Framework
Too often, the quality of patient care is not as uniformly strong as it could be. While providers are aware of quality standards, they are unable to achieve them consistently in day-to-day activities.
The Institute of Medicine defines quality as: "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." Attributes of patient care include improved safety, improved outcomes and improved satisfaction. These improvements result in better value.
There are numerous quality improvement programs that hospital leaders can implement to improve the value of care. These methods focus on reducing waste-primarily in the form of under-use, misuse and overuse.
According to a survey done by the American College of Physician Executives, physician leaders are using a variety of quality improvement programs:
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18.5% using Six Sigma
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13.3% using lean
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12.2% using propriety-vendor owned programs
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26.7% other, including homegrown measures
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29.2% not using a program
Here are a few of the quality improvement programs hospitals are currently implementing.
Major Initiatives
High performing hospitals focus on
The patient experience
Research shows that orienting the health system around the preferences and needs of patients has the potential to improve patients' satisfaction with care as well as their clinical outcomes.
The IOM defines patient centered care as:
"Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions."
For further information:
Strategies for leadership
Patient-centered communication
Creation of a high reliability culture
There are five characteristics of high reliability organizations:
Sensitivity to operations—highly reliable organizations maintain a constant awareness of the state of the systems and processes that affect patient care. This awareness is key to identifying risks and preventing them.
Reluctance to simplify—While simple processes may be good, simplistic explanations about why things work or fail (unqualified staff, inadequate training, communication failure, etc.) do not explain the underlying reasons why errors occur.
Deference to expertise—Reliable systems defer decisions to those individuals with the knowledge to make them, regardless of organizational hierarchy.
Preoccupation with failure—When near-misses occur, they are viewed as evidence of systems that should be improved to reduce potential harm to patients. Rather than regarding near-misses as proof that the system has effective safeguards, they are viewed instead as symptoms of processes that need to be modified.
Resilience—Highly reliable organizations are able to anticipate and quickly recover from an error. They are skilled at mitigating any consequences that stem from the original error. Resilience requires that leaders and staff be trained and prepared to respond when system failures do occur.
For further information:
Building a high reliability organization
Becoming a high reliability organization
Managing organizational variability
Organizational variability is an artificial source of variability that can usually be reduced or eliminated. Organizational variability adds unnecessary costs and reduces quality.
Examples:
Improving Patient Flow by Reducing Variability in the Discharge Process
Smoothing Patient Census
For further information:
Improving patient flow
Removing waste
According to the IOM, waste is any activity that does not add value. Value-added activities are those that the patient/client/customer would be willing to pay for if they had an option. The typical forms of waste in health care are: overuse, waiting, transportation, processing, stock, motion and defects. The Greek Health Center identifies 8 forms of waste.
Example:
Lean—a set of tools to identify and remove waste. There are five steps: specify value in the eyes of the customer; identify the sequence of activities (value stream) and eliminate non-value added steps; make value flow at the pull of the customer; involve and empower employees; and continuously improve till the process is perfected.
For further information:
Toyota lean production methods in health care
Lean health care improves quality
Eliminating defects
A defect is an event or an outcome in a system that does not conform to the process specifications. Defects occur when processes do not produce desired results, such as turnaround times for results not within expected timelines, medication errors, pressure ulcers, etc..
Example:
Six Sigma—an improvement methodology that focuses on understanding and managing customer requirements; aligning key business process to achieve those requirements; utilizing rigorous data analysis to minimize variation in those processes; and drive rapid and sustainable improvement. It has five steps: define, measure, analyze, improve and control (DMAIC).
For further information
Six Sigma promotes patient safety by shifting organizational culture
Surgical center uses Six Sigma to cut costs by $1 million
Six Sigma for health care managers
Reduce process variation
Process variation is a huge source of quality problems. In health care, there are many different types of variation that need to be managed. Variation reduction involves developing a process design that balances customer needs with process capabilities and potential sources of variation. Unmanaged variation and single-episode care leads to poor utilization of resources, poorer outcomes and lower patient satisfaction. Continuous quality improvement cannot be accomplished until a reliable process is developed.
Other strategic initiatives
In addition to the quality programs mentioned above, here are links to several other programs.
IHI
Quest for Quality
Baldrige National Quality Program
SCIP
Key Questions
Is there a way to know which methodology or strategy is optimal for a specific process?
What type of investment of time and money do these strategies take?
What are the pros and cons of implementing these strategies piecemeal versus hospital or culture wide?
