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chapter_2_-_fall_2016.pptxChapter 2
Quality Management Building Blocks
Outline
Introduction
Quality Management Activities
Quality in Other Industries:
Shewart
Deming
Juran
Feigenbaum
Crosby
Baldrige
Outline (2)
Health Care Quality Evolution
Introduction
Accreditation
Quality Assessment versus Quality Improvement
External Factors
Government Regulation
Accreditation
Large Purchasers
Quality Management Requirements
Introduction
For quality to be achieved, a systematic evaluation and improvement process must be implemented
This is known as quality management (QM)
QM ensures continuous improvement of products or services
If you recall from Chapter 1, IOM report Crossing the Quality Chasm found that three primary actions were responsible for low health care quality:
Overuse
Underuse
Misuse
Quality Management Activities
QM Activities
QM involves three activities:
Measurement
Assessment
Improvement
(The purpose of QM is to continually measure performance in order to make improvements)
Health care organizations (such as hospitals or nursing homes) track performance through measurement activities, results are then evaluated by comparing the collected data to expected outcomes
Measurement
How are we doing?
Assessment
Are we meeting expectations?
Improvement
How can we improve performance?
QM Activities (2)
Remember, that all three activities must be performed in order to continually assess performance
The activities can be applied to one department or area (Office reception/lobby) or to an entire organization
An example: Patients at Practice A can fill out a customer satisfaction survey (Measurement-collecting data on a process). When reviewing the quarterly results, administrators at Practice A notice that 85% of patients were dissatisfied with the amount of time they had to wait in the lobby to be seen by their doctor. Practice A has a policy that all patients should be seen within 30 minutes but found that the survey results showed a wait time of 48 minutes on average (Assessment-using the data to see if expectations are being met). After reviewing records and the process at patient check- in, it was found that receptionists were pulling patient records and information once the patient arrived. This process on average takes 10-15 minutes to complete. Administrators implemented a new policy that the patient record and information would be pulled the night before, at close. This improved the average wait time (Improvement-changing a process to improve a function).
Quality in Other Industries
Quality in Other Industries
The basis for QI can be linked to the work of several U.S. contributors:
Walter Shewart
W. Edwards Deming
Joseph M. Juran
Armand V. Feigenbaum
Philip B. Crosby
Walter ShewHart
Walter Shewhart is considered the grandfather of quality improvement and was one of the first to be published in the field
Shewhart, while working for Bell Laboratories, promoted the idea that price was not an indication of value. He is most recognized for the creation of statistical process control and the Plan-Do-Check-Act (PDCA) cycle, both of which are still used today
The Shewhart Cycle, or PDCA cycle as it is more commonly known, combines management philosophies with statistical analysis
**We will explore the PDCA cycle later**
W. Edwards deming
W. Edwards Deming, an American mathematical physicist worked in Japan during the 1950s to help rebuild its economy after the end of World War II.
Although the Japanese implemented his processes in the 1950s, U.S. industries did not start using his business practices until the 1980s.
Deming also worked as a consultant to many companies including Ford Motor Company, Xerox, and Florida Power and Light. He was a proponent of statistical process control (SPC) based on the work by Shewhart.
According to Deming, quality can be defined by 1) what customers want and are willing to pay for and 2) building quality into a process is less expensive than attempting to eliminate defects after the fact.
Joseph Juran
Joseph Moses Juran is known for emphasizing the management aspect of quality control.
He published the Quality Control Handbook in 1951 introducing the concept that quality control should be conducted as a central part of management function.
Juran felt that when quality control issues were delegated to staff and removed from management it led to negative effects on quality overall.
Namely, that no one in the organization felt responsible for quality or quality improvement
There are four main principles that guide Juran’s approach to quality control:
1) it is the responsibility of management
2) a policy on quality should be established
3) quality goals should be established
4) once a goal has been established, management should provide the resources needed to accomplish all goals
Armand v. Feigenbaum
Armand V. Feigenbaum was the head of Quality Control Services at General Electric Company during the 1960s and 1970s.
While at GE, he developed and implemented total quality controls and quality management. He published Total Quality Control in 1961, which introduced the concept that all departments are responsible for achieving quality.
His contributions to the field can be summarized into two principles:
1) quality is the responsibility of everyone, from the unskilled worker to upper level management
2) costs must be minimized by a quality improvement program
Philip B. Crosby
Philip B. Crosby saw quality improvement from a slightly different perspective and focused on the concept of “zero defects.”
Crosby believed, “Quality is free. It is not a gift, but it is free. What costs money were the unquality things – all the actions that involve not doing jobs right the first time” (Nofal et al. 2005, p. 8).
This concept led to his book Quality is Free, published in 1979. Crosby felt that quality could be described and achieved by adhering to what he described as the four absolute requirements of quality:
Do it right the first time
Defect prevention is the only acceptable approach to quality
Having “zero defects” is the only acceptable performance standard
Cost of quality is the only true measure of quality
Malcolm Baldrige
On January 6, 1987, Congress passed the ‘Malcolm Baldrige National Quality Improvement Act of 1987.’
The act had two main objectives: 1) to establish an award program, known as the Malcolm Baldrige National Quality Award and 2) to disseminate QI improvement strategies, techniques, and lessons learned.
The Baldrige award is given annually to organizations that have demonstrated performance excellence. According to the criteria, “customer-driven quality is a key strategic business issue which needs to be an integral part of overall business planning.”
See Required Reading #6: NIST Baldrige Act of 1987
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Malcolm Baldrige (2)
Initially, the awards program was aimed at businesses; however, health care based awards emerged in 2002 and awards for nonprofit organizations began in 2007.
The Health Care Criteria focus on health care and processes, customers, finance and markets, workforce, and leadership and governance.
The Health Care Criteria are adaptable to meet the needs of the organization using them and let the organization choose the most suitable tool or approach for facilitating quality improvement (QI).
**We will explore the Baldrige framework and criteria later**
Health care quality evolution
Introduction
The health care industry did not start implementing QM until the 1980s
It was not until the 1920s that medical education, licensing and certification requirements, and training became more stringent
Before that time, medical education quality varied and there were no licensing requirements in place
In the health care sector, interest in continuous quality improvement (CQI) began to take form in the early 1990s. Uptake of CQI methods in health care was driven by the continuous need to improve medical quality and management.
Early efforts at implementing CQI practices within the health care sector occurred in hospital and inpatient settings. In these settings, CQI was used to help monitor procedures and to lower medical errors resulting in malpractice or increased mortality rates.
Introduction (2)
Total Quality Management (TQM) has its roots in the ideas and principles set forth by W. Edwards Deming, Dr. Joseph M. Juran, and Armand V. Feigenbaum.
TQM is a “participative, systematic approach to planning and implementing a continuous organizational improvement process.”
TQM is characterized by its commitment to customer focus, continuous improvement, and teamwork. The concept of Total Quality Management was not implemented in U.S. industries until the 1980s.
Organizations in the health care sector began taking notice about a decade later and most notably used TQM in clinical health settings to improve medical, administrative, and clinical care processes.
Accreditation
The Joint Commission is the accrediting body for hospitals and health care organizations in the U.S.
Their accreditation standards set the minimum bar for health care quality
The Joint Commission has accredited hospitals for more than 60 years and today it accredits approximately 4,055 general, pediatric, long term acute, psychiatric, rehabilitation and specialty hospitals, and 358 critical access hospitals, through a separate accreditation program.
Approximately 78 percent of the nation's hospitals are currently accredited by The Joint Commission, and approximately 89 percent of hospitals that are accredited in the United States are accredited by The Joint Commission.
Listen to the podcast about accreditation by the Joint Commission:
http://ec.libsyn.com/p/f/6/c/f6c5e6ac8ed0236f/Take_5_Ann_Blouin_FINAL.mp3?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d06ca8431d9cb5db2a5&c_id= 6485807
QI vs. QA
QI is focused on continually improving processes
QI can be described as being Formal or Informal and as big QI (organizational wide) or little qi (in one area or department)
Formal QI-is described as an organization that has: 1) integrated QI into the agency strategic and operational plans, 2) formed a QI council that oversees the implementation of a detailed plan to ensure QI throughout the organization, and 3) commonly uses data for problem-solving and decision-making.
Informal or Ad hoc QI- can be described as practicing discrete QI efforts in isolated instances throughout the organization, without consistent use of data or alignment with the steps in a formal QI process.
QI Vs. Qa (2)
Quality Assurance (QA) are activities aimed at ensuring compliance with standards
A good example of QA is completing chart audits (making sure no coding or billing mistakes were made and that the information in the patient’s chart is correct)
So what is the difference?
QI incorporates continuous improvement activities aimed at improving overall processes (think back to the example under QM)
QA ensures compliance (making sure logs are filled out, dates are placed on medications, etc.)
External factors
Government Regulations
Regulations are issued by the government at the local, state, and national level to protect the health of the public
Regulations are often enforced through licensing (such as health department inspections)
Regulations vary by state
accreditation
Accreditation is a voluntary process that involves a self-assessment and external assessment (usually by a examiner of the board)
Accreditation is based on a set of standards that define the minimum level of performance required to achieve accreditation
Accreditation is an extremely expensive process both monetarily and resource wise (requires extensive staff time)
Organizations seek accreditation because it:
Enhances public confidence
Is an objective evaluation of performance
Stimulates the organization’s QI efforts
Large purchasers
Largest purchaser of health care is the government, health care organizations that participate in government funded programs must meet certain quality standards.
Examples of government funded programs:
Medicare
Medicaid
Children’s Health Insurance Program (CHIP)
Veteran’s Affairs (VA)
Quality Management requirements
Quality management requirements
Conditions of participation-rules that determine an entity’s eligibility for involvement in a particular activity
Essentially a contract between the government purchaser (think back to previous slide on ‘large purchasers’) and the provider
Private insurance companies (especially MCOs) also detail quality requirements in their provider contracts (the contract between the provider and the insurance company)
