time




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g pService

Every job, with all its tasks, decisions, and

responsibilities, is important, since every action affectsthe customer

Only the customer's perception of your product orservice counts for quality

Healthcare Customer Expectations in The



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p21st Century

Healthcare customers provide the perceptive quality

Both internal and external customers tend to focus onhow services meet their perceived needs and whethertheir expected outcomes are met.

Patients add the degree of caring associated with theservice and the outcome of the care related to theirsense of well-being and quality of life to the

interpretive mix.

Expectations From Leadership



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Expectations From Leadership

Leadership integrity before dollars;.

Leadership sensitivity to needs for:

– - More personalization and genuine attention;

– More time for physician caring and compassion.

Leadership involvement in the local community.

Leadership attention to the organization's financialhealth to assure high quality clinicians andtechnology

Expectations From Healthcare



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pDelivery

More attention to the empowered, informed

customer/patient more apt to challenge "doctor's orders”

Reduced hassle, more convenience;

More practitioner time (lack of time perceived asdisrespect);- Child-centered orientation;

Acceptance and coverage of "alternative" approaches.

Expectations From Healthcare System



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Expectations From Healthcare System

Choice of physician and treatment

Optimizing prevention

Access for all

High quality and cost control

Up-to-date technology for diagnosis and treatment

The Healthcare Customer Focus



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The Healthcare Customer Focus

Being truly committed to delivering value to patients

and other customers;.

Listening to and communicating with patients and othercustomers;.

Seeking customer feedback and insight for strategic

initiatives and quality improvement activities;

Identifying and addressing true needs and value-basedexpectations;.

Committing to long-term, rather than quarterly(shareholder) business results; .

The Healthcare Customer Focus 2



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The Healthcare Customer Focus 2

Optimizing treatment patterns and outcomes for cohorts of similar

patients:- – Clinical

– Functional

Enhancing the performance of internal processes to benefit:-

– Patients-

– Vendors

– All who work there.

Respecting patient confidentiality/ privacy and security needs;.

Responding timely to practitioners', providers', and purchasers'appropriate requests for information;.

Building trust, respect, and loyalty in relationships.

In developing a program to evaluate the effectiveness ofphysician care a primary care clinic would select which one of



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physician care, a primary care clinic would select which one ofthe following indicators?

a. The patients will express overall satisfaction withclinic facilities.

b. The contract lab will provide results within 24 hoursof sample delivery.

c. The staff complies with all infection control policiesand procedures.

d. Newly diagnosed hypertensive patients are controlledwithin 6 months.

HealthCare Delivery Settings



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Emergency care is:

– Designated hospital trauma centers,

– Emergency department of hospitals,

– Urgent care centers or

– “in the filed” by paramedical personnel

Acute inpatient (hospital) care

– Intensive/critical care

– Urgent, elective or rehabilitative care considered unsafe as outpatient dependingon:

• Type of diagnostic or therapeutic procedure or

• Patient condition including need for daily physician visit & 24 hour nursing care

Urgent care for immediate care for urgent or emergent conditions notrequiring treatment at a fully equipped (level I) emergency or traumacenter.




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HealthCare Delivery Settings (Cont.)

Ambulatory care including

– Primary care,

– Specialty care, &

– Ambulatory surgery centers providing outpatientservices only

– “in-store health clinics” opened in pharmacy & retailchains generally staffed by nurse practitionersoffering patients fast access to routine medicalservices.

Home care providing certain treatments, services &nursing care in the patient’s home

Hospice care providing psychological, medical &nursing care to the terminally ill & their families,either in outpatient or non acute inpatient settings.




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Transitional, sub acute & skilled care providemedically necessary nursing services requiringlicensed professionals or professional oversight thatmust be provided daily & for therapeutic purposes ata stage of care between acute hospital & custodial.

Assisted Living is group residential setting providingor coordinating personal & health-related services &24 hours supervision & assistance.

Long term care is Custodial or supportive nursingservices that do not require skilled, licensedprofessional intervention.

HealthCare Delivery Settings (C t )



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Behavioral Health & substance abuse programs: are

– Partial hospitalization or :”nonresidential” includingday or evening treatment.

– Crisis stabilization in the home

– Residential.

Wellness & community health are centers providespecial training, education & monitoring for certainhealthcare needs such as stop-smoking, weightcontrol, stress reduction programs or for certainpatient group “with leukemia”

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Healthcare Quality Concepts

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