performance improvement (health Information management)

Group 9 - Evaluating PI Assignment  

When hospital D became part of Western Healthcare system that had a central board of directors, your hospital’s board began to struggle with its revised role. The new organizational environment included several outpatient clinics, multispecialty physician practices, and an insurance entity. Many of the current board members had served the organization since the hospital was built, and board activities always had been performed in a certain way. The administration rigidly controlled board meetings. Board members did not ask questions and routinely approved committee reports. The reports covered topics such as the organization’s financial status and future financial plans, physician credentialing, care quality monitoring, new policies, and plan for a new hospital. 

A new board member with a healthcare background was appointed after extensive screening and a personal interview with the executive committee. She was not part of the local business structure, and the administration was concerned that her appointment might not be a wise move. During her first board meeting, two very interesting reports were given. One report detailed some reengineering projects. One of these involved redesigning nursing staffing patterns. This redesign decreased the number of registered nurses (RNs), and replaced them with licensed practical nurses (LPNs) and certified nursing assistants (CNAs). The current quality report documented a very high quality of care and positive patient satisfaction surveys. Data excerpted from this report can be seen in the First Quarter column of the table below. Given that this was her first board meeting, the new board member remained silent and did not ask any questions. 

Performance data 

Quality Performance Measure	1st Quarter	2nd Quarter
Medication errors	3.2%	10.42%
Patient falls	4.21%	8.56%
Cesarean sections	14.21%	17.87%
Rate of vaginal birth after C-sections	18.27%	15.72%
Healthcare associated infections	1.78%	4.85%
Surgical errors	0.15%	0.21%
Patient Satisfaction Measure	1st Quarter	2nd Quarter
Overall service	40.52%	20.74%
Overall clinical	86.72%	70.82%
Overall quality of service	45.40%	22.34%
Food	30.56%	32.54%
Overall cleanliness	85.89%	83.26%

 

Within four months, the new nursing staffing patterns had been launched. Data excerpted from the quality indicators report presented to the board can be seen in the “2nd Quarter” column of the table. After reviewing the data presented by the nurse administrator, the new board member was very concerned and decided to ask if the values in the quality report, which show a negative trend, were for the nursing units with the new staffing patterns. The administrator reported that there was a direct correlation. This answer initiated discussion among other board members who were accustomed to using quality indicators in their businesses. This was the first substantive board-level discussion that the new board member had seen. One board member wanted to know whether any data had been gathered from patient focus groups. Another board member asked whether the average length-of-stay data had increased, and someone else asked a about a cost-benefit analysis of the new staffing patterns. Following the usual process, the chair called for approval of the report and presentation of the next item on the agenda. 

 

Questions: 

1. What changes or patterns do you see in the data? What remedies might be suggested for any problems?

The changes or patterns seen in the data from the 1st quarter and 2nd quarter reflect a drop in the quality performance measures and the patient satisfaction measures for the Regional Medical Center post nursing staff changes. The data showed: 

· An increase in medication errors, patient falls, C-sections, Nosocomial infections, and X-ray discrepancies, which results in a decline in the quality of performance. 

· A decrease in overall service, overall clinical, overall quality of service, and overall cleanliness, which results in a decline in patient satisfaction. 

Remedies that might be suggested would be to have the healthcare organization clearly define what will be measured, which data will be collected and by whom, and the frequency and intensity of which the data will be collected and reported. Also, the healthcare organization should create a data collection and reporting schedule to ensure that data being collected is consistent, timely, accurate, and reliable. With the implementation of new staffing patterns in the nursing unit, it is unclear if LPNs and CNAs were taught or have gone over what data should be collected and inputted since they would be replacing the roles of RNs, which could change the results. Leaders should provide staff training in basic approaches to PI such as a two-part training program for all employees as part of the organizations new-hire orientation process, which is then repeated or supplemented annually for all staff. Educating leaders and the staff on the principles of PI, data collection, and data analysis is essential in the organization. Also, follow up of audits on a more frequent time frame may lessen the deficits. 

 

2. Has the CEO carried out his or her responsibility for educating the board? Why or why not?

No, I feel that the CEO has not carried out his or her responsibility for educating the board. The CEO is responsible for collecting information and data from other departments within the hospital to be able to present to the board of directors as a performance evaluation. Based on the discussion, or lack of discussion, held by the board members in the meeting and the insufficient information presented to them, the CEO has failed in his or her responsibilities in delivering such an evaluation and in ensuring that the board itself is knowledgeable about its governing responsibilities and educating them on issues related to their responsibilities. The board did not work together to identify community needs, pursue organizational goals, or try to understand the organization’s approach to PI to ensure quality patient care and safety. Especially when the organization has expanded to include several outpatient clinics, multispecialty physician practices, and an insurance entity, this should have been discussed, but was not.  The CEO should ensure the competence and integrity of the medical staff, as well as include more data that will accurately portray what is going on within the hospital and organization.  

3. Depending on the answer to question 2, what strategies would you recommend at this point?

Strategies we would recommend would be to create and enforce a culture of collaboration among the healthcare organization where they are able to identify the organizations overall mission, vision, and goals and focus on PI and plan and provide improvements that endure. Such as having leaders in the organization complete a SWOT analysis that will help to identify the organizations strengths, weaknesses, opportunities, and threats. Also, utilization of a PDCA (Plan-Do-Check-Act) model to be able to assess continuous performance improvement. We would also recommend extensive training and PI education for all medical staff, especially with new nursing staff (LPNs and CNAs) on how to accurately input data, as there could have been miscalculations that could lead to misrepresentation of data. The medical staff needs to be held accountable for their work ethics Patient care, quality of care, and patient safety needs to be addressed. 

4. What quality data should be reported and utilized by this board of directors?

PI priorities should be data driven, which is why it is important that quality data be collected that accurately represents the whole organization in order to implement effective PI strategies. The data collected does not reflect the new structure of the organization and is limited to the hospital side (surgical & inpatient care). Data needs to be collected to represent the whole organization, not just parts of it. A lot of information is missing and does not accurately represent the big picture. Quality data that should be reported should include clinical data, outpatient care, ambulatory care, and data that reflects the insurance entity. Also, data should include overall performance of each of the areas, either by department or units, and how interdisciplinary collaboration is occurring.  

5. Given this administration’s style and leadership approach, how do you think the minutes of the board meeting reflect actual board meeting discussions?

The administration's style and leadership approach seem to be non-collaborative and does not encourage open communication among the organization since “administration rigidly controlled board meetings and board members did not ask questions” also they seem to be somewhat resistant to change since “many of the current board members have been serving the organization since the medical center was built and many of the board activities have always been performed in a certain way”, once a new member was added to the board that was not part of the local business structure, concerns were raised. I believe the approach used by administration does reflect the minutes of the board meeting and the actual board discussions since the new board member noticed that “the current quality report documented a very high quality of care and positive patient satisfaction surveys” but she remained silent and did not ask any questions. The data being very high should have raised a red flag and initiated questions and an investigation to check the quality of the data to find out how reliable and accurate it really is. When the new board member was added, an orientation session should have occurred at the beginning of her tenure that included initiatives and activities that the organization is participating in to improve patient care quality and safety, which I believe also did not occur, since the new board member focused on nursing pattern trends, instead of focusing on the new organizational environment. If an organization has a strategic initiative to add a new service (such as including several outpatient clinics, multispecialty physician practices, and an insurance entity) than all departments, organization leaders, and the board of directors should be included in defining measures and assessment activities for the new service, which was not done. The board of directors' ultimate responsibility is for the quality and safety of patient care received at their organization. The board should have devoted significant amount of time to quality issues/discussions, especially with the data received from the 1st Quarter, but instead the concerns and questions only occurred after the 2nd Quarter, which I believe should have been addressed from the beginning. It seems to me that the board members did not devote sufficient board time and attention to safety, quality, and the patient experience of care. For the board members to effectively implement correct PI initiatives they must first be able to collaborate and brainstorm together, think critically, and be open to new perspectives so that plans can be developed to meet expectations and improve outcomes.  

 

References:  

Shaw, P., & Carter, D. (2015). Quality and Performance Improvement in Healthcare:   

Theory, Practice, and Management.