Reflection 3

Chapter 12

Organizing for Quality

Outline

Introduction

Quality Management System

Quality Management Plan

A Hospitable Environment

Introduction

An organization’s governing body, usually the board of trustees, is ultimately responsible for the quality of health care services. The board exercises this duty through oversight of quality management activities. If a health care organization does not have a board of trustees, the legal owners of the business assume the responsibility of quality.

To accomplish quality management (QM) functions, health care organizations have a quality management system or framework that defines and guides all measurement, assessment, and improvement activities.

Introduction (2)

Many HC organizations are required by accreditation standards or government regulations to have a plan in place that outlines their quality management activities and strategies, known as a quality management plan.

Although a written quality management plan is not required, many accredited organizations have them in place.

Quality Management System

Quality Management System

HC quality management systems vary according to their governance and management structure. In general, six groups fulfill QM roles:

The board-oversees and supports measurement, assessment and improvement activities

Administration-responsible for the organization and management of measurement, assessment, and improvement activities

Coordinating Committee (or Individual)-directs measurement, assessment, and improvement activities

Medical Staff-develop and participate in measurement, assessment, and improvement activities related to the performance of physicians and other medical professionals who practice independently

Departments-develop and participate in measurement, assessment, and improvement activities related to non-physician performance

Quality Support Services-assist all groups in the organization with measurement, assessment, and improvement activities

Please review the aforementioned groups and their responsibilities on pages 304-310.

Quality Management System (2)

Quality Support Services-these are individuals or job titles in an organization that work together to assist with quality management activities. In larger organizations, an entire department may be devoted to these job functions. In smaller organizations, these responsibilities may fall to one or two individuals.

Common quality related positions include:

Quality Director

Patient Safety Coordinator

Physician Quality Advisor

Case Manager/Utilization Reviewer

Patient Advocate

Risk Manager

Infection Control Coordinator

Compliance Officer

Data Analyst

You can read about the specific job duties of these positions on pages 309-310.

Quality Management Plan

Quality Management Plan

The Quality Management Plan describes the organization’s process for measuring, assessing and improving performance. It can also be referred to as a:

Performance improvement plan (most commonly known as this)

Quality and patient safety plan

The purpose of the plan is to serve as a blueprint for all quality functions and activities. At a minimum it includes the following elements:

A quality statement

A description of the quality management infrastructure

Details of performance measurement, assessment, and improvement activities

An evaluation of the effectiveness of quality management activities

Quality management plan (2)

Quality statement-describes the goal to which all QM activities ae directed. The quality statement reflects the organization’s ideals and often incorporates its mission, vision, and values.

Quality management infrastructure-this element of the plan describes each stakeholder and their associated responsibilities. At a minimum, the infrastructure description should include the following:

Major stakeholders and expectations for their participation in QM functions

Committee structure, such as committees involved, their chairs and members, meeting frequency, bylaws if applicable, and methods of communicating)

Quality management plans (3)

Performance measurement, assessment, and improvement activities-these part of the plan details the variables to be measured and the execution of assessment and improvement activities.

It is important to note that in some organizations the QM plan does not change, it is reviewed yearly and updated if needed but in others it is what we describe as a living document-it is updated and revised frequently.

Evaluation of the effectiveness of QM activities-this section of the plan details evaluation activities. The coordinating committee is responsible (yearly) for evaluating overall QM performance by:

Determining whether the quality infrastructure has improved organizational performance

Making changes when necessary

Critical Concept 12.3 on pages 314-315 depict a template for a quality plan

A hospitable environment

Introduction

To improve quality, an organization must have the will to improve, the capacity to translate that will into positive change, the infrastructure necessary to support improvement, and an environment hospitable to quality.

Environment in this sense relates to culture. Culture is a system of shared actions, values, and beliefs that guides the behavior of an organization’s members.

There are three levels of organizational culture:

Observable Culture-the way things are done in the organization

Shared Values-awareness of organizational values and recognition of their importance

Common Assumptions-realties that members take for granted and share as a result of their joint experiences

Organizational culture

Is pivotal to successful continuous improvement, it influences the manner in which QM is implemented and executed.

Cultural tone affects the way all members of the organization interact. In a culture committed to quality, senior leaders and managers lead by example and encourage an environment of open, candid dialogue, and continuous improvement.

It should be noted that there is not a “correct” culture, what works for one organization may not work for others.

However, there are characteristics that are shared across organizations with a high performing culture (please see Critical Concept 12.4 on page 318).

Organizational culture (2)

Organizational culture is the root of many performance problems. If issues are identified (such as lack of trust, complacency, inefficiency, etc.) then leadership must work to achieve cultural change. Cultural change is generally instituted in the following steps:

Uncover core values and beliefs, including both stated goals and goals embedded in employee behavior

Look for cultural characteristics that are undermining the organization’s capacity to continuously improve

Establish new behavioral norms that demonstrate desired values

Repeat the steps over a long period. Emphasize to new hires the importance of the organization’s culture. Reinforce desirable behavior.

End of chapter 12