Quality Management in Healthcare
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Chapter02.pptxChapter 2: Factors Influencing the Application and Diffusion of CQI in Health Care
Outline
Introduction
The dynamic character of CQI
The current state of CQI in healthcare
CQI and the science of innovation
The business case for CQI
Factors affecting successful CQI application
Motivational factors
The quadruple aim
Culture of excellence
Introduction
CQI is utilized across health care sectors (including primary and preventative care) as well as across geographic and economic boundaries
The need for CQI is increasing
One reason: the safety and quality of care has shown improvement since 2000 but further improvement is needed and improvement should be part of everyone’s goal in health care: clinicians, managers, researchers, and patients and their families
Greater complexity and new technology
External forces are increasing the demand for higher quality
Accreditation, legislation(e.g. the ACA in the U.S)
Introduction
Despite the continuing evolution and spread of CQI in health care in the 21st century
Some important questions remain about the adaptation and diffusion of quality improvement methods, especially in regard to the central role of individual health care providers. These include questions such as:
Why aren’t more health care providers using CQI tools and processes?
Why is the gap between knowledge and practice so large?
Why don’t clinical systems incorporate the findings of clinical science or copy the “best known” practices reliably, quickly, and even gratefully into their daily work simply as a matter of course?
How to expand further the implementation of CQI in health care?
This lecture will review a number of factors and processes have been shown to facilitate or impede the implementation of CQI in health care
The Dynamic Character of CQI
CQI methodology is constantly being refined and tested: it is an evolutionary quality improvement mechanism
This is because in response to new challenges, CQI applications develop via continuous, ongoing learning and sharing among disciplines about ways to use CQI philosophies, processes and tools in a variety of settings
Discussion Questions
What is the current state of quality in health care?
What are the problems regarding implementation of CQI in health care?
Given the widespread application of CQI, what factors that contribute to the implementation of CQI across industries and settings?
What are the factors that have influenced the rate of diffusion and spread of CQI in health care?
The Current State of CQI in Healthcare
• A decade after the Institute of Medicine To Err is Human (2000) and Crossing the Quality Chasm (2001) and despite best efforts, improvement in quality and safety remains limited
While progress has been made in understanding and implementing CQI, new challenges have arisen, and old challenges persist. For example, despite incentives for prevention, significant challenges remain in reducing medical errors
Discussion Question
Do you agree with the following quotation? Has it changed since 2010?
“U.S. health care is broken. Although other industries have transformed themselves using tools such as standardization of value-generating processes performance measurement and transparent reporting of quality, the application of these tools to health care is controversial, evoking fears of “cookbook medicine,” loss of professional autonomy, a misinformed focus on the wrong care or a loss of individual attention and the personal touch in care delivery…Our current health care system is essentially a cottage industry of nonintegrated, dedicated artisans who eschew standardization….Growing evidence highlights the dangers of continuing to operate in a cottage-industry mode. Fragmentation of care has led to suboptimal performance.” (Swenson et al. 2010, p. e12(1))
Key Issue
Some notable successes in application of health care CQI have been achieved - but much more needs to be done
How/What can we learn from the progress that has been made to expand CQI across a broader range of health care providers and health sectors
The Current State of CQI in Healthcare
Two key issues have been associated with the lack of improvement in the quality and safety of care in the U.S.:
Complexity and cost
Key points addressed by the triple aim of health care
(Berwick et. al., 2008 - to be discussed later in this lecture)
Complexity of U.S. Healthcare
The complexity of the healthcare system is both a challenge and a source of ideas for how to make improvements (Plsek & Greenhalgh 2001)
Health care is described as a complex adaptive system (Rouse 2008)
This has implications for how to improve the system of healthcare:
Health care can only be designed to a certain extent
Cannot be designed around minimizing costs
Requires a focus on maximizing value
There is a need to be proactive - designing the system required, rather than continuing to let it evolve
Therefore leadership is critical and
There need to be incentives for improvement
Cost of U.S. Healthcare
The U.S. Healthcare system is much more expensive, but not significantly better than other healthcare systems around the world (Leonhardt 2009)
CQI and the Science of Innovation
There are no simple answers about how to move CQI innovations into the mainstream of health care more quickly and efficiently
A common element to all complex systems is the difficulty surrounding diffusion of innovation
Diffusion theory provides one way of understanding the barriers and facilitators of CQI in healthcare
CQI and the Science of Innovation
Complexity must be considered in understanding healthcare innovation
Innovation may not be able to be managed, but organizational conditions can be designed and controlled in a way that “enhance the possibility of innovation occurring and spreading” (Greenhalgh et al. 2005, p.80)
Factors which facilitate these conditions include:
Leadership
The creation of a receptive and even enthusiastic culture (e.g. the development of quality improvement collaboratives).
The Surgical Safety Checklist (One example of diffusion of innovation)
Results vary but after the introduction of the SSC:
The SURPASS group study of six hospitals in the Netherlands, showed a statistically significant decrease in the proportion of patients with one or more complications, from 15.4% to 10.6% (de Vries et al. 2010).
Checklists have been adopted as a CQI tool in many different settings
An example of reinvention and leadership
Factors related to the process of adopting checklists are examples of factors related to diffusion of innovation
CQI and the Science of Innovation
The speed and overall adoption of any change is influenced by the characteristics of the change and how it is perceived by those responsible for implementation
Characteristics affecting change include:
Relative advantage
Compatibility
Simplicity
Trialability
Observability (Rogers 1995)
In the SSC example, compatibility (how closely do the change ideas align with the existing culture and environment) and trialability (the evidence base for whether the change can be adapted and tested in the new environments in which they are being spread) were most pertinent.
CQI and the Science of Innovation
Berwick (2003) identified 7 rules for dissemination of innovation in health care:
Find sound innovations
Find and support innovators
Invest in early adopters
Make early adopter activity observable
Trust and enable reinvention
Create slack for change
Lead by example
CQI and the Science of Innovation
Fundamental levers of CQI include:
Reinvention
Trust
Leadership
CQI and the Science of Innovation
CQI cannot be a top-down mandate
It must be part of the vision of an organization and accepted by all who must implement CQI - requiring trust at all levels
Trust comes from leadership and teamwork and Deming’s concept of “constancy of purpose.”
Top leadership must be involved and support and communicate the vision for innovation and change
The participation, buy-in and support from opinion leaders at all levels within an organization are critical for successful implementation, and the process to reinvention.
One size will not fit all. As described by Berwick (2003, p.1974) “To work, changes must be not only adopted locally, but also locally adapted.” Berwick asserts that for this to happen requires reinvention. “Reinvention is a form of learning, and, in its own way, it is an act of both creativity and courage. Leaders who want to foster innovation … should showcase and celebrate individuals who take ideas from elsewhere and adapt them to make them their own”(Berwick, 2003, p.1974).
CQI and the Science of Innovation
CQI and the Science of Innovation
Health care is complex and requires diligence to spread the improvement process.
Equally complex quality improvement strategies are required, slow adaptation
- Simple PDSA cycles, have enjoyed broad success.
Review of a study by Foy et al. (2002) by Greenhalgh et al
a prospective study of the attributes of 42 clinical practice recommendations in gynecology.
Examples of progress in specific segments of health care
models that can be considered to increase diffusion of CQI ideas.
Social marketing
Discussion Question
“Reinvention is a form of learning, and, in its own way, it is an act of both creativity and courage. Leaders who want to foster innovation … should showcase and celebrate individuals who take ideas from elsewhere and adapt them to make them their own”(Berwick, 2003, p.1974).
Do you agree?
The Business Case for CQI
A business case for a health care improvement intervention exists if the entity that invests in the intervention realizes a financial return on its investment in a reasonable time frame, using a reasonable rate of discounting. This may be realized as “bankable dollars” (profit), a reduction in losses for a given program or population, or avoided costs
A business case may also exist if the investing entity believes that a positive indirect impact on organization function and sustainability will accrue within a reasonable time frame.
The Business Case for CQI
The economic case for an innovation includes the returns to all the actors, not just the individual investing business unit
The social case involves measuring benefits, but not requiring positive returns on the investment
The social case has been overriding consideration in the battle to control medical variation and medical errors (McGlynn et al. 2003)
Economics alone does not provide an argument strongly for or against the use of CQI, but does add to the complexity of the wider and more rapid implementation of CQI in health care.
The Business Case for CQI
The business case for CQI faces the same negative factors as the business case for other preventive health care measures:
all or part of the benefits accruing to other business units or patients, and delayed impacts that get discounted heavily in the reckoning.(Leatherman et al. 2003)
The regulatory arguments for quality improvement efforts are usually justified on the basis of social and economic benefits such as lives saved and overall cost reductions, but are not necessarily profitable to the investor.
Factors Associated with Successful CQI Applications
Despite the need for greater diffusion of CQI in health care, much progress has been made, suggesting a broad array of factors that can be associated with successful CQI implementation. In addition to exploring new concepts, the key to greater diffusion starts with understanding and emphasizing those factors that work; for CQI in health care these include:
Regulatory agencies and accreditation
Motivational factors
Transformational leadership, teamwork and a culture of excellence
Regulatory Agencies and Accreditation
Regulatory mechanisms such as accreditation are key factors that have led to greater diffusion of CQI
The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS) have led to the implementation of a series of initiatives that require hospitals to report on quality measures
Quality Improvement Organizations (QIOs) report extensive CQI activities and findings associated with these activities
TJC has noted the use of robust, evidence based measures, linking process performance and patient outcomes (Chassin,et al. 2010) in the acute sector, but identified more work was required in measurements of quality in ambulatory care
Deming’s System of Profound Knowledge
Appreciation for a system
Knowledge about variation
Theory of knowledge
Psychology
Emphasizes the importance of intrinsic motivation
Motivational Factors
Intrinsic motivation
CQI as job enrichment
Capturing the intellectual capital of the workforce
capitalizing on professional and specialist knowledge of workers
Reducing managerial overhead
unique implications for healthcare setting
Lateral linkages
interdisciplinary care, interdependence and effective teamwork
Intrinsic Motivation
Intrinsic vs. extrinsic (e.g. financial reward, promotions) motivation critical to CQI
Identified in early stages of CQI evolution
Deming – System of profound knowledge
Deming’s point number 12: “eliminating barriers that rob people of pride of workmanship” (Deming, 1986, p.77).
Demotivation
Symptoms/causes of demotivation in health care
Burnout
Emotional exhaustion, diminished personal well-being and longevity and decreased quality of patient care
Triple Aim
Triple Aim: broadens the goals and definition of quality health care, and specifically serves as a model to improve the U.S. health care system through the simultaneous pursuit of three aims: “improving the experience of care, improving the health of populations, and reducing the per capita costs of health care” (Berwick, Nolan & Whittington, 2008, p. 759).
Addresses quality and cost simultaneously
But… for all of its good intentions and examples of notable success, some of the very same factors that led to adoption of the triple aim may have inadvertently led to burnout and demotivation among some health care providers.
One demotivation example often cited is excessive time spent recording information in electronic health records despite their value for promoting the triple aim through tracking, reporting on quality/safety and costs
Triple Aim to Quadruple Aim
To address the potential conflict in pluses and minuses of the triple aim one solution that has been proposed is to expand the triple aim by adding a fourth aim:
Improving the work life of clinicians and health care staff (See Bodenheimer and Sinsky, 2014; Sikka, Morath and Leape, 2015 for more details).
Leads to increasing intrinsic motivation
The key question is how?
How to Emphasize the Principles of the Quadruple AIM and Improve Intrinsic Motivation for CQI ?
Identify factors that influence CQI adoption
Transformational Leadership
Vision
Culture of Excellence
Teamwork / Empowerment
Communication and Feedback
Transformational Leadership, Teamwork, and a Culture of Excellence
Transformational leadership is distinguished by its reliance on vision (including a vision of continuous change, innovation and quality improvement)
Vision leads to a constancy of purpose
Motivation to achieve the goals of CQI shared by all
Through developing a culture of excellence
A culture of excellence is one that ensures excellence and high quality at every customer interface, in which a commitment to the highest quality and CQI is shared by all in the organization
A Cultural Model to Ensure Successful CQI Implementation
Culture of Excellence
Underlying the creation of a culture of excellence is a need for systems view which emphasizes the importance of:
adding value
leadership rather than management
influence rather than power and
the alignment of incentives focused on quality not quantity of services (Rouse 2008).
Culture of Excellence
Customer Focus
Emphasizing the importance of both internal and external customers
Systems Thinking
Optimizing the system as a whole and thereby creating synergy (Deming 1986; Spath and Kelly 2017)
Statistical Thinking
Understanding causes of variation, learning from measurement, and using data to make decisions (Balestracci 2009)
Culture of Excellence
Teamwork
Teams of peers working together to ensure empowerment and motivation, ensuring alignment of the organization, the team and the individual around the CQI vision
Communication and Feedback
Open channels of communication and feedback to make adjustments as needed, including feedback which is fact based and given with true concern for individuals’ organizational success (Balestracci 2009).
Leadership and Diffusion
Innovativeness is seen as critically dependent on good leadership
Organizational leadership is also critical to the development of a culture that fosters innovation (Greenhalgh et al. 2005).
Discussion Question
“Leaders within organizations are critical firstly in creating a cultural context that fosters innovation and secondly, establishing organizational strategy, structure and systems that facilitate innovation”
(Greenhalgh et al. 2005, p. 69)
Is the leadership that is critical to diffusion of innovation limited to those assigned leaders at the top of an organization ?
Leadership and Diffusion
Three types of leaders: opinion leaders, champions, and boundary spanners can contribute to the diffusion of innovation across an organization
Each of these types of leaders is found in the adoption of quality improvement initiatives in health care and often these various types of leaders are found in combination.
Opinion leaders
At all levels of the organization
Influence on the beliefs and actions of their colleagues
Influence can be either positive or negative in regard to embracing innovation
May be experts, respected for formal academic authority in regard to an innovation
Their support represents a form of evidenced based knowledge
May also be peers, respected for their know-how and understanding of the realities of clinical practice (Greenhalgh et al. 2005).
Leadership and Diffusion
Leadership and Diffusion
Champions
Persistently support new ideas
May come from the top management of or within organizations, including technical or business experts
Include team and project leaders and others who have persistence to fight both resistance and/or indifference to promote the acceptance of a new idea or to achieve project goals (Greenhalgh et al. 2005).
Leadership and Diffusion
Boundary spanners
Are a combination of these various types of leaders of innovation
Are distinguished by the fact that they have influence across organizational and other boundaries (Greenhalgh et al. 2005; Kaluzny 1974)
Play an important role in multi-organizational innovations and quality improvement initiatives (ie quality improvement collaboratives)
Teamwork
Teams play a major role in all of health care
Teamwork is one of the most important components of all successful CQI initiatives
Team building centers on the ability to create teams of empowered and motivated people who are leaders themselves and who will take the lead as necessary to foster change, innovation and improvement
The link between leadership and teamwork is the glue which holds CQI together – with leadership exhibited as called for at all levels within a team
“There is no substitute for teamwork and good leaders of teams to bring consistency of effort along with knowledge” (Deming 1986, p.19).
Teamwork
Inherent in teamwork:
A high level of empowerment of team members which in turn leads to high levels of motivation
Empowerment implies that levels of authority match levels of responsibility, and training
Training is critical to the success of leaders, and the training of future leaders is one of the most important responsibilities of a leader (Tichy 1997).
Results in all members of the team being able to make suggestions and interventions can be made to allow improvements and prevent problems or errors(Berwick, 2010)
Teamwork
Improved motivation is the result of empowerment, and both will interact to lead to higher quality
But both require a culture of trust
Deming’s point number eight is:
“Drive out fear. No one can put in his best performance unless he feels secure…Secure means without fear, not afraid to express ideas, not afraid to ask questions” (Deming 1986, p.59).
QICs: Example of leadership and Teamwork in CQI
The linkage between leadership and teamwork to ensure success in quality improvement in health care has been demonstrated in many instances
One very good example
Implementation of quality improvement collaboratives (QICs) - a form of virtual organization, requiring teams to work together “virtually” (across multiple locations), effectively utilizing empowerment, and leadership at all levels
Teamwork and leadership have been associated with success of QICs (Greenhalgh et al., 2005, p.165)
Kotter’s Change Model
Kotter’s work has been used to define a culture of change, including the role of vision and leadership
Eight-stage change model which describes “how to” rather than “what is” major organizational change
Provides guidance on traditional errors to avoid
There is a clear overlap between Kotter’s model and the factors defined in the figure describing the culture of excellence
Common elements include:
Empowerment
Communication
feedback loops to produce more change
the central role of vision and anchoring change in the culture.
Box 2-1: Kotter’s Eight-Stage Process of Creating Major Change
1. Establishing a Sense of Urgency
2. Creating the Guiding Coalition
3. Developing a Vision and Strategy
4. Communicating the Change Vision
5. Empowering Broad-Based Action
6. Generating Short-Term Wins
7. Consolidating Gains and Producing More Change
Anchoring New Approaches in the Culture
Source: Adapted from John Kotter, Leading Change
Despite the spread of CQI its further adoption in health care continues to meet challenges, similar to challenges faced by other forms of innovation in health care
Factors that influence the adoption of CQI include complexity, which can inhibit further adoption and the slowing down of progress after the impact of early adopters has waned
Factors associated with the successful diffusion of innovation provide a strong basis for identifying factors to further implement CQI
Conclusions
Conclusions
The factors that are associated with successful CQI applications can be clearly identified
These include leadership, intrinsic motivation and team work and their role in developing a shared vision leading to a culture of excellence
Culture of Excellence
Ensures excellence and high quality at every customer interface
A commitment to the highest quality and CQI shared by all in the organization
