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L e a r n i n g O b j e c t i v e s

C H A P T E R 2

Q U A L I T Y M A N A G E M E N T B U I L D I N G B L O C K S

After reading this chapter, you will be able to

➤ explain the three primary quality management activities: measurement,

assessment, and improvement;

➤ recognize quality pioneers’ contributions to, and influence on, the manufacturing

industry;

➤ identify factors that prompted healthcare organizations to adopt quality practices

originally developed for use in other industries; and

➤ describe external forces that influence quality management activities in

healthcare organizations.

Spath, P. (2018). Introduction to healthcare quality management, third edition : Third edition. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from westernkentucky on 2021-02-01 10:37:14.

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➤ Accreditation

➤ Accreditation standards

➤ Assessment

➤ Baldrige National Quality Award

➤ Conditions of Participation

➤ Criteria

➤ Data

➤ Harm

➤ Health maintenance organization

(HMO)

➤ High-reliability organizations

(HROs)

➤ Improvement

➤ Measurement

➤ Misuse

➤ Overuse

➤ Performance expectations

➤ Performance improvement

➤ Quality Assurance and Performance

Improvement (QAPI) program

➤ Quality circles

➤ Quality control

➤ Quality management

➤ Quality planning

➤ Statistical thinking

➤ Underuse

Q uality does not develop on its own. For quality to be achieved, a systematic evalu- ation and improvement process must be implemented. In the business world, this process is known as quality management. Quality management is a way of

doing business that ensures continuous improvement of products and services to achieve better performance. According to the American Society for Quality (2017), the goal of quality management in any industry is to achieve maximum customer satisfaction at the lowest overall cost to the organization while continuing to improve the process.

The authors of the 2001 Institute of Medicine (IOM) report Crossing the Quality Chasm recommend eliminating overuse, underuse, and misuse of services to achieve maxi- mum customer service in healthcare (Berwick 2002). Overuse occurs when a service is provided even though no evidence indicates it will help the patient—for example, prescribing antibiotics for patients with viral infections. Underuse occurs when a service that would

Quality management

A way of doing

business that

continuously improves

products and services

to achieve better

performance.

Overuse

Provision of healthcare

services that do not

benefit the patient, are

not clearly indicated,

or are provided in

excessive amounts

or in an unnecessary

setting.

Underuse

Failure to provide

appropriate or

necessary services,

or provision of an

inadequate quantity or

lower level of service

than that required.

K e y w o r d S

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have been medically beneficial to the patient is not provided—for example, performing a necessary diagnostic test. Misuse occurs when a service is not carried out properly—for example, operating on the wrong part of the patient’s body.

Qu a l i t y ma n a g e m e n t aC t i v i t i e S Quality management may appear to be a difficult and bewildering undertaking. While the terminology used to describe the process can be puzzling at first, the basic principles should be familiar to you. Quality management involves measurement, assessment, and improvement—activities people perform almost every day.

Consider this example: Most people must manage their finances. You must mea- sure—that is, keep track of your bank deposits and debits—to know where you stand financially. Occasionally, you have to assess your current financial situation—that is, inquire about your account balance—to determine your financial “health.” Can you afford to go out to dinner, or are you overdrawn? Periodically, you must make improvements—that is, get a part-time job to earn extra cash or remember to record debit card withdrawals—so you do not incur unexpected overdraft charges.

The three primary quality management activities—measurement, assessment, and improvement—evolve in a closely linked cycle (see exhibit 2.1). Healthcare organizations track performance through various measurement activities to gather information about the quality of patient care and support functions. Results are evaluated in the assessment step by comparing measurement data with performance expectations. If expectations are met, organizations continue to measure and assess performance. If expectations are not met, they proceed to the improvement phase to investigate reasons for the performance gap and implement changes on the basis of their findings. The quality management cycle does not end at this point, however. Performance continues to be evaluated through measurement activities.

The financial management example used earlier to explain quality management vocabulary also may help clarify basic quality management techniques. For instance, when you review your expenditures on leisure activities over the last six months, you are monitoring performance—looking for trends in your spending habits. If you decide to put 10 percent of your income into a savings account each month, you are setting a performance goal. Occasionally, you check to see whether you have achieved your goal; in other words, you are evaluating performance. If you need to save more money, you implement an improve- ment plan. You design a new savings strategy, implement that strategy, and periodically check your progress. Application of these techniques to healthcare quality management is covered in later chapters.

Misuse

Incorrect diagnoses,

medical errors,

and other sources

of avoidable

complications.

Measurement

Collection of

information for

the purpose of

understanding

current performance

and seeing how

performance changes

or improves over time.

Assessment

Use of performance

information to

determine whether

an acceptable level

of quality has been

achieved.

Improvement

Planning and making

changes to current

practices to achieve

better performance.

Data

Numbers or facts that

are interpreted for the

purpose of drawing

conclusions.

Performance

expectations

Minimum acceptable or

desired level of quality.

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Ca S e St u d y The following case study illustrates the quality management cycle of measurement, assessment, and improvement in a community health center.

The medical director of a community health center receives information about the center’s patients who have used emergency department (ED) services. The information is used to measure the number of patients seeking ED care for nonemergent conditions that would have been better handled in the community health center. Patients who use the ED for nonemergent care are less likely to receive needed ongoing care and education about their condition. This can lead to repeat ED visits for patients and poor long-term outcomes.

In an assessment of the measurement data, the medical director discovered that in a six-month period 52 percent of the ED visits for the center’s patients were for a non- emergent condition. Improvements were made to ensure the center’s patients get the right care in the right place. The improvements included expanding the center’s hours, creating the position of access coordinator to educate the center’s patients about nonemergency services in the community, and working with the local 911 dispatcher to identify patients who need something other than emergency care. The medical director continues to measure ED use by the center’s patients to evaluate the success of the improvements.

exhibit 2.1 Cycle of

Measurement, Assessment, and

Improvement

Assessment Are we meeting expectations?

Measurement How are we doing?

Improvement How can we improve

performance?

Yes

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Qu a l i t y ma n a g e m e n t mi l e S t o n e S i n in d u S t ry a n d he a lt h C a r e The concept of quality management is timeless. To stay in business, manufacturing and service industries have long sought better ways of meeting customer expectations. Health- care professionals live by the motto primum non nocere—first, do no harm. To fulfill this promise, discovering better ways to care for patients has always been a priority. Although the goal—quality products and services—is the same regardless of the industry, methods for achieving this goal in healthcare have evolved differently than in other fields.

i n d u S t r i a l Q u a l i t y e v o l u t i o n

The contemporary quality movement in the manufacturing industry can be traced to the work of three men in the 1920s at Western Electric Company in Cicero, Illinois. Walter Shewhart, W. Edwards Deming, and Joseph Juran learned and applied the science of qual- ity improvement to the company’s production lines (ASQ 2017). Shewhart used statistical methods to measure variations in the telephone equipment manufacturing process. Waste was reduced and product quality was improved by controlling undesirable process varia- tion. Shewhart is referred to as the father of statistical quality control, a method we explore in chapter 4.

Deming (1994) learned Shewhart’s methods and made the measurement and control of process variation a key element of his philosophy of quality management:

◆ Organizations are a set of interrelated processes with a common aim.

◆ Process variation must be understood.

◆ How new knowledge is generated must be understood.

◆ How people are motivated and work together must be understood.

Following World War II, Japanese manu- facturing companies invited Deming to help them improve the quality of their products. Over a period of several years, as a result of Deming’s advice, many low-quality Japanese products became world class. The Deming model for continuous improvement is described in chapter 5.

Juran combined the science of quality with its practical application, providing a framework for linking finance and management. The components of that framework, the Juran Quality Trilogy, are as follows (Girdler et al. 2016):

Harm

An outcome that

negatively affects a

patient’s health or

quality of life.

DID YOU KNOW??

In the 1950s, W. Edwards Deming, a professor and management

consultant, transformed traditional industrial thinking about

quality control by emphasizing employee empowerment, perfor-

mance feedback, and measurement-based quality management.

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◆ Quality planning—define customers and how to meet their needs

◆ Quality control—keep processes working well

◆ Quality improvement—learn, optimize, refine, and adapt

In the 1950s, Juran, like Deming, helped jump-start product improvements at Japa- nese manufacturing companies. Whereas Deming focused on measuring and controlling process variation, Juran aimed to develop the managerial aspects supporting quality. One of Juran’s management principles—focusing improvements on the “vital few” sources of the problems—is described in chapter 4.

Another individual who had a significant impact on contemporary quality practices in industry was Kaoru Ishikawa, a Japanese engineer who incorporated the science of qual- ity into Japanese culture. He was one of the first people to emphasize the importance of involving all members of the organization in this process, rather than only management- level employees. Ishikawa believed that top-down quality goals could be accomplished only through bottom-up methods (Best and Neuhauser 2008). To support his belief, he introduced the concept of quality circles—groups of 3 to 12 frontline employees who meet regularly to analyze production-related problems and propose solutions (Ishikawa 1990).

Ishikawa stressed that employees should be trained to use data to measure and improve processes that affect product quality. One of the data collection and presentation techniques he recommended for process improvement purposes is covered in chapter 6. The science of industrial quality focuses on improving the quality of products by improving the production process. Improving the production process means removing wasteful practices, standardizing production steps, and controlling variation from expectations. These methods have been proven effective and remain fundamental to industrial quality improvement. The work of Shewhart, Deming, and Ishikawa laid the foundation for many of the modern quality philosophies that underlie the improvement models described in chapter 5.

Following World War II, US manufacturers were under considerable pressure to meet production schedules, and product quality became a secondary consideration. Rec- ognizing the consequences of these lags in quality, in the 1970s US executives visited Japan to discover ways to improve product quality. During these visits, Americans learned about the quality philosophies of Deming, Juran, and Ishikawa; the science of industrial quality; and the concept of quality control as a management tool. In 1980, NBC aired a television program titled If Japan Can . . . Why Can’t We?, which described how Japanese manufacturers had adopted Deming’s approach to continuous improvement, most notably his focus on variation control (Butman 1997). As a result, many US companies began to emulate the Japanese approach. Several quality gurus emerged, each with his own interpretation of qual- ity management. During the 1980s, Juran, Deming, Philip Crosby, Armand Feigenbaum, and others received widespread attention as philosophers of quality in the manufacturing and service industries.

Quality planning

Setting quality

objectives and

specifying operational

processes and related

resources needed to

fulfill the objectives.

Quality control

Operational techniques

and activities used

to fulfill quality

requirements. (Quality

control and quality

assurance may be

used interchangeably

to describe actions

performed to ensure

the quality of a

product, service, or

process.)

Quality circles

Small groups of

employees organized

to solve work-related

problems.

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In 1987, President Ronald Reagan signed into law the Malcolm Baldrige National Quality Improvement Act (Spath 2005). This national quality program, managed by the US Department of Commerce’s National Institute of Standards and Technology, established criteria for performance excellence that organizations can use to evaluate and improve their quality. Many of these criteria originated from the quality philosophies and practices advanced by Shewhart, Deming, Juran, and Ishikawa. The annual Baldrige National Qual- ity Award was also created to recognize US companies that meet the program’s stringent standards. For the first ten years of the award’s existence, eligible companies were limited to three categories: manufacturing, service, and small business. In 1998, two categories— education and healthcare—were added. In 2002, SSM Health Care, based in St. Louis, became the first healthcare organization to win the Baldrige National Quality Award. The core values and concepts of the 2017–2018 Baldrige Performance Excellence Framework (Health Care) are summarized in critical concept 2.1.

Criteria

Standards or principles

by which something is

judged or evaluated.

Baldrige National

Quality Award

Recognition conferred

annually by the

Baldrige Performance

Excellence Program

to US organizations,

including healthcare

organizations,

that demonstrate

performance

excellence.

CRITICAL CONCEPT 2.1 Interrelated Core Values and Concepts in the Baldrige Performance Excellence Framework (Health Care) !

Systems Perspective: Successful management of organization-wide performance re-

quires synthesis, alignment, and integration. Synthesis means looking at the organization

as a whole while incorporating key organizational attributes such as core competencies,

strategic objectives, action plans, and work systems. Alignment means using the key

organizational linkages to ensure consistency of plans, processes, measures, and ac-

tions. Integration means ensuring the individual performance management components

operate in a fully interconnected, unified, and mutually beneficial manner to deliver an-

ticipated results.

Visionary Leadership: Senior leaders set a vision for the organization, create a focus on

patients and other customers, demonstrate clear and visible organizational values and

ethics, and set high expectations for the workforce. The needs of all stakeholders should

be considered when establishing the vision, values, and expectations. Leaders should

also ensure ongoing organizational success through creation of strategies, systems, and

methods for building knowledge and capabilities, stimulating innovation, requiring ac-

countability, and achieving performance excellence.

(continued)

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CRITICAL CONCEPT 2.1 Interrelated Core Values and Concepts in the Baldrige Performance Excellence Framework (Health Care) (continued) !

Patient Focus: The delivery of health care services must be patient and customer fo-

cused—meaning that judgment of satisfaction and value considers all characteristics of

patient care delivery (medical and non-medical) and all modes of customer access and

support that contribute value to your patients and other customers. Patient-focused ex-

cellence has both current and future components: understanding the desires of patients

and other customers today and anticipating future desires and health care marketplace

potential.

Valuing People: The success of an organization depends a great deal on the knowledge,

skills, creativity, and motivation of its staff members. Valuing people means committing

to their satisfaction, development, and well-being and creating a safe, trusting and co-

operative environment. An engaged workforce benefits from meaningful work, clear or-

ganizational direction, the opportunity to learn, and accountability for performance. To

accomplish overall goals, successful organizations also build external partnerships with

people and with other organizations.

Organizational Learning and Agility: Organizational learning refers to continuous im-

provement of existing approaches and processes and adaptation to change, leading to

new goals and approaches. Learning is embedded in the operation of the organization.

Organizations must ensure timely design of new health care delivery systems and pro-

grams and allow for opportunities to continuously improve so patients’ individual needs

are met. Organizational learning and agility is also achieved through strategic partner-

ships or alliances with other health care organizations.

Focus on Success: A focus on success now and into the future requires a willingness to

make long term commitments to key stakeholders—patients and families, staff, commu-

nities, employers, payers, and health profession students. Important for an organization

in the strategic planning process is the anticipation of changes in health care delivery,

resource availability, patient and other stakeholder expectations, technological devel-

opments, new partnering opportunities, evolving regulatory requirements, community/

societal expectations, and new thrust by competitors.

(continued)

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CRITICAL CONCEPT 2.1 Interrelated Core Values and Concepts in the Baldrige Performance Excellence Framework (Health Care) (continued)!

Management for Innovation: Innovation creates new value for stakeholders by making

meaningful changes to improve an organization’s health care services, programs, pro-

cesses, operations, health care delivery model, and business model. To promote innovation

an organization needs a supportive environment, a process for identifying strategic oppor-

tunities, and a desire to pursue intelligent risks. Innovation is important for all aspects of

operations and all work systems and work processes. Successful organizations use both

innovation and continuous incremental improvement approaches to improve performance.

Management by Fact: Measurement and analysis of performance are needed for an effective

health care and administrative management system. Measures are derived from the orga-

nization’s strategy and provide critical data and information about key processes, outputs,

and results. The measures selected should best represent the factors that lead to improved

health care outcomes; improved patient, other customer, operational, financial, and societal

performance; and healthier communities. Analysis involves extracting larger meaning from

data and information to support evaluation, decision-making, improvement, and innovation.

Societal Responsibility and Community Health: Leaders need to emphasize the respon-

sibility all aspects of the organization’s operations have to the public and to the improve-

ment of community health. Leaders should be role models for the organization and its

workforce in the protection of public health, safety, and the environment. Also, the orga-

nization should emphasize resource conservation and waste reduction. The organization

should meet all local, state, and federal laws and regulatory requirements and should

seek to excel beyond minimal compliance.

Ethics and Transparency: The leaders should stress ethical behavior in all stakeholder

transactions and interactions with the governing body monitoring ethical conduct. Senior

leaders should be role models of ethical behavior and clearly articulate ethical principles

and expectations to the workforce. Transparency is characterized by consistently candid

and open communication on the part of leadership and management and by the sharing

of clear and accurate information. Ethical behavior and transparency build trust in the

organization and its leaders.

(continued)

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h e a lt h C a r e Q u a l i t y e v o l u t i o n

Until the 1970s, the fundamental philosophy of healthcare quality management was based on the pre–Industrial Revolution craft model: Train the craftspeople (e.g., physicians, nurses, technicians), license or certify them, supply them with an adequate structure (e.g., facilities, equipment), and then let them provide health services (Merry 2003). In 1913, the American College of Surgeons (ACS) was founded to address variations in the quality of medical education. A few years later, it developed the hospital standardization program to address the quality of facilities in which physicians worked. Training improvement efforts were also under way in nursing; the National League for Nursing Education released its first standard curriculum for schools of nursing in 1917.

Around the time of Shewhart’s work in the 1920s, licensing and certification require- ments for healthcare providers and standards for facilities, equipment, and other aspects of healthcare became more stringent. During the time Deming and Juran were advising Japanese manufacturers, the ACS hospital standardization program was turned over to The Joint Commission (2016), the United States’ oldest and largest healthcare accreditation group, which currently evaluates and accredits more than 21,000 healthcare organizations and programs across the nation. The program’s accreditation standards set a minimum bar for healthcare quality. While the standards stressed the need for physicians and other professional staff to evaluate care provided to individual patients, none of the quality practices espoused by Deming and Juran were initially required of hospitals. The standards

Accreditation

standards

Levels of performance

excellence that

organizations must

attain to become

credentialed by a

competent authority.

CRITICAL CONCEPT 2.1 Interrelated Core Values and Concepts in the Baldrige Performance Excellence Framework (Health Care) (continued)!

Delivering Value and Results: An organization’s performance measurements need to

focus on key results. Results should focus on creating and balancing value for all stake-

holders—patients, their families, staff, the community, payers, businesses, health profes-

sion students, suppliers and partners, stockholders, and the public. Thus results need to

be a composite of measures that include not just financial results, but also health care

and process results; patient, other customer, and workforce satisfaction and engagement

results; and leadership, strategy, and societal performance.

Source: Adapted from National Institute of Standards and Technology (NIST), 2017–2018 Baldrige Excellence

Framework: A Systems Approach to Improving Your Organization’s Performance (Health Care), 40–44. Gaithers-

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centered on structural requirements and eliminating incompetent people, not measuring and controlling variation in healthcare processes.

The Joint Commission accreditation standards served as a model for provider quality requirements of Medicare, the federal healthcare program for the elderly passed by Congress in 1965. Throughout the 1970s, quality requirements in healthcare—whether represented by accreditation standards, state licensing boards, or federal regulations—focused largely on structural details and on the disciplinary actions taken against poorly performing hospitals and physicians (Brennan and Berwick 1996).

The quality revolution affecting other industries in the 1980s also affected health- care services. In 1980, The Joint Commission added a quality assurance (QA) standard loosely based on the work of Deming and Juran (Affeldt 1980). The QA standard required accredited facilities to implement an organization-wide program to

1. identify important or potential problems or concerns with patient care,

2. objectively assess the cause and scope of the problems or concerns,

3. implement decisions or actions designed to eliminate the problems,

4. monitor activities to ensure desired results are achieved and sustained, and

5. document the effectiveness of the overall program to enhance patient care and ensure sound clinical performance (Joint Commission 1979).

In the early 1980s, following years of rapid increases in Medicare and other publicly funded healthcare expenditures, the government established external groups (known as peer review organizations) to monitor the costs and quality of care provided in hospitals and outpatient settings (IOM 2006). These groups used many of the same principles found in The Joint Commission’s 1980 QA standard.

Throughout the 1980s and 1990s, health- care quality management was increasingly influ- enced by the industrial concepts of continuous improvement and statistical quality control, largely in response to pressure from purchasers to slow the growth of healthcare expenditures. Seeking alternative methods to improve healthcare qual- ity and reduce costs, regulatory and accreditation groups turned to other industries for solutions. Soon, the quality practices from other industries were being applied to health services.

Application of innovative quality practices found to be successful in other settings is still a

LEARNING POINT Quality Evolution*

The methods and principles guiding healthcare quality improve-

ment efforts have evolved at a different pace than have those

guiding quality improvement efforts in other industries. Several

factors account for this difference. Healthcare is catching up by

applying the best quality management practices of the manufac-

turing and service industries that can be adapted to the patient

care environment.

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high priority in healthcare. Healthcare costs have continued to grow considerably faster than the economy. National health spending in 2016 grew by 4.8 percent from the previous year and was estimated to be 18.1 percent of the gross national product. National health expenditures totaled $1.378 trillion in 2000, almost doubled to $2.6 trillion in 2010, and reached $3.4 trillion in 2016 (Holahan et al. 2011; Keehan et al. 2017).

Today, many of the fundamental ideas behind quality improvement in the manu- facturing and service industries shape healthcare quality management efforts. For example, The Joint Commission leadership standard incorporates concepts from the Baldrige Criteria for Performance Excellence, and the performance improvement standard requires use of statistical tools and techniques to analyze and display data. Professional groups, such as the Medical Group Management Association (MGMA), teach members to apply statistical thinking to healthcare practices to understand and reduce inappropriate and unintended process variation (MGMA 2017; Kumar 2017). The Institute for Healthcare Improvement (2017) sponsors improvement projects aimed at standardizing patient care practices and minimizing inappropriate variation.

Healthcare facilities have begun using high-reliability concepts to help achieve their safety, quality, and efficiency goals (Chassin and Loeb 2011). High-reliability organizations (HROs) experience fewer accidents than would be anticipated given the high-risk nature of the work because they have developed ways of managing the unexpected better than most organizations (Weick and Sutcliffe 2015). Early adopters of HRO philosophies were industries whose past failures had extremely catastrophic consequences (e.g., commercial airplane crashes, nuclear reactor meltdowns). Safety managers in aviation and nuclear power realized they needed to (1) identify the weak danger signals, (2) strengthen those signals, (3) address the dangers while maintaining functionality, and (4) avoid future disasters. Now, the naval and commercial aviation field and the nuclear power–generation processes are considered highly reliable. The complex systems in these organizations consistently perform nearly error free, thereby avoiding potentially catastrophic failures. Case studies illustrating the adaptation of industrial quality science and high-reliability concepts to health services improvement are found throughout this book.

Some industrial quality improvement techniques are not transferrable to healthcare. The manufacturing industry, for example, deals with machines and processes designed to be meticulously measured and controlled. At the heart of healthcare are patients whose behaviors and conditions vary from individual to individual and change over time. These factors create unpredictability that presents healthcare providers with challenges not found in other industries (Hines et al. 2008). Also, unlike the manufacturing industry, healthcare is “predominantly designed to be capacity-led, and hence there is limited ability to influence demand or make full use of freed-up resources” (Radnor, Holweg, and Waring 2012, 364).

In addition to adopting the quality practices of other industries focused on reducing waste and variation, healthcare organizations still use some components of the pre–Industrial Revolution craft model to manage quality. Adequate training and continuous monitoring are essential to building and maintaining a competent provider staff. Structural details

Statistical thinking

A philosophy of

learning and action

based on the

following fundamental

principles: All work

occurs in a system

of interconnected

processes, variation

exists in all processes,

and understanding and

reducing variation are

keys to success.

High-reliability

organizations (HROs)

Entities or businesses

with systems in place

that are exceptionally

consistent in

accomplishing their

goals and avoiding

potentially catastrophic

errors.

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remain important; considerable attention in healthcare is given to maintaining adequate facilities and equipment.

ex t e r n a l fo r C e S af f e C t i n g he a lt h C a r e Qu a l i t y ma n a g e m e n t Healthcare organizations, like all businesses, do not operate in a vacuum. Many external forces influence business activities, including quality management. Government regulations and the activities of accreditation groups and of large purchasers of health services exert a major influence on the operation of healthcare organizations.

g o v e r n m e n t r e g u l at i o n S

Regulations are issued by governments at the local, state, and national levels to protect the health and safety of the public. Regulation is often enforced through licensing. For instance, to maintain its license, a restaurant must comply with state health department rules and periodically undergo inspection.

Just as the restaurant owner must follow state health department rules or risk clo- sure, organizations that provide healthcare services or offer health insurance must follow government regulations, usually at the state level. Regulations differ from state to state. If a healthcare organization receives money from the federal government for providing services to consumers, it must comply with federal regulations in addition to state regulations. Both state and federal regulations include quality management requirements (discussed in more detail later). For example, licensing regulations in all states require that hospitals have a system for measuring, evaluating, and reducing patient infection rates. Similar requirements are found in federal regulations (CMS 2016b).

a C C r e d i tat i o n g r o u p S

Accreditation is a voluntary process by which the performance of an organization is mea- sured against nationally accepted standards of performance. Accreditation standards are based on government regulations and input from individuals and groups in the healthcare industry. Healthcare organizations seek accreditation because it

◆ enhances public confidence,

◆ is an objective evaluation of the organization’s performance, and

◆ stimulates the organization’s quality improvement efforts.

The Joint Commission’s standards have always included quality measurement, assessment, and improvement requirements. All other groups that accredit healthcare

Accreditation

A self-assessment

and external

assessment process

used by healthcare

organizations to

gauge their level

of performance in

relation to established

standards and

implement ways to

continuously improve.

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organizations and programs also require quality management activities. Exhibit 2.2 lists healthcare accreditation groups and the organizations or programs they accredit. Accredi- tation is an ongoing process, and visits are made to healthcare organizations at regularly scheduled or unannounced intervals to monitor their compliance with accreditation require- ments. While accreditation is considered voluntary, an increasing number of purchasers and government entities mandate it.

Accreditation Group Organizations and Programs Accredited

AABB (formerly American Association of Blood Banks) (www.aabb.org)

Freestanding and provider-based blood banks, transfusion services, and blood donation centers

Accreditation Association for Ambulatory Health Care (www.aaahc.org)

Ambulatory healthcare clinics and surgery centers, urgent care facilities, community health centers, medical home organizations, multispecialty group practices, university student health centers, and a wide range of other outpatient services

Accreditation Commission for Health Care (www.achc.org)

Home health, hospice, and private duty; DMEPOS (durable medical equipment, prosthetics, orthotics, and suppliers) agencies

American Association for Accreditation of Ambulatory Surgery Facilities (www.aaaasf.org)

Ambulatory surgery facilities, oral/maxillofacial facilities, outpatient physical therapy clinics, and rural health clinics

American College of Surgeons (www.facs.org) Cancer programs at hospitals and freestanding treatment centers, breast centers, oncology medical homes, and stereotactic breast biopsy services

Center for Improvement in Healthcare Quality (www.cihq.org)

Hospitals

Commission for the Accreditation of Birth Centers (www.birthcenteraccreditation.org)

Birth centers

Commission on Accreditation of Medical Transport Systems (www.camts.org)

Rotorwing, fixed wing, and ground medical transport systems

Commission on Accreditation of Rehabilitation Facilities (www.carf.org)

Freestanding and provider-based medical rehabilitation and human service programs, such as behavioral health, child and youth services, and opioid treatment and continuing care retirement communities and aging services networks

Commission on Laboratory Accreditation of the College of American Pathologists (www.cap.org)

Freestanding and provider-based laboratories, forensic drug testing services, biorepository facilities, and reproductive laboratory services

exhibit 2.2 Healthcare

Accreditation Groups

(continued)

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Accreditation Group Organizations and Programs Accredited

Community Health Accreditation Partner (www.chapinc.org)

Community-based health services, including home health agencies, hospices, home medical equipment providers, and private duty home care services

Compliance Team (www.thecomplianceteam.org)

Rural health clinics, patient-centered medical homes, immediate care clinics, and sleep care management; DMEPOS agencies, private duty, ocularist/anaplastologist, and pharmacy services

Diagnostic Modality Accreditation Program of the American College of Radiology (www.acr.org)

A variety of services in freestanding and provider-based imaging facilities, including radiology and nuclear medicine

DNV GL-Healthcare (www.dnvglhealthcare.com) Hospitals

Foundation for the Accreditation of Cellular Therapy (www.factwebsite.org)

Cellular therapy and cord blood banking services

Global Healthcare Accreditation Program (www.globalhealthcareaccreditation.com)

Medical travel program organizations

Healthcare Facilities Accreditation Program (www.hfap.org)

Hospitals; clinical laboratories; ambulatory care/ surgery, mental health, substance abuse, and physical rehabilitation facilities; and primary stroke centers

Healthcare Quality Association on Accreditation (www.hqaa.org)

Durable medical and home medical equipment providers and services

Institute for Medical Quality (www.imq.org)

Surgery centers and various types of ambulatory facilities

Intersocietal Accreditation Commission (www.icanl.org)

Freestanding and provider-based nuclear medicine, nuclear cardiology, positron emission tomography, and superficial vein services

Joint Commission (www.jointcommission.org) General, psychiatric, children’s, and rehabilitation hospitals; critical access hospitals; medical equipment services, hospice services, and other home care organizations; nursing homes and other long-term care facilities; behavioral healthcare organizations and addiction services; rehabilitation centers, group practices, office-based surgeries, and other ambulatory care providers; independent or freestanding laboratories; and medical homes

National Commission on Correctional Health Care (www.ncchc.org)

Healthcare services in jails, prisons, and juvenile confinement facilities

exhibit 2.2 Healthcare Accreditation Groups (continued)

(continued)

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l a r g e p u r C h a S e r S

The largest purchaser of healthcare services is the government. For 2017, the Centers for Medicare & Medicaid Services (CMS) was projected to spend more than $718 billion on

patient care for Medicare enrollees, and in that same year, federal and state governments com- bined were projected to spend more than $586 billion on Medicaid enrollees (Keehan et al. 2017). Healthcare organizations participating in these government- funded insurance programs must comply with the quality management require- ments found in state and federal regulations (see next section). For example, home health agencies that care for Medicare patients must report to CMS on the quality of care they provide, includ-

ing information on patients’ physical and mental health and their ability to perform basic daily activities (CMS 2016a).

Qu a l i t y ma n a g e m e n t re Q u i r e m e n t S Quality management requirements for each provider category are cited in federal regula- tions called Conditions of Participation. These regulations form a contract between

Conditions of

Participation

Federal regulations

that determine an

entity’s eligibility

for involvement in a

particular activity.

Accreditation Group Organizations and Programs Accredited

National Committee for Quality Assurance (www.ncqa.org)

Health plans, managed behavioral healthcare organizations, disease management programs, case management programs, wellness and health promotion programs, and accountable care organizations

Public Health Accreditation Board (www.phaboard.org)

Tribal, state, local, and territorial public health departments

URAC (American Accreditation HealthCare Commission, Inc.) (www.urac.org)

Health plans, credential-verification organizations, independent review organizations, medical homes, mail service pharmacies, and others; also accredits specific functions in healthcare organizations (e.g., case management, pharmacy benefit management, consumer education and support, disease management)

exhibit 2.2 Healthcare

Accreditation Groups

(continued)

DID YOU KNOW??

There is an increasing link between quality and revenue for

healthcare facilities. In early 2015, the US Department of Health

and Human Services (2015) set a goal of linking 90 percent of

Medicare payments to quality or value.

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the government purchaser and the provider. If a provider wants to participate in a feder- ally funded insurance program, it must abide by the conditions spelled out in myriad regulations.

For example, CMS requires nursing homes to implement a Quality Assurance and Performance Improvement (QAPI) program, which involves the coordinated application of two mutually reinforcing aspects of a quality management system: quality assurance (QA) and performance improvement (PI). This systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes is intended to involve all nursing home caregivers in practical and creative prob- lem solving (CMS 2016c). This program consists of five key elements of effective quality management: design and scope; governance and leadership; feedback, data systems, and monitoring; performance improvement projects; and systematic analysis and systemic action (CMS 2016c).

Some other regulations and accreditation standards affecting quality management activities are detailed in later chapters. However, these requirements change often, and healthcare organizations must keep up to date on the latest rules. The websites listed in exhibit 2.2 and those found at the end of this chapter contain information on cur- rent regulations and accreditation standards affecting healthcare quality management activities.

Private insurance companies also pay a large amount of health services costs in the United States. For 2017, private insurance plans were projected to pay more than $1.208 billion to providers for the care of their enrollees (Keehan et al. 2017). For the most part, these plans rely on government regulations and accreditation standards to define basic quality management requirements for healthcare organizations. However, some private insurance companies have additional quality measurement and improvement requirements for participating providers. For example, outpatient clinics that provide care for patients in a health maintenance organization (HMO) may be required to report to the health plan the percentage of calls received by the clinic that are answered by a live voice within 30 seconds. The HMO uses this information, along with other data, to measure the quality of customer service in the clinic.

The measurement, assessment, and improvement requirements of private insurance companies are detailed in provider contracts. If a provider wants to participate in a health plan, it must agree to abide by the rules in the contract, some of which place quality management respon- sibilities on the provider.

Quality Assurance

and Performance

Improvement (QAPI)

program

This CMS requirement

for nursing homes

involves the coordinated

application of two

mutually reinforcing

aspects of a quality

management system:

quality assurance

(QA) and performance

improvement (PI).

Performance

improvement

A method for

analyzing performance

problems and enacting

improvements

to ensure good

performance.

Health maintenance

organization (HMO)

Public or private

organization providing

comprehensive medical

care to subscribers on

the basis of a prepaid

contract.

LEARNING POINT External Influences*

The measurement, assessment, and improvement activities

in healthcare organizations are influenced by three external

forces: accreditation standards, government regulations, and

purchaser requirements.

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Quality management activities in healthcare organizations are constantly evolving. These changes often occur in reaction to external forces, such as regulation or accreditation standard revisions and pressures to control costs. Healthcare quality management is also influenced by other industries. Improvement strategies used to enhance the quality of products and services are frequently updated as new learning emerges. Since their inception in 1982, the criteria of the Malcolm Baldrige National Quality Award have undergone several revisions. Healthcare quality management changed in 1998 when the Baldrige Criteria were adapted for use by healthcare organizations. In addition, the science of quality management, once reserved for the manufacturing industry, is now used in healthcare organizations.

The rules and tools of healthcare quality management will continue to evolve, but the basic principles of measurement, assessment, and improvement will remain the same. For instance, many people sort household garbage into two bins—one for recyclable materials and one for everything else. Garbage collection rules have changed, yet the basic principle—removing garbage from the house—is the same. Thirty years ago, people never would have imagined they’d be using wireless devices to make phone calls. The tool has changed, but the basic principle—communicating—has not.

Why should healthcare organizations be involved in quality management activities? Foremost, quality management is the right thing to do. Providers have an ethical obligation to patients to provide the best quality care possible. In addition, all stakeholders—consumers, purchasers, regulators, and accreditation groups—require continuous improvement. Competition among healthcare organizations is growing in intensity, and demand for high-quality services is increasing. Healthcare organizations that study and implement quality management techniques attract more patients than organizations that do not engage in such activities.

1. Describe how you use the cycle of measurement, assessment, and improvement (see exhibit 2.1) to evaluate and make changes in your personal life.

2. How do quality practices that originated in the manufacturing industry differ from the traditional quality practices of healthcare organizations?

C o n C l u S i o n

f o r d i S C u S S i o n

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3. How would applying the core values and concepts of the Baldrige Performance Excellence Framework (Health Care) improve healthcare quality? (See critical concept 2.1.)

4. Consider the healthcare encounter you described in chapter 1 (see “For Discussion” question 2). If wasteful practices had been eliminated or steps in the process had been standardized, would you have had a different encounter? How would it have changed?

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