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School of Health Services Administration

Faculty Notes

HCS/451 Version 6Health Care Quality Management and Outcomes Analysis

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Faculty NotesHCS/451 Version 6

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Edited in accordance with University of Phoenix® editorial standards and practices.


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Module Revision HistoryMODULE CODE REVISION(S) DETAIL

U1 Original UniModule™ course

R1 Converted UniModule™ to rEsource

R2 Addition of SIM; streamlined assignments to match eCad model

R3 Updated course, streamlined course, and addition of Read Me Firsts

R4 Revised topics, objectives, weekly assignments, Read Me Firsts, Faculty Notes, textbooks, and ERRs

R5 Revised Faculty Notes, weekly readings and textbook edition has been updated. Combined week two and three individual assignments and made it due on week three.

R6 In Version 6 we removed the risk management content and placed it in the new Risk Management course (HCS/456). Students are still exposed to risk management in an introductory level in this course. Updated course content, topics and objectives, textbooks, weekly readings, learning activities, assignments, and included a signature assignment in Week 4.


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Course OverviewCOURSE DESCRIPTION

This course examines the relationships between health care quality and organizational performance management. The student is introduced to the rationale for performance management and quality improvement tools used in health care. Methods for assuring quality in process and outcome management are described. Changing trends in the provision and reimbursement of health care services are reviewed.

TOPICS AND OBJECTIVES

Week One: Quality Improvement Concepts

Explain the evolution of continuous quality improvement in health care. Explain basic concepts of quality improvement. Identify quality dimensions and corresponding system measurements.

Week Two: Quality Improvement in Health Care

Explain how leadership and philosophy drive quality management in health care. Explain the concept of value as it relates to health care. Identify key quality indicators used in health care systems and current policy.

Week Three: Organizational Performance

Explain the concept of risk management in the health care industry. Explain how to develop improvement capability for organizational performance. Explain Transformational Improvement in relation to organizational performance.

Week Four: Tools and Decision-Making Processes

Analyze the information needed for decision-making processes in risk and quality management.

Explain challenges in making risk- and quality-management decisions. Analyze key risk- and quality-management tools in the health care industry.

Week Five: Ongoing Performance Management

Analyze strategies for ongoing performance improvement in the changing health care industry.

Analyze current and future trends in risk management.


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Week One Faculty NotesQuality Improvement Concepts

Explain the evolution of continuous quality improvement in health care. Explain basic concepts of quality improvement. Identify quality dimensions and corresponding system measurements.

WEEK ONE CURRICULUM DESIGN NOTES

Version six of this course has been completely revised. It focuses on basic quality theories and the concept of Continuous Quality Improvement (CQI) that can be applied to any setting within health care. The Plan-Do-Study-Act (PDSA) cycle model is introduced to provide a simple yet powerful framework for performance improvement. This course mainly concentrates on quality and brings in only basic risk material instead of equal coverage of quality and risk topics as in prior versions.

In the first week you will find the basic foundational material for CQI concepts. Students will learn about the factors that lead to the development of quality improvement science and a brief history of this relatively new field. The current state of CQI in health care is described after introducing the concepts of CQI in general, and the usefulness of CQI in business is discussed is discussed.

The five fundamental principles of improvement and the three fundamental questions which make up the Model for Improvement are presented. Finally, Week One introduces basic quality dimensions and shows a link to specific system measures that most health care organizations use to evaluate performance.

CONTENT OUTLINE

1. Quality Improvement Conceptsa. Explain the evolution of continuous quality improvement in health care.

1) Continuous Quality Improvement (CQI)a) CQI started in the quality science field in manufacturingb) CQI was originally called total quality management (TQM)c) CQI has developed exponentially and on a global scaled) CQI went from a business solution to a philosophical movement after World War

II2) CQI in health care

a) Florence Nightingale – application of statistics to health careb) Institute of Medicine reports – To Err is Human: Building a Safer Health System

and Crossing the Quality Chasmc) Don Berwick - patient centerednessd) Business case for quality in health care

b. Explain basic concepts of quality improvement. 1) Quality Improvement

a) Foundation(1) W. Edwards Deming and Walter Shewhart are two pioneers in the quality

improvement field who developed quality improvement philosophies and tools.


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(a) W. Edwards Deming believed that quality improvement must be driven from the process level rather than the organization’s structures.

(b) Believed that management had the final responsibility for quality because employees were part of the system and management was responsible for controlling the system itself. Therefore, quality improvement must come from a top down system in organizations.

(c) W. Edwards Deming is known for his 14 point program for managers to improve quality. When implemented, the recommendations of this plan lead to continuous quality improvement in an organization.

(2) Walter A. Shewhart(a) Shewhart developed the Shewhart Cycle in 1931. Also called the Plan-

Do-Study-Act cycle (PDSA). i. One of the simplest yet most powerful tools in quality improvement

that is based on the scientific method ii. In the tool one plans a test of change, which could lead to

improvement iii. An intervention and hypothesis is designed in the plan stage iv. The next step is to execute the test of change and record findings v. Later the findings are studied and compared to the hypothesis vi. Finally, the change is adopted, adapted, or abandoned. Future tests

(improvement cycles) can be conducted, which build off prior test results

vii. The individual or organization learns from each test of change in a logical manner. This can be contrasted to traditional management methods which may not be as deliberate or incremental. Other methods aimed at improvement might not fully frame the problem and jump to solutions.

2) Quality improvement uses a system’s view to address customer needs 3) It is a data driven process4) It seeks to find causation in operations that lead to defects 5) Processes are optimized and subsequent data show improvement in outcomes 6) Model for Improvement framework

a) Improvement should be defined with the fundamentals of improvement science in mind

b) Improvement comes from the application of knowledge (1) Five fundamental principles of improvement

(a) Knowing why you need to improve(b) Having a feedback mechanism to tell you if the improvement is

happening(c) Developing an effective change that will result in improvement (d) Testing a change before attempting to implement(e) Knowing when and how to make the change permanent

(2) Three fundamental questions for improvement(a) What are we trying to accomplish?(b) How will we know that a change is an improvement?(c) What changes can we make that will result in improvement?

c. Identify quality dimensions and corresponding system measurements.


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1) A method to measure the quality of care at the health care system levela) Dimensions and Measures

(1) Institute of Medicine (IOM) Dimensions (a) IOM provides independent and objective analysis to inform public policy

in science, technology, and medicine.(b) IOM recommends that health care quality should be measured in six

dimensions. i. Safe- quality health care should not harm individuals (example-

reducing medication errors)ii. Effective- quality health care should be effective (example- antibiotic

appropriateness)iii. Efficient- quality health care should be efficient (example- reducing

supply waste)iv. Timely- quality health care should be delivered in a timely manner

(example- time to make follow-up appointments)v. Patient-Centered- quality health care should focus on the patient’s

individual and cultural needs (examples- patient engagement and use of electronic health record)

vi. Equitable- quality health care means that race, ethnicity, gender, income, and other factors should not result in systematic variations in health access or health outcomes.

(2) Whole System Measures (a) Operational measures health care organizations can use to compare

outcomes between organizations(b) Help identify opportunities for collaboration and improvement(c) Based on the six quality dimensions

(3) Examples of Whole System Measures(a) Adverse Event Rate(b) Incidence of Nonfatal Occupational Injuries and Illnesses(c) Hospital Standardized Mortality Ratio(d) Unadjusted Raw Mortality Percentage(e) Functional Health Outcomes Score(f) Hospital Readmission Percentage(g) Reliability of Core Measures(h) Patient Satisfaction with Care Score(i) Patient Experience Score(j) Days to Third Next Available Appointment(k) Hospital Days per Decedent During the Efficient Last Six Months of Life(l) Health Care Cost per Capita(m) Equity (Stratification of Whole System Measures)

DISCUSSION STARTERS

1. How is the Shewart Cycle (PDSA) different from traditional business improvement techniques?

2. How does health care quality improvement differ from quality improvement in manufacturing?

3. What are examples of measures based on the IOM dimensions?


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Week Two Faculty NotesQuality Improvement in Health Care

Explain how leadership and philosophy drive quality management in health care. Explain the concept of value as it relates to health care. Identify key quality indicators used in health care systems and current policy.

WEEK TWO CURRICULUM DESIGN NOTES

This week you will find material on quality leadership and philosophy for health care organizations. Models for organizational performance and their characteristics are introduced. Deming’s concept of Profound Knowledge is discussed. This week also investigates what quality improvement organizations are and what they do for health care organizations and consumers.

The concept of health care value is discussed with reference to key quality indicators. Methods to improve value are also given. Finally, health care quality indicators and current government policy with respect to payment for quality is discussed.

CONTENT OUTLINE

2. Quality Improvement in Health Care a. Explain how leadership and philosophy drive quality management in health care.

1) Quality Leadershipa) Models for organizational performance

(1)Common Professional, CQI, and Transformational Model Characteristics(a) Responsibility(b) Leadership (c) Decision making(d) Planning

2) Profound Knowledgea) Appreciation for a systemb) Knowledgec) Theory of knowledged) Psychology

3) Quality Improvement Organizationsa) Main infrastructure for quality improvement in the USb) Focus on clinical areas and topics

b. Explain the concept of value as it relates to health care. 1) Health care has only recently focused on value 2) The U.S. Department of Health and Human Services defines the outcomes that the

Centers for Medicare and Medicaid Services (CMS) aim to achieve through the care it purchases for its beneficiaries

3) The strategy's three aims are better health, better care, and lower costs 4) These three aims represent CMS's definition of value 5) The CMS and other organizations now force health care providers to address value

with financial incentives, shared savings, and financial penalties


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6) Value is entirely customer focuseda) Value = Quality/Total Cost

(1)Ways to improve value(a) Eliminating quality problems that arise because we fail to meet the

expectations of customers(b) Reducing costs significantly while maintaining or improving quality(c) Expanding customer expectations

c. Identify key quality indicators used in health care systems and current policy.1) Health care quality performance and measures

a) Agency for Healthcare Research and Quality (AHRQ) indicators(1) The Agency for Healthcare Research and Quality works within the U.S.

Department of Health and Human Services to make health care safer, higher quality, more accessible, equitable, and affordable

(2) The organization uses evidence to develop indicators that are a part of health care provider’s financial incentive programs

(3) Many health providers must report their performance on these indicators (4) Quality Indicators

(a) Prevention (example-pediatric asthma readmission rate)(b) Inpatient (example-heart failure mortality rate)(c) Patient safety (example-pressure ulcer rate)(d) Pediatric (example-neonatal blood stream infection rate)

b) Accountable Care Act(1) CMS provides financial rewards or penalties with the Value Based

Purchasing program (2) This is the quality measurement component of the Affordable Care Act(3) Health care providers are graded on how well they perform compared to

other providers and how much internal improvement they make from year to year

(4) Value Based Purchasing – CMS payment adjustment based on quality performance in specified domains

(a) Clinical process of care (example-prophylactic antibiotics discontinued within 24 hours after surgery end time)

(b) Patient experience of care (example-communication about medicines in patient satisfaction survey response score)

(c) Outcome (example-central line-associated blood stream infection rate)(d) Efficiency (example-Medicare spending per beneficiary)

DISCUSSION STARTERS

4. Why are health care organizations changing their focus to value? 5. How do Quality Improvement Organizations empower the health care consumer?6. How does the Value Based Purchasing program reward or punish health care

organizations based on performance achievement or improvement?


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Week Three Faculty NotesOrganizational Performance

Explain the concept of risk management in the health care industry. Explain how to develop improvement capability for organizational performance. Explain Transformational Improvement in relation to organizational performance.

WEEK THREE CURRICULUM DESIGN NOTES

This week the concepts of risk and improvement are discussed. The health care system has only recently started to approach patient safety in a systematic way. Health care organizations are increasing patient safety and reducing risk by moving towards a culture of safety and high reliability organizations.

Organizations must purposefully act to develop improvement capability for organizational performance. This includes a commitment to a quality structure and resources. Organizations that seek both incremental and radical gains can use the model of transformational improvement.

Note to faculty: The Week Three Learning Team Assignment, Quality Dimensions and Measures Table Paper, instructs Learning Teams to write a 1,050- to 1,400-word paper in which the team compares the Normal Accident Theory to the Culture of Safety model. For this assignment, faculty are responsible for providing Learning Teams with one of the scenarios given below. Our goal in providing you with multiple scenarios is to limit plagiarism. Please ensure you only use one scenario per course.

Scenario #1:On December 7, 2000, the Cincinnati OSHA Office heard through media and police reports that there were two deaths at a nursing home in Ohio. OSHA determined that the FDA should take a lead role in performing an investigation.

Since the nursing home had residents who had unhealthy respiratory systems, the nursing home routinely ordered and received tanks that contained pure oxygen. During one delivery, the supplier mistakenly delivered one tank of pure nitrogen in addition to the three tanks of pure oxygen that had been ordered. The nitrogen tank had both an oxygen and nitrogen label. An employee at the nursing home connected the nitrogen tank to the nursing home's oxygen delivery system. This event caused two nursing home residents to die, and three additional nursing home residents were admitted to hospitals in critical condition. Within the following month, two of these three additional residents also died, bringing the total death toll to four. (Based on accident # 837914 www.osha.gov)

Scenario #2:A man who had Ebola was seen in a hospital emergency room and sent home. During the visit a nurse documented the man’s symptoms and medical history, which included travel from Liberia during an Ebola outbreak. The hospital’s electronic health records contained separate physician and nursing workflows. Documentation of travel history was located in the nursing workflow portion of the electronic health record. This information did not populate in the physician's standard workflow in the electronic health record, and the physician did not consult the nursing notes during the visit. Consequently, an individual with a communicable disease returned to the public.


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Scenario #3:A hospital located ten feet above sea level experienced a catastrophic power failure during a storm surge from a hurricane. The hospital also lost municipal power during the hurricane. The hospital had functioning emergency generators well above the storm surge on the roof while the generator fuel and fuel pumps were located on the ground level of the hospital. Fuel pumps normally move the fuel up to the generators; however, the storm surge flooded the pumps and subsequently shut down the generators. The hospital had to perform a complete evacuation of all patients after power was lost.

CONTENT OUTLINE

3. Organizational Performancea. Explain the concept of risk management in the health care industry.

1) Risk backgrounda) Normal Accidents Theory of causation

(1) Theory developed by Charles Perrow (2) In this theory accidents are inevitable(3) Barriers can be placed to block accidents, but they do not work 100% of the

time. There are sometimes “holes” in the system. (a) This relates to the Swiss Cheese model of accident prevention.

i. In this model we put barriers in place to prevent different defects ii. However, even with multiple barriers (like stacked pieces of Swiss

cheese), we sometimes have a hole that aligns on several layers and lets a defect through

b) Normal Accidents Theory(1) All human beings, regardless of their skills, abilities, and special training,

make fallible decisions and commit unsafe acts(2) All man-made systems possess latent failures to some degree (3) All human endeavors involve some measure of risk

c) Risk Management Modeling(1) We can predict the total effect of risky conditions by combining the

probability and impact in a Failure Mode and Effect Analysis(2) Failure Mode and Effect Analysis

(a) Impact– Minor, Moderate, Significant(b) Probability– Low, Medium, High

2) Engineering a culture of safetya) Instead of putting up multiple barriers such as with the Swiss cheese model,

health care organizations can transition to a culture of safety which uses high reliability principles to promote safety.

b) This system uses communication and teamwork to help employees check each other and identify risks.

c) When these characteristics are followed organizations don’t have to put up barriers which do not work reliably.(1) Culture of safety characteristics(2) Commitment of the leadership to discuss and learn from errors(3) Communications founded on mutual trust and respect(4) Shared perceptions of the importance of safety(5) Encouragement and practice of teamwork


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(6) Incorporation of non-punitive systems for reporting and analyzing adverse events

(7) High reliability organizations use these principles to promote safetyb. Explain how to develop improvement capability for organizational performance.

1) Resources needed to develop improvement capabilitya) Organizational focus on improvementb) Employee time for quality trainingc) Database and data analysis capabilitiesd) Capabilities to integrate knowledge into the system

2) Structurea) Incorporate quality with existing employees and dutiesb) Improvement management positionsc) Facilitator positionsd) Special teams or committeese) Steering committees or improvement councils

3) Development activitiesa) Discoveryb) Learningc) Implementationd) External promotion to others

c. Explain Transformational Improvement in relation to organizational performance.1) Traditional CQI provides skills to improve performance while transformational models

provide those skills plus the capability for incremental and radical learning to meet the challenges of uncertain and complex environments.a) Transformational leadership characteristics

(1) Shared responsibility(2) Leadership at multiple levels(3) Outcome and value driven processes(4) Shared decision making(5) Continuous planning(6) Future focus(7) Performance enhancement appraisals(8) Continuous innovation

2) The Model for Improvement can be used for transformational changea) The Model for Improvement addresses three fundamental questions for

improvement(1) What are we trying to accomplish? (example- increase patient satisfaction

for care received in a hospital clinic)(2) How will we know that a change is an improvement? (example- increase

patient satisfaction scores)(3) What change can we make that will result in an improvement?

(a) Here we can try many tests of change (b) For example, use a “how was your visit” questionnaire, interview

people about their visit and satisfaction, have the nurse manager meet with every patient before they checkout, and provide better discharge materials to every patient


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(c) These tests can identify causes of satisfaction and dissatisfaction as well as potential interventions based on customer feedback

(4) The Model for Improvement uses the PDSA methodology and PDSA cycles for rapid learning and improvement. For example, a clinic can get a baseline score for one day without interventions and then use each of the interventions listed above to see what to adopt, adapt, or abandon based on results.

DISCUSSION STARTERS

7. How do high reliability organizations differ in their approach to patient safety from other organizations?

8. Why may transformational leadership organizations be more successful in quality improvement?

9. How can a health care organization develop a culture of safety?


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Week Four Faculty NotesTools and Decision-Making Processes

Analyze the information needed for decision-making processes in risk and quality management.

Explain challenges in making risk- and quality-management decisions. Analyze key risk- and quality-management tools in the health care industry.

WEEK FOUR CURRICULUM DESIGN NOTES

This week investigates the decision-making process and tools for improvement. The basis for Continuous Quality Improvement (CQI) is that CQI is based on data and the scientific method. Once we have the data, we need to develop or change ideas to make improvements in a system. Six areas for successful sustained improvement are discussed. Finally, quality improvement tools are given.

CONTENT OUTLINE

4. Tools and Decision-Making Processesa. Analyze the information needed for decision-making processes in risk and quality

management.1) CQI is based on data.

a) This is the most important concept in this course b) Actual performances and goals are based solely on data and not on beliefs,

conceptions, executive directives, or anything else. (1)For example, a hospital can try to improve patient satisfaction scores by

using one executive’s idea that nurses should always smile when giving discharge instructions.

(2) Most quality improvement solutions are not this simple. The likelihood of success with this intervention is low. A more reliable and sustainable method of improvement would be to use Plan-Do-Study-Act (PDSA) rapid cycle improvements to test many interventions and fully address the issues. The following points must be kept in mind:(a) Improvements must occur in a system(b) Qualitative and quantitative data can be used(c) Measurement is not intended to be used for selection, reward, or

punishment(d) Multiple causation is assumed(e) Specific tools (listed below under the objective “Analyze key risk- and

quality-management tools in the health care industry”) may be used for analysis and decision making

b. Explain challenges in making risk- and quality-management decisions.1) Challenges to improvement initiatives

a) Data b) Change in ideasc) Change in testingd) Implementatione) Spread


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f) People (i.e., patients, health care workers, etc.)2) Supporting change with data

a) Selecting the data(1) How can we use data to guide actions for improvement?

(a) Timely and discrete data is required to measure improvement (b) For example, daily or weekly satisfaction scores are needed to validate

daily tests of change3) Developing a change

a) Change comes from trying new ideasb) A culture of change must be encouraged to be successfulc) The change must be aimed at both short- and long-term goals

(1) Where do ideas for change come from?(a) Long-term goals

4) Testing a changea) Can we increase the possibility that a change will result in improvement?b) Timing- What is the testing scope and interval for change testing?

(1) The power of one (one patient, one registration, one discharge, one day, one physician, and do on). Test frequently and on a small scale to learn quickly.

(a) It may take a long time to learn an optimal process but it does not take long at all to learn what does not work

(b) Test frequently and on a small scale then adapt, adopt, or abandon based on the results of each test of change

5) Implementing a changea) Difference between implementing and testing a change?

(1) Implementing is just following a plan or orders while testing a change must allow for failure and development of new ideas since the optimal process is not known beforehand

6) Spreading improvementsa) How can we get wider impact from successful change?

(1) Change should be proven on a small scale before wider testing(2) Successful quality improvement personnel should not be afraid to fail early

and fail small (3) A widespread change that does not work can harm business operations(4) This is seen in implementations

7) The human side of changea) Excellent quality improvement plans may not work if there is not buy-in from staff.

(1) How will the change affect people?(2) How do we obtain the cooperation necessary to make and sustain

improvements?8) Other challenges

a) Providers(1) Quality initiatives a “threat” to autonomy

b) Health care staff fear of changec) Consumers

(1)Health literacy


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(2) Information(a) Publically reported quality measures

i. Old data- some measures lag in reporting time up to four or more years

ii. Conflicting data- publically reported data versus marketing dataiii. Pharmaceutical advertisements and influenceiv. Unfiltered internet health information

d) Organizations(1) Strong leadership is needed for quality improvement(2) Improvements must be viewed as part of a system and not just a unit or

department(3) Leaders must resist the urge to oversimplify processes

c. Analyze key risk- and quality-management tools in the health care industry.1) Tools for Improvement. There are many tools which can be used in quality

improvement. Some common uses and tools:a) Process description and variation

(1) Flow chart(2) Process mapping(3) Cause and effect diagram

b) Gathering information(1) Surveys(2) Benchmarking(3) Frequency plot

c) Analysis (1) Pareto(2) Failure mode and effects analysis (FMEA)(3) Scatter plot

d) Alternatives(1) Pareto(2) Regression analysis

e) Monitor progress(1) Run chart(2) Control chart

f) Organizing information(1) Affinity diagram(2) Force field analysis(3) Driver diagram

DISCUSSION STARTERS

1. What are the three alternatives after completion of a test of change in a Plan-Do-Study-Act (PDSA) cycle? What should be done after each one?

2. A hospital executive is excited that the hospital patient satisfaction scores have increased two out of the past three months. The total increase is one standard deviation from the mean (+1 sigma). What would you tell her about the statistical significance of the change? What improvement tool could be used to track progress? Why?


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Week Five Faculty NotesOngoing Performance Management

Analyze strategies for ongoing performance improvement in the changing health care industry.

Analyze current and future trends in risk management.

WEEK FIVE CURRICULUM DESIGN NOTES

This week examines ongoing performance improvement and the characteristics of an organization that has embraced Continuous Quality Improvement (CQI). The CQI approach is outlined. This week also discusses current and future trends for hospitals that wish to improve quality and risk outcomes.

CONTENT OUTLINE

5. Ongoing Performance Managementa. Analyze strategies for ongoing performance improvement in the changing health care

industry.1) Organizations must embrace CQI to survive in health care today

a) Training in the quantitative sciences is necessary but not sufficient b) Statistical thinking must be woven into the culture for all to understand.c) Statistical thinking must be used to drive decision making in organizations.d) CQI differs from rigorous evidence-based practice methods used in health care

but can more valuable since learning and implementation is much faster 2) CQI approach

a) The basics of statistical thinking start with measurement and the ability to learn from the data collected

b) We must take the time to understand what the data shows, particularly about causes of variation before taking action to make changes

c) Plan-Do-Study-Act (PDSA) cycles are a fast and effective way to develop sustained improvements

b. Analyze current and future trends in risk management.1) Educational Components for successful future health care leaders include

leadership, teamwork, and CQI knowledge2) Increased collaboration across institutions to improve quality and safety is a

promising direction for the futurea) Cincinnati Children’s Hospital Learning Networksb) These following institutions have joined the Chronic Care Network and share

data on outcomes, quality, and costs across a range of common and costly conditions and treatments(1) Dartmouth Institute for Health Policy and Clinical Practice Collaborative-

Dartmouth-Hitchcock (2) Cleveland Clinic (3) Denver Health (4) Geisinger Health System(5) Intermountain Healthcare (6) Mayo Clinic


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3) Information management and health information technology a) Technology advances daily b) Government, provider, and consumer knowledge is also growingc) Increased transparency of hospital quality data d) ICD-10 implications for greater data granularity and increased research

emphasis in health care.

DISCUSSION STARTERS

1. How can hospitals leverage quality and risk outcomes research to improve performance?2. What are some advantages and disadvantages of hospital learning networks with respect

to quality and risk?3. Why must CQI be embraced by all areas of a hospital to be most successful?

Documents

Faculty Notes - University of Phoenixmyresource.phoenix.edu/.../HCS451r6_faculty_notes.doc · Web viewAnalyze current and future trends in risk management. Week One Faculty Notes