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Chapter 18

Effective Quality and Productivity Management

What You Will Learn

•  Productivity and quality are interrelated. Both can be improved without compromising the other. Poor quality carries high costs.

•  Quality is a multifaceted concept. Services delivered must consistently produce desirable outcomes and prevent undesirable consequences.

•  Both technical quality as well as consumer-defined quality must be evaluated. Evidence-based protocols standardize clinical processes, decrease care variability, and improve outcomes.

•  Three domains of quality—structure, process, and outcome—are equally important in driving quality improvement.

•  Compliance with certification standards has been widely used as a proxy for quality, but regulatory requirements are not without criticism.

•  The Affordable Care Act requires implementation of a Quality Assurance Performance Improvement (QAPI) program in certified nursing facilities.

•  The focus of measurement must be on outcomes for both technical and consumer-defined quality. Several private firms specialize in developing and conducting client satisfaction surveys. Scores obtained through measurement must be evaluated in relation to some benchmark.

•  Level of cognitive impairment has a substantial influence on the validity of quality of life measures.

•  Continuous quality improvement (CQI) is based on six principles: meeting customer needs, building a culture of quality, statistical evaluation, involvement of all departments, interdisciplinary teamwork, and continuous learning and training.

•  The four-step Deming’s continuous improvement cycle can be applied to any process.

•  The ultimate aim of CQI is to build a culture in which quality becomes institutionalized.

Introduction

Efficiency, productivity, and quality improvement are often regarded as isolated and even contradictory concepts. Some people instinctively equate “efficiency” and “productivity” with “doing more with less.” Nursing home personnel have a tendency to presume that improved efficiency means working harder, doing more in less time, and constantly rushing to meet patients’ needs. It is also assumed that quality suffers when greater efficiency is required and that an organization may achieve either higher quality or greater efficiency but not both. Years of research and experience in various industries, however, have demonstrated that such ideas are flawed.

Modern methods of improving quality and productivity were developed in manufacturing industries. Service organizations, in general, lagged behind the manufacturing sector in implementing these methods. Hospitals, nursing facilities, and other health care organizations were even slower than other service industries in adopting the concepts and methods of quality improvement. First, health care managers were skeptical that quality could be improved. Second, they were skeptical that quality and productivity could both be improved without compromising one of them. Increasingly, however, health care managers have realized that quality and productivity can indeed be managed and that effectively managing these areas can provide a competitive edge to an organization.

Productivity and Quality

For all practical purposes, productivity and efficiency are synonymous. Measuring productivity and efficiency means taking into account the cost of inputs used in the production of certain outputs. Delivery of patient care is particularly labor intensive, which means that people have to provide hands-on services that, in most instances, cannot be taken over by technology. Hence, improving productivity is challenging in the delivery of health care.

Although productivity is often viewed as physical outputs produced in exchange for certain quantified inputs, a sole focus on physical outputs can actually be counterproductive. The notion of outputs must incorporate the quality of the outputs produced, not merely their quantity.

For simplicity, outputs in a nursing facility are collectively called patient care. These outputs are the result of the various patient care delivery processes such as social services; medical care, nursing, and rehabilitation; recreation and activities; dietary services; plant and environmental services; and administrative and information systems. Productivity is enhanced when the most desirable outputs are produced at the least cost for these services.

Productivity and quality are interrelated. According to current management thought, improved quality can lead to improved efficiency and vice versa. From this perspective,  productivity  is defined as maximization of quality for each unit of resources used in delivering health care. Accordingly, productivity can be expressed as “desired quality at the lowest possible cost” (equation 1) or as “highest possible quality for a given cost” (equation 2) (Palmer, 1991, p. 12). Measuring productivity therefore requires assessing how effectively a nursing facility’s resources are used in delivering patient care services that meet certain standards of quality.  Inefficiency,  on the other hand, reduces the opportunity for quality at a given level of resources (Griffith & White, 2002). In other words, when resources are deployed without enhancing quality, the use of such resources becomes inefficient.

To borrow language from the manufacturing industry: “It takes just as many resources to make a bad product as it does to make a good one” (Evans & Lindsay, 1993, p. 30). In a nursing home, delivering poor patient care would still require the same level of resources as it would to deliver good patient care. In fact, the cost of poor quality can be very high. In the long run, the cost of poor quality may actually far exceed the cost of producing high-quality services. Just think of the many costs associated with low quality. Direct costs can include fines and penalties imposed by regulatory agencies, legal costs incurred in defending against lawsuits, and payment of legal settlements. Indirect costs emanate from the long-term negative effect on the facility when trust in the community erodes, followed by declining reputation and a drop in patient census. Certain hidden costs may include increased staff turnover and absenteeism. Costs associated with investigation of complaints are also hidden costs of poor quality.

Quality improvement should enhance the profitability of a nursing facility. Various studies have shown that nursing homes that produce high-quality services are able to lower their costs for delivering patient care because quality improvement often improves processes of care as well as productivity. As an example, even when higher costs are incurred by increasing hours for RNs in relation to other staff, an indirect inverse effect on overall costs is observed through the positive effect of these extra RN hours on outcomes of care (Weech-Maldonado et al., 2003). Through a higher skill mix, care-related problems can be addressed more promptly, better direction can be given to paraprofessionals, and regulatory and legal sanctions can be avoided through improved care.

What Is Quality?

Quality  in a nursing facility can be defined as the consistent delivery of services that maximizes the physical, mental, social, and spiritual well-being of all residents, produces desirable clinical outcomes, and minimizes the likelihood of undesirable consequences. Note that delivery of high-quality care in the nursing home has four essential components: consistency, holistic well-being, desirable clinical outcomes, and prevention of undesirable consequences. Hence, quality is a multifaceted concept.

Consistency

The word consistency signifies four characteristics that apply to nursing home services:

•  Continuity

•  Regularity

•  Uniformity

•  Reliability

Continuity means that delivery of high-quality services must be sustained over time. Variations from one day to another must be kept to a minimum. In practical terms, continuity means that the facility should, among other things, be just as clean on the weekend as it is on a weekday and that the food served should taste just as good at supper as it does at lunch.

Regularity means timeliness. Regularity emphasizes timely attention to patient needs. Examples of regularity in a facility include regular bed checks for incontinent patients, prompt response to call signals from patients who need staff attention, and timely attention to situations that require the intervention of social services.

Uniformity is sustained delivery of quality not only over time but also across the patient population within the facility. Uniformity means delivering the same caliber of services to all patients regardless of their pay status, race, or any other characteristics.

Reliability is the acid test of consistent quality. Reliability is achieved when a facility’s associates can deliver uncompromised quality when no one is watching, because management and family members cannot be in the facility all the time to monitor quality. Trust and dependability are built when family members can be free from undue worry about the total well-being of their loved ones.

Holistic Well-Being

Holistic care is one of the key characteristics of long-term care. The holistic approach emphasizes delivery of services that meet the patient’s physical, mental, social, and spiritual needs in the context of the whole person. Hence, quality includes much more than clinical care. It must also emphasize all aspects of quality of life.

Desirable Clinical Outcomes

An  outcome  is an actual result obtained from medical, nursing, and other clinical interventions. An increase in positive outcomes indicates that quality has improved. For example, quality is improved when a greater number of patients than before undergo rehabilitation therapy after orthopedic surgery and return home, when there is notable progress with the healing of pressure ulcers that were present when patients were admitted, and when patients are weaned off urinary catheters. On the flip side, incidence of new pressure ulcers acquired in the facility, prevalence of falls or injuries, frequency of infections, and occurrence of health-threatening weight loss or dehydration are indicators of negative quality outcomes.

Prevention of Undesirable Consequences

An important aspect of quality is the system a nursing facility implements to prevent negative outcomes—and how effectively that system is actually used and monitored. Such negative outcomes as accidental deaths and injury from negligence can have catastrophic consequences. Waiting for negative outcomes to occur is obviously not the desirable approach. Clinical errors, lapses in safety, unsanitary conditions, and untimely maintenance and repairs do not always produce negative consequences, but they often have the potential to cause harm. For example, a patient smokes unsupervised in a smokers’ lounge. Even though nothing happens, the situation is really not as innocuous as it may appear. What if the patient was severely burned or a section of the building had caught fire? The potential devastation is unimaginable.

Technical and Consumer-Defined Quality

An understanding of total quality must incorporate both technical and consumer perspectives. The outcomes of care delivery are just as important as client satisfaction.

Technical Quality

The preceding description of quality, related to care delivery, can be called technical quality. The level of a facility’s technical quality depends on its clinical structures, its processes and practices, and the technical competence of its staff. Increasingly, in health care delivery, evidence-based practices—also referred to as  best practices —are being used as a means of reducing inappropriate care and improving patient outcomes (Berlowitz et al., 2001). Hence, the use of evidence-based practices is an essential characteristic of long-term care. Best practice guidelines are available for a number of clinical situations, such as management of urinary incontinence, prevention of pressure ulcers, treatment of pressure ulcers, prevention of urinary tract infection, diabetes management, post-stroke rehabilitation, and pain management for cancer patients, etc. The American Geriatric Society, the Agency for Healthcare Research and Quality, and the American Medical Directors Association (AMDA) have been at the forefront of developing best practice guidelines for the care of elderly patients. The AMDA has also developed training tools on how to implement the guidelines. The underlying premise of evidence-based protocols is that standardizing work processes decreases variability in care delivery and improves outcomes (Finch-Guthrie, 2000). However, implementation of standardized guidelines has been challenging in nursing homes because care delivery in nursing homes requires interdisciplinary decision making, and as much as 70% of the care is provided by paraprofessionals who have little formal training. Hence, training of associates is critical to improving quality.

Consumer-Defined Quality

Consumers’ impressions about quality can be called consumer-defined quality. Even though patients and family members are not equipped to evaluate technical quality, they form impressions about quality on the basis of their personal observations and experiences, what they may hear from other family members, stories they may encounter in the news media, and how the facility’s staff interact and communicate with them. Consumers are also better able to assess quality-of-life factors than technical quality. Their impressions are influenced by the aesthetics of the physical premises, cleanliness and comfort, food, activities, staff attitudes, interactions with management, and the facility’s accommodation of individual needs and preferences.

It is possible for consumer-defined quality to actually be at odds with a facility’s technical level of quality. In general, consumers seek more than technically correct health care. They seek humanistic qualities as well as technical competence (Palmer, 1991). For this reason, staff members must be trained in communicating with the patient and family, listening for signs of distress, responsiveness, respect, empathy, honesty, and sensitivity.

Framework of Quality

The management of quality requires an understanding of the framework to guide the improvement of organizational quality. This framework has been credited to the work of Avedis Donabedian (1919–2000). He proposed three domains in which health care quality should be examined: structures, processes, and outcomes. All three domains are equally important in driving quality improvement, and they are closely linked in a hierarchical manner (see  Figure 18–1 ); structures influence processes, and both structures and processes together influence outcomes. Structures and processes in long-term care are shaped by regulations as well as by other changes in the external environment such as new technology, culture change, ecological forces (new infections, antibiotic-resistant strains of bacteria, natural events, etc.); and management philosophies and practices.

Figure 18–1  Framework of Quality

Structures

Structure provides the necessary foundation without which high-quality patient care cannot be delivered. In that sense, structure is where quality begins. Structural criteria refer to the availability of resources, such as facilities, equipment, staffing levels, staff qualifications, programs, and the administrative structure (McElroy & Herbelin, 1989). Space, building layout, furnishings, technology, adequate supplies, trained associates, staffing levels and skill mix, minimum absenteeism and turnover, and facility policies constitute structural elements of quality. The structural elements determine a nursing home’s capabilities to deliver an adequate level of care. Inadequate structural quality would negatively affect processes and outcomes.

Processes

Processes are methods designed for producing desired outputs and the application of those methods to actually produce desired outcomes. Processes entail staff functions, timeliness, accuracy, following established protocols, monitoring and observation, and taking appropriate action to counter negative observations. Each department of the nursing facility must establish functional protocols to aid in the achievement of the process elements of quality. Examples of such protocols include clinical practice guidelines; quality improvement program; cleaning and sanitizing procedures; pest control; food purchasing, storage, production, and service; building and equipment maintenance procedures; and activities and recreational programming.

The quality of nursing home processes is governed by achieving excellence in the delivery of services that can be classified into three categories: individualized services, common services, and common practices.

Individualized Services

Patient assessment is the cornerstone on which clinical processes (such as plan of care and the delivery of services) are based to meet individual needs. Individualized care plans establish clinical expectations that guide the delivery of individual care such as administration of medications, nursing treatments, rehabilitation therapies, social interventions, recreational support, special diets, and assisting the patient with activities of daily living (ADLs).

Common Services

Common services consist of routine functional protocols that apply to all patients unless contraindicated in the care plan. Examples include daily hygiene and grooming, scheduled shower or bath, hydration, bedding change, and clean towels. Other types of common services include accurate billing, timely and complete medical records, communication with family about the patient’s status, and notification to physicians. Although the nature of these services is common to all patients, their application is individualized.

Common Practices

Common practices include infection control, quality improvement, environmental cleanliness and comfort, safety and security, respect and dignity, privacy, and active promotion of patient rights. Protocols for common practices should ensure that certain practices are consistently followed to meet the basic needs of the entire patient population in the nursing facility.

Outcomes

Outcomes are the final results produced by the structures and processes. Primarily, clinical outcomes are evaluated against individualized care plans to determine whether preestablished treatment and intervention goals have been met. Other outcomes include elements outside the plan of care and focus mainly on preventing negative incidents such as drug interactions, accidents, alleged abuse, infections, and facility-acquired (nosocomial) pressure ulcers. In almost all cases, outcome issues can be addressed only by retrospectively evaluating structures and processes and by taking appropriate corrective action.

Regulatory Minimum Standards

Historically, quality in nursing facilities has been defined by standards established for participation in the Medicare and Medicaid programs. Nursing home inspections conducted by the states, known as the survey process, have been used to ascertain compliance with certification standards. Compliance with these standards has been widely used as a proxy for quality.

Over the years, quality of care in nursing homes has improved, mainly in response to the enforcement of regulatory standards. The survey process, however, has had three major limitations:

  1.  Regulations establish only minimum standards of quality.

  2.  Nursing facilities cannot be monitored on a continuous basis by regulatory agencies.

  3.  There are wide variations in survey results, despite the government’s efforts to standardize the process and train its surveyors.

According to the Requirements of Participation, nursing facilities must establish a quality assessment and assurance committee. The committee must include the director of nursing, a physician, and at least three other members of the facility’s staff. Some major nursing home corporations have based their quality assurance programs on the certification standards, and these corporations internally monitor compliance more frequently than federal regulators do.

The Affordable Care Act has required the Centers for Medicare and Medicaid Services (CMS) to develop and implement a Quality Assurance Performance Improvement (QAPI) program in certified nursing facilities. One of the main objectives of QAPI is to institutionalize the use of clinical practice guidelines. The program is intended to continuously study the processes of care delivery with the intent of preventing or decreasing the likelihood of quality problems. QAPI is a data-driven approach that would involve members at all levels of the organization (CMS, 2014).

Measurement and Evaluation of Quality

Quality cannot be improved without measuring it.  Measurement  refers to collection of meaningful data, analysis of the data, and comparison of the data to objective benchmarks of quality. Measurement and evaluation of quality are geared to pinpoint deficiencies so that corrective actions can be taken to improve quality.

Focus on Outcomes

Although structure, process, and outcome data all have a place in measurement of quality, the focus of measurement must be on outcomes. Structural measures only serve to ensure that staff, facilities, equipment, and organizational features meet at least the minimal necessary conditions for delivering good care (Palmer, 1991). Process measures evaluate methods and practices intended to maintain or improve quality. Outcomes, however, define whether quality goals are being met. When anticipated outcomes are not achieved, administrators must reexamine the structures and processes to determine where the breakdown occurred and what actions should be undertaken to prevent future failures.

Quality measurement can be illustrated by using the simple example of a meal tray delivered to a patient who requested to have the noon meal in her room. Placing the meal tray before the patient is the main outcome, without which the output would be zero, a total failure of quality. But, assuming that a meal tray is delivered, other attributes of this output—such as timeliness of delivery, conformance of the food items placed on the tray with the patient’s diet, compliance with the patient’s prior indications of likes and dislikes regarding choice of food items, size of the portions served, temperatures of the hot and cold items, the amount of food actually eaten by the patient, and the patient’s level of satisfaction with the meal—must be evaluated. Each of these attributes is measurable, so a composite score can be used to quantify the level of quality.

Measuring Customer Satisfaction

Customer satisfaction is best assessed through a satisfaction survey—called a survey instrument—completed by patients and their surrogates. It is critical, however, that the reliability and validity of the survey instrument be established in order to get meaningful information about customer satisfaction.  Reliability  is the extent to which the same results occur from repeated applications of a measure under identical conditions. Reliability deals with the precision of measurement. Unless a survey instrument delivers reliable results, the results obtained by surveying customers at repeated intervals, such as every year, cannot be compared. For example, if in the first year of using the survey a facility scored a 7 on a scale of 1 to 10, and in the second year the same facility scored a 7.5, improvement in customer satisfaction can be inferred only if the instrument used to assess satisfaction had a high degree of reliability. The  validity  of a survey instrument denotes the extent to which the instrument actually measures what it purports to measure. Reliability in itself does not ensure that a measure is valid. An instrument can have very high reliability, but if it has poor validity, the results become useless. For example, if a survey instrument measures customers’ satisfaction with factors other than those associated with the facility’s services, such as satisfaction with location, geographic access, and opinions of friends, such an instrument will be useless in helping the facility improve satisfaction by improving the facility’s services. Reliable and valid measurement instruments can be designed by health care researchers.

Individually rated responses from consumer surveys are consolidated to determine an overall score of customer satisfaction. Such aggregated scores derived from all the responses to a survey provide an estimate of the average perceived quality (Lawton, 2001). When necessary, survey results can be supplemented with other approaches such as focus groups, particularly when further clarification or additional information is needed. Research has demonstrated that there is a high degree of correlation between subjective assessments of satisfaction and key outcomes.

Several private firms specialize in developing and conducting client satisfaction surveys for health care organizations. Many of the instruments have undergone extensive development and testing. Separate survey instruments should be used for nursing home residents and their family members. For nursing home residents, a survey administered by an interviewer is likely to produce more objective results than one that the resident fills out independently.

Evaluation and Interpretation

Once outcomes have been measured, the results must be interpreted (or evaluated). For instance, a numerical score is meaningless unless its relevance is clearly established. The goal of evaluation is to transform numerical scores into meaningful information that would be useful for improving quality. Evaluation is always done in relation to some benchmark. A benchmark can be anything that management considers acceptable. For example, staff turnover is an inverse and indirect measure of quality; a high score indicates low quality of human resource and leadership practices and vice versa. Suppose a given nursing home has an annual turnover rate of 30% for licensed nurses. This measure is not very helpful unless it can be interpreted in relation to some benchmark such as nurse turnover rates in the nursing home industry or within a multifacility corporation or a target established by the administrator and the governing board.

Measuring Quality of Life

For nursing home residents, quality of care and quality of life (QoL) are closely intertwined. However, measuring QoL has been challenging even though various scales have been developed. One main barrier is the ability of all residents to complete the surveys because of various levels of cognitive impairment. Although it is possible to interview care personnel or family members to obtain proxies of a resident’s QoL, research shows that staff and family answer questions differently than residents do (Kane et al., 2003). Only in high cognition groups can 80 to 90% of the residents answer QoL-related questions. Hence, the level of cognitive impairment has a substantial influence on the validity of QoL measures (Gerritsen et al., 2007).

CMS’s Quality Initiative

CMS’s Nursing Home Compare and 5-Star Ratings is a public reporting system (sometimes referred to as Nursing Home Report Cards) that, over time, has incorporated various quality indicators. Although the policy goal of report cards is to improve the quality of care, research has found that the report cards have generally had only a modest effect on nursing home performance. More recently, Grabowski and Town (2011) concluded that nursing homes operating in more competitive markets improved their reported quality more than facilities in less competitive markets. Hence, quality improvement lies mostly in the operational domain of nursing home administrators.

Quality Improvement

The current focus in health care is on  continuous quality improvement (CQI) , which is an ongoing undertaking to improve quality throughout the nursing facility. Also called total quality management (TQM), quality improvement requires total effort involving all associates in the organization. Quality improvement in long-term care embodies six basic principles (adapted from Evans & Lindsay, 1993) that form the framework for CQI:

  1.  A facility can be successful only by understanding and fulfilling the needs of its customers.

  2.  Leadership in improving quality is the responsibility of the nursing home administrator, with full support from the governing board. Leaders must work toward establishing a culture of quality.

  3.  Statistical evaluation using factual data is the basis for CQI.

  4.  All departments within the facility must implement CQI.

  5.  Problem solving and process improvement are best performed by interdisciplinary (or multidisciplinary) work teams.

  6.  Continuous learning, training, and education are the responsibility of everyone in the organization, but these activities require support from the top.

Meeting Customer Needs

Quality management is primarily based on understanding who the customers are. Here, the term  customer  is used in a broad sense as any entity that receives the product of a transaction. Patients and their families are the primary customers. There are other customers, however, who may not receive the end product but have a vested interest in the quality of the products. Griffith and White (2002) referred to them as customer partners. Customer partners or external customers are the stakeholders. They include payers (Medicaid, Medicare, managed care organizations, and other insurers), regulatory agencies (state departments of health, agencies on aging, local health and fire departments, and the Joint Commission), and referral agencies (hospitals, physicians, and others). A nursing facility also has internal customers, which include all personnel who receive information, services, or other professional support from fellow employees. To deliver what external customers expect, these internal customers have to depend on each others’ outputs (Bradley & Thompson, 2000). Attending physicians, for example, rely on information and support from the facility’s nursing staff, and these physicians should be regarded as critical internal customers. The same attending physicians can also be regarded as external customers when they refer patients to the facility. Certified nursing assistants (CNAs) need the support of professional nurses, and nurses in turn often rely on the CNAs to report problems or changes in a patient’s condition. Fulfilling the needs of internal customers affects the way the needs of external customers are addressed.

Quality cannot be improved without a strong commitment on the part of all associates to meet the needs and expectations of all customers. Also, the requirements of internal customers should be linked to those of the external customers. If an internal requirement does not in some way help meet external customer requirements, then its value should be questioned (Gaucher & Coffey, 1993).

Leadership and Culture

Commitment, leadership, and support from top management play a vital role in establishing the overall tone for CQI. Empirical evidence demonstrates that success in CQI implementation is strongly associated with the commitment and culture of top management. In organizations characterized by top management commitment, turnover at key top-level positions is low, the associates view top management as strong advocates of CQI, leaders are open minded and communicative, leadership styles are participatory and team oriented, and top managers demonstrate a clear understanding of CQI principles (Parker et al., 1999).

Top managers must first understand the concepts of CQI and then become knowledgeable about the tools, processes, and methods necessary for quality improvement (Baird et al., 1993). Commitment to CQI includes allocation of necessary resources. Top managers should then set goals and plans for implementing principles and practices for quality improvement. Top managers must be committed to involving all associates by providing proper training and a reward system for accomplishing quality goals (Evans & Lindsay, 1993).

Most experts agree that quality improvement occurs in an organizational culture that values quality. On the other hand, one of the key barriers to change is the conscious or unconscious retention of old beliefs and actions that discourage innovation, creativity, empowerment, or other components of CQI (Gaucher & Coffey, 1993). Once a CQI program is implemented, both managers and workers should be prepared to accept failures along the way. However, patience and perseverance are necessary. Fear of failure only stifles innovation.

Management must seriously engage in building a culture of quality. A CQI culture has the following characteristics (Parker et al., 1999):

•  CQI is viewed not as a distinct initiative but as an everyday part of each associate’s job.

•  Morale is high, and staff turnover is low.

•  Associates have a strong sense of pride in the organization.

•  Communication is open, and risk taking is rewarded.

•  Change is readily accepted.

•  Strong team orientation is apparent.

Organizational culture can change only gradually over time. Management must continually emphasize to its associates that quality remains a top priority; otherwise, the organization risks losing the commitment of its associates (Evans & Lindsay, 1993). Relatively short tenures of nursing home administrators and other key personnel disrupt the cultural continuity that is so essential for CQI. Job-hopping administrators never get to understand the facilities they manage for short durations. Such administrators do a great disservice to the patients and to their profession because follow-through over time is necessary for building quality and productivity. A culture of quality is built over time with staff stability and consistency. This culture requires empowering leadership that is open to the ideas of others. Managers share organizational power by giving autonomy and discretion over tasks to the associates; they build teams by coaching and mentoring; they use rewards and recognition to change behaviors that would otherwise stifle quality improvement (Gaucher & Coffey, 1993).

Statistical Evaluation

Quality improvement is anchored on a quantitative approach in which data and measurements are used to evaluate the current state of quality, improve processes, and track progress. Sources of data may be the facility’s own internal records and information systems, special surveys, logs, checksheets, or observational studies. The data can be charted to show trends and deviations from benchmarks.

Encompassing All Departments

CQI must focus on all departmental functions in the facility. At any given time, each department in the nursing facility can have some area of concern to improve upon. CQI also requires scrutiny of interdepartmental communications, process interlinkages, and horizontal coordination among the various organizational units, all in the context of meeting the expectations of internal and external customers.

Interdisciplinary Work Teams

A team approach to quality improvement is likely to make the process unbiased, systematic, and thorough. The team approach can be accomplished by formulating a quality improvement committee composed of associates representing every discipline. Under the leadership of the administrator or a consultant, the composition of the committee should change as new quality issues are addressed. As different associates get the opportunity to be on the team, the team becomes a mechanism for building a culture of quality in the organization, in training associates, and in building a sense of ownership in quality improvement. Once the CQI is well established, more than one team can work on different quality improvement projects.

Hiring a consultant may be necessary for CQI, especially when a facility initiates a CQI program. The consultant can evaluate the cultural aspects of the organization that could pose barriers to the success of a CQI program. When substantial barriers are foreseen, the administrator is in a better position to develop a strategy for gradual change. The consultant can also be instrumental in training associates at all levels as well as senior management. Such organization-wide training is how CQI programs are almost always formally begun. Training is necessary to reach a common understanding about CQI, clarify goals, and establish reasonable expectations.

Continuous Learning

A well-developed CQI program involves the participation of associates at all levels of the organization. Continuous learning then becomes institutionalized alongside continuous improvement of quality as associates discover improved methods and play a role in implementing them. In an interdisciplinary environment, associates get to better understand how their actions affect the work of others and how their actions, in turn, affect the expectations and satisfaction of both internal and external customers.

Deming’s Process Improvement Cycle

The Deming cycle, named after W. Edwards Deming (1900–1993), is used to focus on improving processes that would result in improved outcomes. It involves four steps: plan, do, study, and act (PDSA). The PDSA cycle is a continuous improvement cycle ( Figure 18–2 ) that can be applied to any process.

Plan

The plan stage focuses on uncovering quality problems. It involves selecting a specific area for improvement, studying the current situation, deciding on which measures would be appropriate and how data would be collected, and planning for improvement. Initially, it may be best to address small-scale problems that would facilitate learning the PDSA process and build the confidence of associates in applying this process. If benchmarks or standards are available, variations are measured to determine how much current outcomes deviate from the standards. In the absence of benchmarks, data should be collected to establish a baseline from which future progress can be measured.

Figure 18–2  The PDSA Cycle

Once the PDSA system is learned, the selection of topics should be driven by priorities in addressing areas where outcomes are less than acceptable. Improvement in patient care should outweigh all other goals of a quality improvement program. Answering certain questions can help focus on the most important topics (Vitale & Vengroski, 1993): Does the problem interfere with the delivery of high-quality care? Is it a high-risk concern? Will the benefit of improved outcomes outweigh the cost of monitoring and correcting the problem? Is the problem common enough to warrant the effort and cost to solve it? Can the problem be solved with available financial and human resources?

Do

The do stage involves actual measurement and data gathering. Certain types of flowcharts or diagrams can provide a clear understanding of the various steps and interfaces involved in a given process to help pinpoint critical elements that can be improved. For example, the flow of centralized food service from the main kitchen involves starting the food service by a certain time, maintaining the right temperatures at the service line, checking plated foods against diet cards, picking of trays by CNAs, serving the food to the residents, pouring beverages, etc.

Once the point at which a breakdown occurs has been identified, changes are then discussed and implemented on a small-scale trial basis, referred to as field testing. Field testing is particularly important when best practice protocols are not available. In the previous example, tray accuracy studies can be a useful diagnostic tool for evaluating the quantity and seriousness of diet errors (Dowling & Cotner, 1988). Field testing an intervention in the meal delivery system may involve, for example, assigning a food checker at the end of the tray line to check all items on the meal trays against diet cards for individual patients.

Study

The study stage requires an evaluation of the changes that have been made in a selected process and the effect of those changes on quality improvement. This stage requires ongoing data collection to determine the effectiveness of implemented changes and the extent of improvement. If the changes do not produce the desired improvement, other interventions should be discussed, tried, and field tested. In the meal tray example, ongoing data collection will tell whether the change results in reducing diet errors and whether the change should be made permanent.

Act

The act stage deals with implementing a change after the value of that change has been confirmed. New practices are institutionalized by training all associates who are affected by the changes and by communicating, updating policies and procedures, and monitoring to ensure that the improved methods become routine.

The PDSA process is repeated to further improve the same process, if outcomes show the need for additional improvement, or to address a different area of concern. Ongoing use of the PDSA cycle produces continuous improvement in quality.

Quality Culture

The end result of CQI is the emergence of an organization-wide culture of excellence. When quality is institutionalized, it produces an organizational culture that retains and attracts like-minded associates who are dedicated to delivering excellence. In such an environment, all associates receive social and psychological gratification by knowing that because they have chosen to put excellence first and foremost, others are better off. Management recognizes the contribution of the associates by expressing appreciation in various forms, including financial rewards. The reward system is designed so that it promotes cooperation and team effort, not envy and competitiveness. As such, the reward system does not exclude any member of the organization. Finally, such a nursing facility gains a community-wide reputation for excellence. But, even at this stage, facility management continues to seek ways to improve structures, processes, and outcomes. Management ensures the satisfaction of customers through a firm commitment to never-ending improvement in quality.

In studying the ongoing pursuit of quality, some thoughts from Deming are noteworthy. Deming is counted among the greatest pioneers of the quality improvement movement. Many books on CQI have reproduced, in one form or another, his 14 principles of quality improvement. These principles are directed at management attitudes and actions, because Deming believed that quality breakdowns were attributable to management, not workers. Much of the earlier discussion in this chapter incorporates these principles. The following thoughts summarize the remaining pertinent requirements that are also necessary for building a culture of quality in nursing facilities:

•  A facility must create value to remain ahead of the competition. Cost reduction

efforts that reduce quality are likely to decrease value. On the other hand, improving quality may increase cost somewhat, but improved quality should enhance value to a greater extent than cost increases (Lighter & Fair, 2000). Hence, CQI efforts should aim to increase both quality and productivity (efficiency).

•  Cease dependence on inspections to improve quality. Eliminate the need for inspections on a mass basis by building quality into the product (service) in the first place. Inspection should be used as an information-gathering tool for improvement, not as the principal tool for quality control (Evans & Lindsay, 1993).

•  Drive out fear so that everyone may work effectively for the organization. Fear may promote short-term gains, but longer term accomplishments are less likely, because workers spend more time inventing ways of avoiding difficult situations than finding methods of improving output. Empowerment rather than threats should be used to motivate employees (Lighter & Fair, 2000). CQI should be used to find process problems, not to assign blame to workers. Otherwise, they would spend their time covering up problems for fear of being blamed for problems.

•  Break down barriers between departments. Internal competition for raises, performance ratings, and recognition can be counterproductive. Incentives associated with CQI should promote cooperation and teamwork, not competition.

•  Eliminate slogans and exhortations. Posters and slogans assume that all quality problems are attributable to people. They overlook the fact that most quality problems are systemic and cannot be improved through posters, slogans, or the wearing of happyface buttons. Attacking problems rather than workers, understanding the causes of problems, and using statistical thinking and training to improve processes are necessary for achieving higher quality.

•  Eliminate quotas. Standards and quotas that workers are often held to are generally used punitively. These standards and quotas are born out of short-term perspectives and create fear. A quota, such as requiring each CNA to take sole responsibility for a predefined number of patients, promotes shortcuts in quality in order to reach a numerical goal. Once numerical goals are achieved, there is no incentive to continue production or to improve quality. When these standards are not achieved workers become frustrated and resentful (Evans & Lindsay, 1993).

•  Remove barriers to pride in workmanship. Hourly workers such as CNAs, housekeepers, dishwashers, and laundry workers are often treated by management as commodities. Pride in workmanship can be achieved through teamwork and continuous improvement strategies when workers are treated as valuable resources, not as commodities. According to Deming, there are three categories of employees: most work within the system, some are outside the system on the superior side, and others are outside the system on the inferior side. Superior performers should receive special compensation; inferior performers need extra training or they should be replaced (Evans & Lindsay, 1993).

Terminology for Review

best practices

continuous quality improvement

customer

inefficiency

measurement

outcome

productivity

quality

reliability

validity

For Further Thought

Case

Eliminating Pressure Ulcers at Lakeview

Frustrated with ongoing complaints from family members, Reba Sanders, the administrator of 100-bed Lakeview Skilled Care and Rehabilitation Facility, replaced the director of nursing (DON) after she had been on the job for less than 2 years. At the exit conference with Reba, the DON had remarked, “I don’t think pressure ulcers have been a problem in this facility the way it is made out to be by some families. Some patients develop the ulcers at the hospital before they come here; we try our best to take care of them, and I have explained to the families what we are doing. I think firing me is unfair, but it is your decision.” Before the new DON, James Osterwal, was hired for the job, Reba had mentioned to him that looking into the pressure ulcer problem would be his first priority. Reba arranged for James to attend meetings of the local chapter of a national quality improvement organization for nursing homes. Based on some of the information presented at the meetings, James quickly settled on making pressure ulcer elimination as his primary goal. James was quite familiar with the PDSA quality improvement cycle. He discussed it with the charge nurses, decided how data would be collected, and started a campaign asking all nursing staff to adopt the motto: “We will eliminate pressure ulcers at Lakeview.” The associates liked the motto because it gave them a specific goal to work toward. At James’ request, Reba approved hiring an RN nurse coordinator to float between the three shifts. The charge nurses asked their nursing assistants to report to them right away all cases of skin breakdown. James trained the nurses in best practice protocols to treat pressure ulcers. After 4 months, data showed little to no improvement in the prevalence (total number of cases) of pressure ulcers at Lakeview. Both Reba and James could not understand why.

Questions

1.  Based on what you have learned in this chapter, evaluate the quality improvement program as it pertains to pressure ulcers at Lakeview. Provide a specific outline of weaknesses in the overall approach.

2.  Use the PDSA cycle to address the issue of pressure ulcers. Be specific. For example, how should data be collected? How would you go about identifying root causes of the problem? What interventions would you implement? What roles should the various personnel and the administrator have?

FOR FURTHER LEARNING

The Quality Assurance/Performance Improvement program proposed by the Centers for Medicare and Medicaid Services.

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/NHQAPI.html

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