Assignment
RADS 4633 CQI
Module I
Quality Improvement Development and Principles
Terminal Performance Objective
Upon completion of this unit, the student should be able to identify opportunities for integrating traditional quality assurance models with continuous improvement models.
Enabling Objectives
Upon completion of this unit, the student should be able to:
- Compare structure methods and scopes of continuous quality improvement to those of traditional quality assurance.
- Discuss the historical perspective of quality improvement development.
- State examples which illustrate the "right things done right" interface.
- Identify factors which contribute to customer satisfaction.
- Identify factors which contribute to staff retention.
- Explain the effect of continuous quality improvement on financial viability.
- Identify strategies for the advancement of continuous quality improvement.
- State the four facets of a comprehensive strategy for continuous quality improvement.
Introduction
The design characteristics and implementation strategies of a continuous quality improvement program cannot be fully examined until it is compared to traditional quality assurance characteristics and strategies. This unit will give a name to some of the procedures you have performed in the past and equate them to procedures performed in a continuous quality improvement program. Be mindful that past procedures are not wrong, nor was the department lacking quality by using these procedures, but instead may now be outdated. Some of ethical and business essentials to be aware of in the present health care environment are:
- Change threatens quality. Consumers are demanding higher quality and standards than ever before. Change can contribute to turbulence in the health care environment and if attention is not given to quality, it will deteriorate.
- Quality is the right and ethical thing. You cannot profess to care about patients and their outcomes if a commitment to quality is not evident to them.
- Quality results in optimal patient health outcomes. Customers look for providers who exceed their expectations of quality. They, in turn, tell friends and family.
- Commitment to quality reduces cost. Up to a third of an organization's expenditures can be from waste, mistakes, redundancy, untrained personnel and inefficient systems.
- Elimination of quality problems lowers staff and customer frustration.
Health care professionals want to be associated with high-quality institutions. The more attention spent on quality with the involvement of the staff, the more invested staff will feel and then will contribute more to the quality process. A focus on quality results in documented effective strategies that will easily meet standards of outside review organizations such as the Joint Commission.
Continuous Quality Improvement versus Traditional Quality Assurance
Traditional quality assurance is described here as defensive and reactive. This means that quality assurance of the past concentrated on satisfying (defensive) agency requirements and regulations and many times made changes after citations were received (reactive).
Continuous quality improvement, on the other hand, focuses on processes: making changes (proactive) in order to rise to exceed expectations rather than merely meeting what is required or minimal (deliberate). Possible citable problems are fixed before committed reviews.
Methods
The traditional quality assurance approach is to measure performance against standards. For example, if the state inspector found that an x-ray machine's radiation output was higher than the standard, a procedure would be initiated to bring that machine to standard, making it "good enough" to meet the standard. Performance standards are met by eliminating those who are displaying poor performance. In other words, the focus is on single events and individuals.
Continuous quality improvement deals with the "whole picture" rather than on individuals. When a problem is identified, as in the example of the x-ray machine output, the focus would be on the cause of the problem, how it could be improved to exceed the standard and to prevent future problems. Performance is investigated as to why it is poor - looking at what kinds of things are affecting the individual's performance an effort is made to improve the process, thereby improving the individual's performance.
Scope
The bottom-line difference between traditional quality assurance and continuous quality improvement is that traditional quality assurance focuses on pieces of the picture while continuous quality improvement focuses on 'the whole picture". Motivation, attitude, means, focus, and scope differs between the two systems. Look at these differences and see if you can determine which system is in place in your organization.
Comparison of QA and CI
Quality Assurance |
Continuous Quality Improvement |
|
|---|---|---|
Scope |
Certain departments |
Organization-wide |
Focus |
Individuals, outcomes |
Common and special causes, processes |
Means |
Meet standards, repair |
Exceed standards, prevention |
Attitude |
Defensive |
Proactive |
Motivation |
Accreditation |
Effective competition, raise satisfaction |
Getting There
If one task is given to twenty people, chances are that even though the outcome is the same, there will be twenty different approaches to the task. While individuality should be celebrated, often wide variance in approach leads to wide variance in outcome. Small differences add up and will eventually degrade quality rather than improve it. Some type of management of methods and approaches is necessary to prevent this variance. This should sound like common sense--get everyone on the same page and things will go more smoothly. It comes as no surprise then that the effort to integrate quality management into business has been around for many years.
History
As long as there have been civilizations, there have been customers wanting the right good or service for their need. In the late 1800s, Frederick Taylor devised a scientific management system which used experts to develop mandatory standards for workers. This system was built around the idea that workers really didn't have the desire or ability to make systems better so they had to constantly be controlled and directed. It did significantly improve productivity but without input from workers.
In the late 1930s, Dr. W.A. Shewhart from Bell laboratories developed a chart to measure the use and effectiveness of equipment. This is the what we have come to know as the control chart. In the late 1940s and early 1950s, Bell Laboratories introduced the idea of quality control to Japan and in 1950, Dr. Edwards Deming began lecturing on quality control to Japanese business and academic leaders. Dr. Deming's approach to quality control will be discussed later in this unit.
The Radiation Health and Safety Act was established in 1968 and by the mid-seventies, the Bureau of Radiological Health was regulating medical and dental x-ray equipment. By the early 1980s, total quality management was introduced to American business and in 1981, the Consumer Radiation Health and Safety Act was established. The Joint Commission, formerly known as The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), adopted total quality management principles into their Agenda of Change in the late 1980s, followed in 1991 by the Safe Medical Devices Act and the Mammographic Quality Standards Act in 1992.
As you can see, quality management, total quality management, quality control, or continuous quality improvement became a reality because of the need to increase productivity and lower cost. A lucky byproduct turned out to be safety, and, eventually, the worker gained recognition and importance.
Quality - Doing the Right Things Right
It is important that you realize that the right outcomes can be achieved the wrong way and that the right way will lead to higher quality and avoid additional problems. The following examples should help you determine if and to what extent the right things are being done right:
- Doing the right things wrong
You have a great piece of equipment that is capable of producing very accurate and important test results, but the technologists don't use the equipment correctly, or your organization has designed a very accessible chart retrieval system, but the people using it don't return borrowed charts
- Doing the wrong things wrong
You have an inefficient system for scheduling patients for pre-admission tests and the people using this system make many mistakes when they enter people's names and appointment times.
- Doing the wrong things right
Using that same inefficient scheduling system, employees do a perfect job of entering people's names, appointment times, and all other information.
- Doing the right things right
You have excellent equipment and you use it correctly 100 percent of the time.
While you are reading, try to think of examples in your own department that fit into the four performance processes. There are four performance processes which should be achieved if the right things are being done right and continuous improvements are being made.
Optimal Clinical Outcomes
The appropriateness and effectiveness of clinical procedures are key to optimal clinical outcomes. If the right things are done right, then the appropriate things have been done effectively. Is the action relevant and necessary and, if so, how can we be sure it will be done right? In other words, how do we ensure appropriateness and effectiveness?
- Appropriate things are done effectively (right things done right).
If you were doing the right things right, all care would be appropriate. The patient would meet diagnostic criteria to indicate removal of the gallbladder. If antibiotics were prescribed, the right drug at the right time and in the right dose would be prescribed and administered. There would be no avoidable complications of either the surgery or the process of care. The surgery would be performed expeditiously and skillfully without the development of infection.
- Inappropriate things are done effectively (wrong things done right).
Assume that the patient does not meet clinical criteria for having a cholecystectomy, but the surgeon recommends it and the patient undergoes the procedure. The surgery is inappropriate. All goes well during the surgery, and the patient is discharged in a timely fashion without complications or errors. Being in a position to evaluate outcomes better than appropriateness, the patient believes that the right things were done right. It is up to healthcare providers to apply their professional standards to ensure that the right things are being done for patients and being done right.
Another example of wrong things done right involves the administration of antibiotics for prophylaxis. If the patient doesn't need antibiotic prophylaxis or doesn't need a third-generation cephalosporin for antibiotic prophylaxis and it is administered at the right time and in the right dose, you have another example of doing the wrong things right, or the inappropriate things effectively.
- Inappropriate things done ineffectively (wrong things done wrong).
Doing inappropriate things ineffectively falls into the ultimate disaster zone. The most obvious example of this situation is that of a patient who dies as the result of undergoing an unnecessary surgical procedure.
The preceding model points out that even if patients perceive health care services to be of high quality, professionals must use their expertise to judge the appropriateness and effectiveness of decisions made on behalf of those patients and the process of care provided. Optimal clinical outcomes will then result.
Customers
The use of the broad, inclusive term, customer, helps us to focus improvement on the multiple constituents that are important to a health care organization. Many different groups of customers judge the quality of health care services-patients, their families and friends, physicians, internal customers, payers, and the community. Each of these customer groups has expectations of the organization's service.
For example, most patients want the best state of health they can achieve; convenient, timely service; courteous, compassionate treatment from the staff; and accurate information about their condition. Their families and friends also typically want sufficient information, access to the patient, and responsiveness and compassion from hospital staff members. Physicians want your organization to be user-friendly (easy to practice in) and supportive of their efforts to serve their patients. Payers want information in a timely fashion and optimal health outcomes for patients at the lowest possible cost.
Customer Types
- External customers are those who are affected by services of the organization but who are from outside the facility. Examples of external customers are outpatients, physicians, patient family and friends, visitors, and other agencies who refer patients or services, or who supply goods.
- Internal customers are those who are from the providing facility. Examples of internal customers are facility staff, inpatients, each internal department, and administration.
Customer Satisfaction
A satisfied customer, whether external or internal, results when quality is high and their needs have been met. There are three levels of customer satisfaction:
- Basic
- Intermediate
- High
Remember that the term "customer" applies to everyone with whom the organization has contact - patients, staff, administration, family members, visitors, vendors, etc. The "customer" always wants to be treated fairly and with respect, just as you do. Everyone involved with the organization must meet the needs of everyone else if peak satisfaction is to be reached. When working on a problem, do not discount anyone, even if that person is the one working on the problem. For example, say the issue is that wait times for patients are too long. Just because it is the technologist complaining doesn't mean he/she is not considered a customer. Everyone involved in the process is a customer.
Staff Retention
As a working technologist, what is most important to you on the job? When trying to recruit and retain employees, care must be taken to make the organization the type of place an employee can be proud of and be a reflection of that pride. Keeping the right employees for the right reasons is critical to a stable and efficient workforce. If managers do not develop the employees and work diligently to keep them, then we have an onslaught of unfilled vacancies, short-term employees, and high sign-on bonuses. While increases in pay may not always be the option readily available, many things can be done to keep good employees.
Keep in mind that even though the premise of continuous quality improvement focuses on process rather than a person, a bad employee sometimes cannot be saved. There may be times when the removal of an employee or a change in their job position will be the only solution to a problem. CQI does not mean that everyone is suited to the organization or should be worked around. In fact, retaining a particularly troublesome employee can erode the process and the attitudes of people around them that an improvement program is nearly impossible. CQI can help provide documentation of problems with an employee and ensure a fair review of that employee's performance.
Financial Viability
Providing the best service at the lowest cost ensures success. It is important to lessen the causes of inefficiency in order to reduce cost. Customers are happier throughout the organization especially those most directly involved. Cost should never be the only or most important factor to consider when implementing a quality improvement program, but it cannot be ignored. Certainly, when resources are being wasted, whether those resources be goods or people, the cost is significantly increased. By improving efficiency, costs will decrease and valuable resources can be allocated where they will do the most good.
Continuous Improvement
The key to this section is realizing that constant change must occur in order to constantly improve. One of the mistakes that are typically made when making changes is the failure to expect the discovery of new problems. Change can be the proverbial "can of worms" but that does not mean that improvement is impossible - it just may be slower in moving forward than is hoped. Rapid changes in healthcare lead to rapid changes in patient needs, and wide variability in needs. With those changes, processes must be revised, added, and eliminated to best serve customers. Identifying problems with work processes versus employee shortcomings demonstrates that by improving process capability, and eliminating process variability, consistency and predictability increase and the mean level of outputs also increases.
Strategies
Think about how the eleven strategy components listed below would affect the radiology department.
- Leadership
- Customer expectations
- Quality management
- Measurement and feedback
- Accountability
- Problem-solving
- Employee involvement
- Staff training
- Communication
- Recognition
- Resources
Without the support of the technical director, radiologists, and supervisors, quality improvement would not be attainable. Identifying customer expectation, and planning for the implementation of a quality management program is critical for the forward progress of the program. In addition, proper follow-up, documentation, and testing are necessary to identify trends and track solutions.
Perhaps the most important components are the ones that deal with people--getting the staff involved, providing feedback, incentives, and recognition will help bind the organization into a group effort working towards the same goal.
It should be recognized that, even though a continuous quality improvement program will save money in the long run, initially some financial commitment will be necessary. The cost may be highest in man-hours as it takes many people to make this system work. Additionally, with the discovery of problem causes, the solutions may also require financial support.
Four Facets of a Comprehensive Strategy for Continous Quality Improvement
- Customers- Remember how we defined customers previously? With this in mind, think about why the customer is the heart of the strategy. Any breach in this loop would result in more time, more cost, and decreased customer satisfaction. For example:
- The physician orders the examination, expecting that it will be done correctly and in a timely manner;
- The technologist expects the examination ordered is appropriate and that the patient will be informed and ready for it;
- The patient expects the examination to be quick and painless;
- The nursing staff expects that no equipment will be disturbed and that little participation or intervention will be necessary;
- The radiologist expects the films to be of high diagnostic quality and that as much information is available as possible;
- The physician expects a report of the findings without avoidable problems.
- Performance improvement- The focus must be on the highest quality. Improved performance improves customer satisfaction.
- Process improvement - You can have the finest staff on earth, but if the work processes are inefficient, staff talent is being wasted. Improving the process improves performance and again increases customer satisfaction.
- Supportive environment- If everyone involved with the organization is interested in and will work toward improvement, the other three facets will fall in line.
The Bottom Line
It is understandable that any organization wants to make money. But it has been proven time after time that if no attention is paid to the wants and needs of the customer, soon there will be no customer. Recognizing that the customer is not limited to one segment of the population has resulted in the analysis of worker development and training. By doing that, valuable employees are retained, a sense of ownership is instilled, and focusing on the process rather than the person, efficiency is increased and costs are decreased. No system is perfect, but the effort to improve how an organization functions is much more effective than assuming that people are the sole cause of problems. Take some time and try to determine where your organization fits into the use of quality improvement as a system to help decrease costs, and eliminate waste and loss of valuable resources. Also keep in mind that the provider (sometimes, that means you as a provider of diagnostic imaging) is also a customer of the process that you conduct every day.