Instructor’s Manual Chapter 1: Concepts of Quality Management

Instructor’s Manual

Chapter 1: Concepts of Quality Management

Healthcare Quality in the United States:

A Snapshot In 2003, U.S. healthcare expenditures totaled $1.679 trillion and accounted

for 15 percent of the gross domestic product (U.S. Census Bureau 2005; OECD 2005).

In 2003, the United States spent more on healthcare, as measured by percentage of gross domestic product, than did any other country in the world; yet of 30 OECD countries, the United States ranked 22nd in male life expectancy at birth and 23rd in female life expectancy at birth, and 26th in infant mortality rate (OECD Health Data 2005).

55 percent of those surveyed are dissatisfied with the quality of healthcare in the United States and 40 percent responded that in the past five years quality of care has gotten worse (Kaiser Family Foundation et al. 2004).

Adult Americans received 54.9 percent of recommended preventive care, acute care, and chronic care (McGlynn et al. 2003).

Sources: See References in Chapter 1 of Applying Quality Management in Healthcare, 2nd Edition, by D. L. Kelly.

Between 44,000 and 98,000 deaths per year in the United States have been attributed to preventable medical errors, making medical errors the eighth leading cause of death—causing more deaths than motor vehicle accidents, breast cancer, or AIDS (Kohn, Corrigan, and Donaldson 1999).

Taking into account direct costs (e.g., healthcare costs) and indirect costs

(e.g., lost income, lost productivity, and disability), preventable medical errors cost the United States between $17 billion and $29 billion a year (Kohn, Corrigan, and Donaldson 1999).

In 2003, more than 45 million Americans, or 15.6 percent of the 290 million U.S. residents at the time, had no health insurance (U.S. Census Bureau 2005).

In the United States, persons between the ages of 45 and 64 years with the lowest levels of education have 2.5 times the mortality rates of those with the highest levels of education, Poverty accounts for 6 percent of the nation’s mortality (McGinnis et al. 2002).

Healthcare Quality in the United States:

A Snapshot

Sources: See References in Chapter 1 of Applying Quality Management in Healthcare, 2nd Edition, by D. L. Kelly.

Quality Assurance

better worse better worse

thresholdthreshold

Source: James, B. 1989. Quality Management for Healthcare Delivery, 37. Chicago: The Health Research and Educational Trust of the American Hospital Association. Reprinted with permission.

Quality Improvement

better worse better worse

Source: James, B. 1989. Quality Management for Healthcare Delivery, 37. Chicago: The Health Research and Educational Trust of the American Hospital Association. Reprinted with permission.


Chapter 2: Three Principles of Total Quality

To find out about patient safety in the accreditation process, visit

www.jointcommission.org

To find out about the specific safety practice endorsed by The Leapfrog Group,

visit

www.leapfroggroup.org


Chapter 3: The Manager’s Toolbox

Shewhart Cycle

Plan

Do

Check

Act

To find out about the Picker Institute’s dimensions of care, visit

http://nrcpicker.com/

Dimensions of Care

Respect for patients’ values, preferences, and expressed needs

Coordination and integration of care Information and education Physical comfort Emotional support and alleviation of fear and anxiety Involvement of family and friends Transition and continuity Access to care

Source: http://nrcpicker.com.

Flowchart Symbols

Begin/End

Action step

Decision

SimpleFlowchart Example Alarm

goes off

Too tired?

Hit snooze alarm

Start

Get out of bed

End

yes

no

Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.


DeploymentFlowchart Example

WorkflowDiagram Example


Lead Time Analysis Grid


Fishbone Diagram: Four Ps

Problem

People Procedures

Policies Plant Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Problem

Fishbone Diagram: Four Ms

Manpower Materials

Methods Machinery Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Fishbone Diagram Example

PEOPLE PROCEDURES

Patient discomfort with ID band other ways used to ID patient accountability for re-banding unclear

too tight too looseverbal familiarity

edema multiple points of patient entry/admissionID band and care issues

different procedures many people doing ithidden (ex. OR drapes) IV line

Problem: inconsistent patientidentification prior to

multiple types of band rendering services policies not coordinated

emergency banding equipment inaccessibleinadequate training policies

ID band malfunction incorrect information on original ID band

POLICIES PLANT/EQUIPMENT


Patient not taking hypertension medication

Simple Fishbone Diagram Example

PeopleProcedures

Policies Plant

Unpleasant side effects

Inconsistent patient education

Medication too expensive

Pharmacy hours of operation

Simple Check Sheet Example

Number of times

Unpleasant side effects

Inconsistent patient education

Medication too expensive

Pharmacy hours of operation

Simple Pareto Chart Example

Reasons for Medication Non-Compliance

0

5

10

15

20

25

Patient Education Side Effects Too Expensive Pharmacy Hours

nu

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er o

f pat

ien

ts

Check Sheet Example

Type of call 8:00-9:00 9:01-10:00 10:01-11:00 11:01-2:00 12:01-1:00 1:01-2:00 2:01-3:00 3:01-4:00 4:01-5:00

Make an appointment

Call for nurse: patient

Call for nurse: nonpatient

Call for MD: patient

Call for MD: nonpatient

Personal calls

Wrong number

Asking for a phone number

Other

Name: Day of the week: M T W Th Fri


Pareto Chart ExampleOB / GYN Phone Room: Types of Calls

June 5-9

0

200

400

600

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1000

1200

1400

appointment other patient call tonurse

patient call to MD personal phone number non-pt call tonurse

non-pt call to MD wrong number


Run Chart Example

Breast Imaging ServicesDiagnostic and Screening Visits

893

990

857

943881 898

656

999

1087

930

1043 1049

0

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Tota

l Num

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of V

isits

Multiple procedures per visit not reflected in this data


Run Chart Example Overall Patient Satisfaction

Internal Medicine Clinic

75

80

85

90

95

100

Intervention



Chapter 4: A Systems Perspective of Quality Management

Systems thinking…

“…is a discipline for seeing wholes. It is a framework for seeing interrelationships, rather than things, for seeing patterns of change rather than static ‘snapshots’.”

--Peter Senge in The Fifth Discipline: The

Artand Practice of the LearningOrganization. 1990. New

York: Doubleday Currency.

Characteristics of Dynamic Complexity

Change Trade-offs History dependency Tight coupling Nonlinearity

Unintended Consequences


Chapter 5: Systems Models for Healthcare Managers

Organizations as Systems

Simple System

Inputs Conversion Process Outputs

•Patients•Personnel•Supplies•Equipment•Facilities•Capital

•Diagnostic•Treatment•Operations•Business•Management•Support

•Clinical status•Functional status•Satisfaction•Cost-effectiveness•Culture

Inputs Conversion Process

Outputs

Healthcare Organizations as Systems

Open Feedback System

Inputs Conversion Process

Outputs

Feedback

Quality Management as an Open Feedback System


Feedback

Improve Improve

Medical PersonnelLicensureContinuing educationPerformance reviews

TechnologyClinical trialsGovernmental bodiesStandards

Facilities and StructuresInspectionsStandards and guidelines

Health Technology AssessmentPractice guidelinesProcess improvementWork simplificationPolicy (immunizations)

Tracking and Monitoring Outcome Measures Individual, organizational, state, national Health statusBusiness status


Quality Management in Healthcare

Three Core Process Model

Outcomes Excellent clinical outcomes Value to patient Patient satisfaction Functional status

Culture

Patient Flow/Operational Processes

Clinical/Medical Processes

Administrative Decision-Making Processes

Administrative Decision-Making Processes


Source: www.baldrige.gov.

Systems Model of Organizational Accidents

Socioecological Framework:Determinants, Interventions, Evaluation

Determinant Intervention Evaluation / Impact Evaluation / Outcome

Indivividual

Organizational

Health and HealthBehaviors

Community

Population

Source: Reprinted with permission by JoAnne Earp, Sc.D.; Peter Reed, M.P.H.; and the instructors of HBHE 131, Introduction to Social Behavior in Public Health, Department of Health Behavior and Health Education, University of North Carolina at Chapel Hill, School of Public Health, 2001.

Systems Models: Lessons for Managers

Three Core Process Model

Baldrige National Quality Program

Systems Model of Organizational

Accidents

Socioecological Framework

Encourages concurrent improvement of inter-dependent processes

Aligns processes around patient needs

Values all provider and employee groups

Views administrative role as a process not a function

Shows how the components of performance excellence are related

Recognizes the context in which the organization operates

Promotes alignment of all activities within the organization

Promotes alignment of performance indicators

Enhances communication around performance excellence

Explains administrators and managers as sources of latent errors

Describes frontline consequences of system errors

Emphasizes importance of management competence

Broadens and expands the manager’s view

Addresses community and policy influences on health outcomes



Chapter 6: Expanding the Boundaries of the System: The Role of Policy

To find out about the Joint Commission’s Shared Visions-New Pathways

accreditation process, visit

www.jointcommission.org

Source: © Joint Commission Resources: Tracer Methodology: Tips and Strategies for Continuous Systems Improvement. Oak Brook Terrace, IL. JCAHO, 2004, p. 5-6. Reprinted with permission.




Chapter 7: Systemic Structure

The Iceberg Metaphor

Source: Reprinted with permission from Innovations Associates, Inc. 1995. “Systems Thinking: A Language for Learning and Action.” Participant manual, version 95.4.1. Waltham, Massachusetts.

Comparison of Organizational Models

Source: From Health Care Management: Organization Design and Behavior, 4th Edition, by S. M. Shortell and A. D. Kaluzny. © 2000. Reprinted with permission of Delmar Learning, a division of Thomson Learning: www.thomsonrights.com. Fax 800 730-2215.

Organizational Characteristic

Rational Model Political Model

Goals, preferences

Power and control

Decision process

Information

Cause-and-effect relationship

Decisions

Ideology

Consistent across members

Centralized

Logical, orderly, sequential

Extensive, systematic, accurate

Predictable

Based on outcome-maximizing choices

Efficiency and effectiveness

Inconsistent, pluralistic within the organization

Diffuse, shifting coalitions and interest groups

Disorderly, give and take of competing interests

Ambiguous, selectively available, used as a power resource

Uncertain

Results from bargaining and interplay among interests

Struggle, conflict, winners and losers

http://www.thomsonrights.com/


Chapter 10: Performance Measurement

Why measure performance?

Reacting to a Problem Approach

Reacting to a Problem Approach

Poorly defined strategic and operational goals

Operations characterized by activities rather than processes

Operations reactive to immediate needs and problems

Source: Adapted from Baldrige National Quality Program Health Care Criteria for Performance Excellence. www.baldrige.gov.

Early Systematic Approach

Early Systemic Approach

Strategic and quantitative goals are beginning to be defined

Beginning stages of conducting operations by processes with repeatability, evaluation, and improvement

Early coordination among operating units


Aligned Approach

Aligned Approaches

Processes address key strategies and goals of the organization

Operations are characterized by processes that are repeatable and regularly evaluated for improvement

Learning is shared and coordinated among organizational units


Integrated Approach

Operations characterized repeatable processes

Operational processes regularly evaluated for change and improvement in collaboration with other affected units

Efficiencies across units are achieved through analysis, innovation, and sharing

Processes and measures track progress on key strategic and operational goals

Integrated Approach


Internally used performance

measures

Externally required

performance measures

Performance measures used for multiple purposes

Int

ern

al

Extern

al

Integrating Internal and External Measures


Normal Distribution


Statistical Process Control Chart


Control Chart Example Operating Room: Overtime Hours

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Year 1 Year 2 Year 3 Year 4

Pay Period

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of

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Overtime hours per pay period mean UCL LCL


Control Chart Example

Operating Room: Overtime Hours

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Year 3 ↓



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Year 4




Chapter 11: Organizational Traction

Why do we use snow tires, chains, and four-

wheel drive?

…creative tension


Chapter 12: Implementation Lessons

Incremental Versus Breakthrough Improvement

Paper/pen Breakthrough: Typewriter

Breakthrough: Word Processing

Incremental improvements to typewriters (i.e. electric/erasable ribbons)

Incremental improvements to paper/pen products

A

B

C


Refining Vision/Context as Management Breakthroughs

Incremental improvements

Breakthrough Vision/ Redefine Context

Refinements to vision/ context

Breakthrough Vision/ Redefining Context

A

B


Breakthrough Vision, Incremental Implementation

History/Mission

Ideal Vision

PerformanceMeasurement System


Breakthrough Vision, Incremental Implementation

History/Mission

Ideal Vision


Intervention #1

Intervention

#2Interventio

n #3a

Intervention

#3bInterventio

n #4


Breakthrough Vision, Incremental Implementation:Surgical Services Example

Mission

Ideal Vision


Administrative Team

Medical Executive Committee

Shared Governance

Surgical Services Executive Committee

Pre-operative testing protocol

First case start times

Pre-Admission Process

Pre-procedure/ Post-procedure processes

Etc.



Chapter 13: Team Strategies

Anna Smith’s First Grade Daily Self-EvaluationScroggs Elementary School, Chapel Hill, NC


Epilog

Tools for Improving How We Do Our Work:Improving the Process

Category Frequency

ABC

lllllll llllll

Process Flowcharts

Data Collection

Cause and Effect

Data Analysis

Tools for Improving What We Do: Improving the Content

Driving Restraining

Benchmarking Best Practices

Force Field Analysis

Evidence-based Practice

Why are these new tools helpful?

…the highest-leverage tools help us to improve how we think.

Leveraging Performance Improvement in Healthcare

Low leverage High Leverage

•Improving Process•Improving Content•Improving Process

Appreciating a Systems PerspectiveAddressing Underlying Assumptions:

•Goals•Purpose•Measurement•Traction•Implementation•Teams

•Improving Content•Improving Process

How we do it

What we do

How we think


Documents

Instructor’s Manual Chapter 1: Concepts of Quality Management