1 Introduction to Quality Improvement Medioimages/Photodisc/Thinkstock Learning Objectives After reading this chapter, you should be able to do the following: • Describe potential benefits that quality improvement can bring to healthcare organizations. • Discuss the history of quality improvement and the use of its methods as a new concept for the healthcare industry. • Analyze the global, national, regional, and state efforts toward healthcare quality improvement. 1 fin81226_01_c01_001-018.indd 1 10/29/14 8:46 PM Introduction Introduction Josh Nahum was a skydiving instructor in Colorado in 2006 when he fractured his skull and broke his leg in an accident that occurred while doing what he loved best—jumping out of airplanes. Amazingly, he survived his injuries and was on the mend in the hospital when he caught an antibiotic-resistant bacterial infection. Within weeks, the once healthy, active college student, who had dreams of becoming a child psychologist, was dead. He was 27 years old. During his almost six-week stay in a hospital intensive care unit (ICU), Nahum developed a healthcare-associated infection called methicillin-resistant Staphylococcus aureus, also known as MRSA, which is a contagious staph bacteria that can be difficult to treat because it is resistant to many commonly used antibiotics. Doctors treated the infection with antibiotics and eventually Nahum was doing well enough to be transferred to a rehabilitation facility to continue his recovery. However, just as he was recuperating, he began to run a fever that spiked at 103 degrees. An infection caused by what’s called antibiotic-resistant gram-negative bacteria—one that is resistant to treatment with virtually every antibiotic medication—was found in his cerebral spinal fluid. Despite efforts to treat the infection, it spread rapidly, causing pressure around his brain, paralyzing him, and making him a permanent quadriplegic dependent on a ventilator to breathe. He died two weeks later. His family, hoping to alert others to the dangers of healthcare-associated infections and the need for better infection control practices, education, and solutions, told his story on the website of the Infectious Diseases Society of America (Nahum & Nahum, 2010). His parents say the family has never recovered from his death. When people think about hospitals or other healthcare organizations, many think of them as safe places where people go to get well or help ensure that they stay well. But in reality, hospitals and other healthcare facilities can pose risks to patients. A patient can go into a hospital or surgery center for elective surgery (or, like Josh Nahum, for treatment after an accident) and end up with a dangerous, even life-threatening, infection. Hospitals house sick patients, many of them with illnesses and germs that can spread to other patients and even staff members. It may amaze you to know that one of the key actions that can help prevent the spread of these healthcare-associated infections is a simple one: hand hygiene. But surely, you think, doctors and nurses are constantly washing their hands or using a hand sanitizer. Maybe—but perhaps they aren’t washing them properly or in every circumstance that they need to, such as after direct contact with each patient. Therefore, one major initiative in hospitals and healthcare facilities around the country is to ensure that doctors, nurses, and all their workers comply with hand hygiene guidelines, such as those developed by the World Health Organization (WHO) or the U.S. Centers for Disease Control and Prevention (CDC). Proper hand hygiene is the best way to reduce the risk of healthcare-associated infections and keep patients safe. Quality improvement teams in thousands of hospitals are looking at the problem of making sure staff members follow proper hand hygiene and coming up with ways to promote fin81226_01_c01_001-018.indd 2 10/29/14 8:46 PM Focus on Quality Section 1.1 improved hand hygiene practices to reduce transmission of germs to patients and personnel in healthcare settings. Hands are the conduit for almost every transfer of potential pathogens from one patient to another, from a contaminated object such as a bed tray or bed rail to a patient, or from facility staff to a patient. Healthcare organizations want to ensure that staff follow proven guidelines to reduce infections. What are some of the steps they are taking? They range from prohibiting staff who have direct patient contact from wearing artificial fingernails, which can harbor germs, to requiring staff to wear gloves whenever they may come into contact with blood or other potentially infectious materials. It’s not only doctors and nurses who need to wear gloves. What about housekeeping staff who may be called to clean up an operating room or emergency department where blood has dripped on the floor? Or food service staff who pick up used trays from patient rooms following meals? Once hospitals have measures in place to promote good hand hygiene, they must check to ensure that people are following them. Supervisors may be assigned to watch for proper hand hygiene among staff. Did Dr. Smith clean his hands before providing patient care? What about after caring for the patient? Did he clean his hands after removing his gloves or other protective equipment, such as a gown and mask? Failure to follow these kinds of steps can spread an infection from one patient to another. Hospitals are monitoring for compliance with their hand hygiene program and tracking their infection rates. How well are they doing protecting patients from healthcare-associated infections? Their financial well-being, accreditation survey, public image, and liability risks may depend on it. That’s why hand hygiene and other quality improvement projects are so critical to healthcare organizations. 1.1 Focus on Quality Quality has become a major focus within healthcare. Over the last 15 years or so, healthcare organizations have become more focused than ever on providing safe, quality care to patients. After all, patients are consumers and want to get the best possible care they can. Patients, communities, insurance companies, and government agencies are demanding excellence from healthcare institutions, and healthcare organizations are striving to do the best job they can in caring for their patients. As this focus continues, it is important that everyone working in healthcare organizations has an understanding of quality improvement (QI) and why it matters. There is a simple way to think about quality improvement. Quality improvement encourages all members of an organization to continuously ask the questions “How are we doing?” and “Can we do it better?” By asking, “How are we doing?” a healthcare organization will undoubtedly uncover problem areas that should be made better. Data that healthcare organizations collect can pinpoint problem areas. A hospital may find that a large number of patients discharged from its facility fin81226_01_c01_001-018.indd 3 10/29/14 8:46 PM Focus on Quality Section 1.1 need to be readmitted within 30 days for reasons that are avoidable. An ambulatory surgery center may discover a high rate of surgical site infections in its patients. A nursing home may find that its elderly residents have a much higher rate of falls and subsequent injuries than other facilities in the state. Quality improvement is also the way to answer the second question, “Can we do it better?” The purpose of continuous quality improvement (CQI) programs is to improve healthcare by identifying problems, implementing and then monitoring the corrective actions an organization puts in place, and studying the effectiveness of those improvements. Ultimately, the question is: Do they work? The hospital with high readmission rates may discover that its staff members need to take more time to educate patients when they are discharged so they understand the need to take their medications as prescribed and plan for follow-up visits with their primary care physicians. Or perhaps hospital social workers can better coordinate post-hospital care and services so that patients have the home care they need and won’t need another hospital visit. The ambulatory surgery center may need to better educate health workers who are involved in surgical procedures, as well as the patients themselves, about the importance of preventing infections and ways to do that. The nursing home may need to better assess residents who are at a risk of falling and put safety measures in place, such as lowering beds and putting stars or other identifiers on doors that alert staff members to at-risk residents. Why Quality Improvement Matters It is important that healthcare organizations implement a quality improvement program that is responsive to patients, the community, and customers who demand and deserve excellence. If healthcare organizations do not care about quality, patients will suffer. Quality improvement is a concept that has taken hold in many industries; certainly, in healthcare the consequences could not be greater. Quality in medicine can be a matter of life or death for patients. Failing to ensure quality in the airline industry or in the pharmaceutical industry can also cost lives if a plane crashes or a contaminated drug hits the market. But quality may not be a matter of life and death for every industry; for example, a book publishing company or paperclip manufacturer may make errors that harm no one. However, if a physician doesn’t order the proper tests for a patient with diabetes, that patient may lose his eyesight. A housekeeper who doesn’t thoroughly clean a bed before a new patient occupies the hospital room may leave behind germs that cause severe diarrhea in an elderly Monkeybusinessimages/iStock/Thinkstock patient that takes weeks to cure. Responsive quality improvement programs ensure that patients receive the best care possible. fin81226_01_c01_001-018.indd 4 10/29/14 8:46 PM Focus on Quality Section 1.1 Quality improvement is the responsibility of all individuals at all levels of the delivery system. Whether those working in healthcare serve patients directly or support those who do, they must be committed to continuous quality improvement and excellence. Quality improvement is also a management tool that can help achieve that excellence so that patients receive the best possible care and service. It is about evaluating the quality of an organization’s care and services, setting a high standard, and continuously improving on each patient’s behalf. Quality improvement can apply to almost any process or product and can improve patient care and customer service. A Look Ahead In this chapter, we will introduce you to quality improvement and its importance in the healthcare field. Subsequent chapters will delve more deeply into how healthcare organizations can carry out quality improvement projects. Chapter 2 will provide a more detailed overview of quality in healthcare. Chapter 3 provides a look at continuous quality improvement, which must be an ongoing effort to strive to do a better job. Chapter 4 considers how accreditation, regulatory agencies, and other organizations have an impact on quality improvement. Chapter 5 looks at data resources—the data that pinpoint problems and can lead to solutions and better care. Chapter 6 covers data measurement and the ways to demonstrate improvement in quality. Chapter 7 details how two of the most popular quality improvement models, Six Sigma and lean theory, work. Chapter 8 looks at real-world aspects of quality improvement. This book will introduce you to concepts that will help you understand and implement quality improvement in a healthcare organization. After all, quality improvement is everyone’s job when it comes to the healthcare field. Questions to Consider 1. What do you think is the primary reason that quality improvement is so important in the healthcare industry? 2. Can you think of a problem in the healthcare industry that a quality improvement project might address? fin81226_01_c01_001-018.indd 5 10/29/14 8:46 PM A New Concept for Healthcare Section 1.2 1.2 A New Concept for Healthcare As important as quality improvement is in healthcare, its history is quite short. Quality improvement has its roots in industry and came to the forefront as a way to improve manufacturing in post-World War II Japan, but its application is relatively new to healthcare. To be clear, improving the quality of patient care and processes is not a new concept for healthcare organizations, but the use of these methods is quite new. While the focus on quality improvement in industry is on efforts such as preventing product failures and work-related injuries, in the healthcare world the focus is often on reducing medical errors and protecting patients from bad outcomes—although quality improvement encompasses every aspect of the healthcare operation. Applying these methods of continuous quality improvement to the delivery of healthcare did not become widely established until quite recently. It wasn’t really until the 1990s that healthcare organizations began undertaking these formal quality improvement projects. These projects were prompted by the increasing focus on performance improvement standards by The Joint Commission, the leading accreditor of hospitals, and the creation of the National Committee for Quality Assurance, a major accreditor of health plans and physician groups. Since the 1990s, there has been an explosion of interest in quality improvement in healthcare. Some of that interest was spurred by the critical eye that was turned on the healthcare industry, which found shortcomings that the public, government agencies, and patient safety advocates demanded organizations address. Organizations have researched ways to improve care and delivery of services—from the way the facility functions, to how the billing office operates, to the clinical care of the sickest patients. Healthcare organizations have begun sharing best practices and solutions to problems that are widespread in the industry. While some of the most widely publicized quality improvement projects involve clinical care, every department in a healthcare organization can become involved in quality improvement. For instance, efforts to ensure air quality in hospitals where there are patients with airborne transmitted infectious diseases may involve air quality and engineering professionals, facility management, and infection control professionals working together to address issues. The Patient Safety Movement and Improving Systems Quality improvement was certainly spurred on by the patient safety movement. Two major reports published by the Institute of Medicine (IOM) put the spotlight squarely on patient safety. To Err is Human, released in 1999, created public demand for change with the rather shocking news that medical errors cause 44,000 to 98,000 patient deaths in the United States annually (Institute of Medicine, 1999). The report found that more deaths occur in hospitals each year from preventable medical mistakes than occur from motor vehicle accidents, breast cancer, and AIDS. However, given the fact that healthcare is a human-driven system and people do make mistakes, it’s important to recognize that there will always be some errors. The goal of quality improvement is to minimize the errors to the lowest possible level, but it is unrealistic to expect that healthcare organizations can ever eliminate every medical error. The IOM’s Crossing the Quality Chasm report in 2001 made the argument that quality comes from having appropriate systems in place (Institute of Medicine, 2001). The report states that people will always make mistakes, but systems can help prevent those errors. For example, fin81226_01_c01_001-018.indd 6 10/29/14 8:46 PM A New Concept for Healthcare Section 1.2 computerized physician order entry systems can minimize medication errors that result from illegible physician handwriting. By having hospital staff enter medication orders via computer linked to prescribing error prevention software, the computer can catch mistakes, such as a high dosage of a medication that could sicken or even kill a patient. Such systems have been shown to reduce serious prescribing errors by more than 50% (Bates et al., 1998). Healthcare organizations need to build such systems and ensure they focus on delivery of high quality care and services. Quality improvement is a formal approach to the analysis of performance (i.e., how are we doing?) and systematic efforts to improve that performance. There are numerous models used in quality improvement. Two of those models, Six Sigma and lean theory, are discussed in detail in Chapter 7. The purpose of quality improvement is to measure where an organization is and determine ways to make things better. It is not about attributing blame for an error, but about creating systems to prevent errors from happening. These efforts look to find the defect in the system. For instance, wrong-site surgeries, in which a surgeon might replace the right knee instead of the left, can be prevented by simple steps, such as staff members or the patient marking the site prior to the operation. Current thinking in quality improveAjpfilm/age fotostock/SuperStock ment acknowledges the importance Entering prescription orders on a computer rather of individual performance and com- than writing them out by hand can minimize errors petence, but concludes that individual resulting from illegible handwriting. competence is insufficient to ensure consistently high quality. Rather, it is the system that must be evaluated and improved. Better strategies and ways of doing things can avert failures and errors. The result has been a vast national effort to discover the best strategies to develop quality improvements and share that information. For example, how can hospitals and nursing homes keep patients and residents from developing bed sores? Can technology help prevent medication errors? Can decreasing patient wait time help improve their overall satisfaction with a physician’s office? Healthcare has not had to reinvent the wheel. Organizations are adopting quality theories from the pioneers who brought quality improvement to industries and applying them in the healthcare field to improve their own processes. The automobile industry was the first to institute CQI and its methods were adapted in many other industries. Many ideas that have translated to healthcare initiatives have come from the aviation and nuclear power industries. For instance, similar to how pilots use a standardized checklist to ensure a plane is safe and ready for takeoff, surgeons and other operating room personnel use a checklist to ensure they are ready to proceed with a surgical procedure. fin81226_01_c01_001-018.indd 7 10/29/14 8:46 PM A New Concept for Healthcare Section 1.2 One of the best-known quality improvement models is Dr. William Edwards Deming’s Plan-Do-Study-Act (PDSA) cycle. Many consider Deming the father of quality improvement; PDSA is the one model that various other quality improvement methods stem from. (Students of quality improvement will sometimes see this model referred to as Plan-Do-CheckAct [PDCA]—and then Repeat is added to the sequence, since it is meant to be a continuous process.) Deming changed the model in the 1980s from PDCA to PDSA. As the model evolved, Deming amended his description of PDCA to emphasize the importance of not just checking, but studying and using the knowledge gained to better understand the process being improved. Under the old model, some organizations could be confused about how to apply the “C” or “check” stage of the model. Some organizations thought it meant that they were to measure the improvement and move on to “Act.” The intention was actually to analyze or “study” the results of the measure—to take what you learned about the system and use that new information to improve it. To avoid misinterpretation, Deming changed the name of the stage to “study” and the model became known as PDSA . Sometimes PDCA is still used, but we will refer to PDSA throughout this book (Strongin, 2014).) Consider the quality improvement efforts to improve hand hygiene and thus cut the number of infections that can threaten patients’ health and lives. A healthcare organization will need to plan the steps it wants to implement to achieve its goal of reducing infections, such as requiring staff to change gloves during patient care if moving from an infected body site to a clean body site. The organization can then create a policy that outlines the exact actions it expects its workers to follow. The organization will then implement its plan and policy, requiring its staff to do these things to help protect patients. Then it will track infection rates and other data for the subsequent study phase, in which it will analyze the information and determine the success or failure of various interventions. For instance, are all nurses following the organization policy? If not, why not? Is more education needed? Is the hand hygiene policy unclear? In the act phase, the organization will make modifications or corrections to the initial plan if necessary. Perhaps it will need to hold in-house educational sessions on each floor to make sure staff members understand when they must wash or sanitize their hands and when gloves should be worn. Perhaps it will need to rewrite its policy in clearer, simpler language that staff members will not be likely to misinterpret. (Readers will find more information on PDSA in Chapter 5.) In recent years, attention has also focused on the satisfaction of patients and their families. That is another factor driving quality care. Healthcare leaders have looked at how patient satisfaction is a factor in better health outcomes, fewer lawsuits, and lower costs. Reputations and Public Disclosure of Quality Measures Healthcare organizations’ reputations, as well as those of individual physicians, are tied to the quality care they provide for patients. Today, consumers have more information than ever on which to base decisions about where they will have open heart surgery, where to place an aging parent who is no longer safe living independently, or which physician they want to go to. But it’s not just a hospital’s national or worldwide reputation, the word-of-mouth knowledge of which nursing home is the best in town, or a neighbor’s opinion about who is a good doctor that consumers rely on. Now there is the public disclosure of quality data and outcomes, which consumers can use to select a physician, hospital, nursing home, or other healthcare provider. The Medicare fin81226_01_c01_001-018.indd 8 10/29/14 8:46 PM A New Concept for Healthcare Section 1.2 website includes processes and outcome data that allow consumers to compare hospitals, home health agencies, nursing homes, physicians, and dialysis facilities (https://data .medicare.gov/). For example, a consumer can find out how the nursing homes in a community compare in terms of urinary tract infection rates, treating pain, numbers of residents who develop bed sores, or how many lose too much weight. Or consumers can view a physician’s individual page, which has information such as board certifications, residencies, and hospital affiliations. Consumers are also able to check quality reports to help them choose a physician, as report cards are available through the majority of major health plans. The Leapfrog Group, a consortium of public and private organizations that provide healthcare benefits, also posts ratings information about hospitals, disclosing how well they comply with an array of quality processes on its website (http://www.leapfroggroup.org/). Information is included for about 1,300 hospitals that voluntarily complete a standardized survey intended to capture performance in patient safety, quality, and resource use. Accreditors also provide quality information about organizations that they review and accredit. The Joint Commission publishes on its website measures similar to those that Medicare publishes for hospitals, as well as scores that demonstrate how well organizations comply with its National Patient Safety Goals, which focus on problems in healthcare safety and how to solve them. For example, the goals for hospitals include efforts to prevent infections, prevent mistakes in surgery, and properly identify patients so they receive the correct medicine and treatment. The NCQA, which accredits health plans and physician groups, also publishes quality information on its website (http://www.ncqa.org/). Then there are private companies, such as Healthgrades, that publish information about providers, including hospitals and physicians (http://www.healthgrades.com/). Healthgrades, one of the best-known private sites, says it evaluates hospitals solely on clinical outcomes— data on risk-adjusted mortality and in-hospital complications. It says its analysis is based on approximately 40 million Medicare discharges for the most recent three-year time period, with data measuring 31 common procedures and conditions and adjustments made for each patient’s age, gender, and medical condition. Healthgrades also rates individual physicians, based in part on patient satisfaction surveys. For instance, a consumer who lives in Anytown, USA, can find a list of physicians in his or her area that specialize in treating Parkinson’s disease or a host of other medical conditions. The consumer can narrow the search for only doctors who are board certified in neurology. The consumer can then view an individual physician’s page to see a patient satisfaction rating based on factors such as the ease of scheduling urgent appointments or the level of trust in the doctor’s decisions. However, the patient satisfaction rating may be based on a limited number of patient surveys (perhaps only a handful), as patients are asked on the website to complete a review of their physician. There’s also information on the physician’s experience, the quality of the hospital he or she is affiliated with, and whether any sanctions or board actions were reported. Along with Healthgrades, there are other websites that offer physician ratings. Lifescript (http://www.lifescript.com/) offers reviews on 720,000 doctors nationwide. RateMDs (https://www.ratemds.com/) has free reviews and ratings for doctors, dentists, and other health professionals based on patient comments. Vitals (http://www.vitals.com/) has profiles on doctors, dentists, and medical facilities, as well as doctor ratings and reviews. fin81226_01_c01_001-018.indd 9 10/29/14 8:46 PM Global, National, Regional, and State Systems Section 1.3 It’s important to note that using a directory or ratings site is one type of resource that consumers can use to help choose a doctor or hospital, but it shouldn’t be the only one. Some websites are there only to make money for their owners, and consumers should carefully review the usefulness of the information and its source. As you can see, there is great interest in quality ratings for hospitals, physicians, and other healthcare providers in the United States. However, interest in quality improvement is not limited to the United States, and there are efforts to improve the quality of healthcare in institutions worldwide. Questions to Consider 1. What factor do you think was most critical in spurring the explosion of interest in quality improvement in healthcare? 2. How might quality information influence your selection of a healthcare provider, whether it is a hospital or physician? 1.3 Global, National, Regional, and State Systems While many U.S. healthcare organizations have adopted continuous quality improvement processes, there is also worldwide interest in quality that has given rise to professional bodies, scientific publications, and organizations dedicated to sharing ideas and innovations in quality improvement. Organizations such as the Institute for Health Care Improvement and the Robert Wood Johnson Foundation bring people and organizations together to learn from each other. Global Efforts Quality improvement is spreading globally. There are numerous projects to improve the quality of healthcare in countries around the world, including some of the poorest countries where healthcare needs are among the greatest. Some of those projects are focused on HIV/ AIDS, tuberculosis, control and prevention of malaria, and reducing infant mortality. The World Health Organization has promoted quality improvement efforts, including improving the safety of surgical care around the world, by ensuring adherence to proven standards of care in all countries. For example, the WHO has promoted use of a surgical safety checklist that includes having a patient confirm his or her identity, surgery site, procedure, and consent, as well as to having a nurse verbally confirm the completion of instrument, sponge, and needle counts before a surgeon closes up a patient. And as previously mentioned, the WHO has established hand hygiene guidelines to help prevent healthcare-associated infections. One organization active in developing countries is the Council on Health Research for Development (COHRED), a global, non-profit organization whose goal is to maximize the potential of research and innovation in order to deliver solutions to the health and development problems of people living in low- and middle-income countries. fin81226_01_c01_001-018.indd 10 10/29/14 8:46 PM Section 1.3 Global, National, Regional, and State Systems While the problems are sometimes different in other countries, the quality improvement concepts work the same way. An example of this involves a case of a quality improvement team in a small clinic in a remote African village (Smits, Leatherman, & Berwick, 2002). The team assessed whether children were taking a medication called choloroquine that was part of a standard treatment plan for a common infectious disease, malaria. The team found compliance was poor. Why wouldn’t children take a drug that could protect them against this potentially fatal disease? Looking for a reason, the team discovered the bad taste of the medication was a major problem. Working with mothers in the village, the team identified foods that could be used to conceal the bad taste. In the clinic waiting area, they put up a poster showing how to use the foods to disguise the taste. When they checked again in the next test cycle, compliance with the treatment protocol had increased from 48% to 70%, meaning many more village children were now protected (Smits et al., 2002). Burger/Phanie/SuperStock HIV/AIDS prevention is one example of global efforts to improve the quality of healthcare. The Efforts of Various Individual Countries Many industrial countries are using quality improvement processes to help ensure high quality care, better outcomes, and cost-effective treatments. Examples of institutions supporting these efforts include the U.S. Agency for Health Care Research and Quality, the U.K. National Institute for Health and Care Excellence (NICE), and the Dutch College of General Practitioners. The United Kingdom has also established the National Patient Safety Agency, an agency that has become part of the National Health Service, whose goal is to reduce risks to patients and improve safety. NICE, for example, publishes clinical guidelines that recommend appropriate treatment and care of people with specific diseases and conditions based on the best evidence available in order to improve the quality of care. NICE (2014b) has urged healthcare providers to take further steps to tackle the risk of heart attacks and strokes, suggesting physicians should consider many more patients to be at risk of cardiovascular disease, which causes one in three deaths in the United Kingdom. It has suggested the wider use of statins, drugs that can lower the risk of heart attacks by lowering cholesterol levels. NICE (2014b) says up to 8,000 lives could be saved every three years by offering statins to anyone with a 10% risk of developing cardiovascular disease within a decade. The agency’s public health guidance has aimed at tackling some of the biggest problems facing the country, including obesity, lack of physical exercise, and smoking. One guidance from NICE concerned adequate staffing at the country’s acute care hospitals. The guidance (NICE, 2014a) resulted from a public inquiry into the so-called Stafford Hospital fin81226_01_c01_001-018.indd 11 10/29/14 8:46 PM Global, National, Regional, and State Systems Section 1.3 scandal, which revealed poor care and high mortality rates among patients at the hospital in Stafford, England, in the late 2000s. The scandal came to national attention following an investigation into the hospital’s operation after reports of high mortality rates in patients who were admitted as emergencies. The investigation resulted in a report that criticized management of the hospital and detailed poor conditions and inadequacies. NICE issued its guidance at the request of the country’s Department of Health and the National Health Service after the issue of staffing levels was raised in the report on failings in Stafford Hospital and others, with neglect allegedly resulting in unnecessary deaths. While it didn’t set minimum staffing levels for the country’s hospitals, the guidance outlined “red flag events,” intended to set off warnings whereby nurses in charge of hospital shifts must act immediately to ensure that they have enough staff to meet the needs of patients on that ward. Red flag events include lapses in basic care, such as patients not getting medications at the time they should be given, patients having to wait more than 30 minutes to receive pain relief, vital signs not being taken when they should be, or regular checks not being done (such as helping patients get to the bathroom) (NICE, 2014a). When there is not enough nursing staff to provide that basic level of care, the hospitals are expected to provide more skilled nurses or increase numbers of staff. The guidance is designed to help ensure safe and efficient nursing staffing levels on all acute hospital wards that provide overnight care for adult patients in England. The red flag events are so serious they should trigger an instant investigation to check if staffing levels are adequate, with extra nurses sent to a floor if shortages are found. A staffing check should also occur if any ward has fewer than two registered nurses working at any one time. Regional Efforts The quality improvement movement has also resulted in a number of regional health improvement organizations. The Network for Regional Health Improvement (NRHI) was formed in 2004 in the United States to bring together leaders of regional healthcare coalitions into a network of regional health improvement collaboratives. The collaboratives are made up of healthcare providers (i.e., physicians, medical practices, hospitals, and health systems), healthcare payers (i.e., health insurance plans and public programs such as Medicaid), healthcare purchasers (i.e., employers who purchase health insurance for their employees), and healthcare consumers and organizations that represent consumer interests. The collaboratives are governed by individuals and organizations from all four of these key groups and address quality and cost issues across a broad range of patients and providers. They establish their direction through consensus among their members and implement their efforts through voluntary cooperation of the members, rather than through government mandates or financial rewards or penalties. The group now has over 30 members across the United States, from California to Massachusetts. Regional coalitions can lead and implement initiatives based on their understanding of local marketplace issues and ability to mobilize local energy for change (Mosser, Karp, & Rabson, n.d.). fin81226_01_c01_001-018.indd 12 10/29/14 8:46 PM Global, National, Regional, and State Systems Section 1.3 For example, in Maine, “community care teams,” which include a registered nurse and physician, among other team members, are calling elderly patients with chronic health conditions in their homes to check on factors such as medications, blood pressure, and diet (Japsen, 2014). This effort is part of a statewide Patient-Centered Medical Home Pilot, launched in 2010 by a purchaser-led collaborative called the Maine Health Management Coalition, a Maine state agency called the Dirigo Health Agency’s Maine Quality Forum, and Maine Quality Counts, a regional healthcare collaborative funded by the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative. The program has improved the quality of life for patients and their families and also eliminated unnecessary and expensive hospital admissions and emergency room visits. At Eastern Maine Medical Center, the attention to chronic heart failure patients from registered nurse care coordinators has helped the hospital reduce its readmission rate for Medicare patients to 12% from almost 20% in 2009 (Japsen, 2014). Primary care practices are supported by these multidisciplinary community care teams that include nurse care managers, social workers, health coaches, and pharmacists. If the pilots are successful in Maine, the federal government wants to roll them out nationwide to help seniors across the country. Numerous healthcare alliances are also involved in promoting performance measures, public reporting, and other quality improvement tools. The alliances or collaboratives do their work in markets that range from combined metropolitan areas or multi-country regions to entire states. They are made up of various stakeholders. State Efforts There are also state organizations that promote quality improvement. These include the Medicare system’s Quality Improvement Organizations (QIO) that currently operate in each state to champion improvement in the healthcare system. The Centers for Medicare & Medicaid Services (CMS) contracts with one organization in each state to serve as that state’s QIO contractor. There are also provisions in the Medicare Modernization Act that provide for bonuses, so-called pay for performance, partly based on quality metrics. QIOs are private, mostly not-for-profit organizations, staffed by professionals, mainly doctors and other healthcare professionals, who are trained to review medical care and help Medicare beneficiaries with complaints. While they are currently state-based, CMS may change that set-up in the future. In May 2013, the agency sought comment about options it may use to divide work among a number of QIO contractors, setting up jurisdictions or regions focused on quality improvement-related work only. CMS has said that starting in August 2014, it will launch the next round of QIO program contracts with a new approach to operations and the service areas for QIOs. States also contract with independent entities called External Quality Review Organizations (EQRO). Federal regulations require that states that contract with Medicaid managed care organizations (MCO) or Prepaid Inpatient Health Plans (PIHP) conduct an external quality review (EQR) of each entity to ensure it is providing quality care. States can perform the EQR directly or contract with these EQROs to conduct the review to ensure the quality, timeliness, and access to healthcare services that an MCO or PIHP furnishes to Medicaid recipients. EQROs must validate performance improvement projects and performance measures, as well as review the MCO or PIHP to determine its compliance with state standards for access to care, structure and operations, and quality measurement and improvement. fin81226_01_c01_001-018.indd 13 10/29/14 8:46 PM Summary & Resources State governments and organizations in various states are also involved in quality improvement efforts. For example, the Iowa Health Collaborative (IHC), which focuses on quality improvement, is a partnership of the Iowa Hospital Association and the Iowa Medical Society. Among its recent initiatives to improve healthcare quality in the state, the IHC has partnered with the Iowa Department of Public Health and the University of Iowa College of Public Health to improve stroke triage, treatment, and outcomes for patients in that state. With funding from a grant, the partnership is focused on increasing the quality of care in hospitals and that provided by emergency medical services. The partnership is promoting the adherence to best practice guidelines, and improving communication between providers, patients, and families. The emphasis is on transitions of care—providing quality from the first responders who arrive by ambulance to treat a stroke patient though the patient’s discharge from the hospital. The Iowa Coverdall Stroke Registry is collecting stroke data from participating healthcare systems, which will be analyzed and used to improve current stroke treatment practices. The ultimate goal of the registry is to use the data to improve stroke protocols throughout the state. Many states are also posting quality improvement measures to allow consumers to compare healthcare organizations. For example, in Massachusetts, hospitals report data such as the number of patient falls and adverse drug events to the PatientCareLink, a healthcare quality and transparency collaborative comprised of hospitals, nursing leaders, and home healthcare agencies (http://www.patientcarelink.org/). Questions to Consider 1. What kinds of quality improvement issues might affect healthcare in countries around the globe, regardless of their wealth or resources? 2. How can quality improvement efforts benefit from collaboration among countries, regions, and states? Summary & Resources Chapter Summary The healthcare field has become more focused than ever on improving quality. Patients, communities, insurance companies, and the government are demanding excellence from healthcare organizations. It’s a life and death issue, since poor quality care can harm and even kill patients. While most healthcare organizations have always cared about providing quality care, the methods of quality improvement—founded in industry—are relatively new to this field. Methodologies, which have their roots in the Plan-Do-Study-Act model, are now being applied by healthcare facilities to improve the quality of the entire patient experience. The patient safety movement, including two monumental IOM reports that turned a critical eye on the healthcare field, created a surge of quality improvement initiatives. No longer will fin81226_01_c01_001-018.indd 14 10/29/14 8:46 PM Summary & Resources people settle for hospitals, physicians, and other healthcare providers who do not provide quality care. With quality measures in the public domain, the reputations of healthcare organizations and physicians are at stake. Their “report cards” are now on display for all to see. The quality improvement movement extends beyond the United States to other individual countries and to global, international efforts to improve healthcare. Mini Case Study Harry had a seizure and crashed his car into a tree, crushing both of his legs. When he arrived at the hospital, x-rays showed that his right leg could be saved, but his left leg would have to be amputated. Unfortunately, the x-ray technician mislabeled the films, mixing up the left and the right. The orthopedic surgeon amputated Bill’s good right leg. The Joint Commission, the largest accreditor of hospitals in the United States, has made the prevention of wrong-site surgery one of its main safety goals. It requires hospitals, as well as ambulatory surgery centers and office-based surgery sites, to establish protocols to prevent wrong-site surgeries. The Joint Commission mandates the standardization of preoperative procedures to verify that the correct surgery is performed on the correct patient and at the correct site. Guidelines include marking the surgical site, involving the patient in the marking process when possible, and having all members of the surgical team double-check information in the operating room. Despite these efforts, wrong-site surgery occurs about 40 times a week nationwide, a 2011 Joint Commission Center for Transforming Healthcare study found. The center involved eight hospitals and ambulatory surgery centers in a study to determine the risks that contributed to wrong-site surgery. What did they find were the factors contributing to the risk? Problems with scheduling and preoperative/holding processes, as well as ineffective communication and distractions in the operating room, created risks for patients. The risk also increased if all key people in the operating room did not fully participate in a “time out” prior to beginning surgery to check all information and decide on how they would proceed (The Joint Commission, 2013d). One of the biggest problems was inadequate information about the patient. For instance, often information is taken by a staff member in the surgeon’s office, who may be dealing with several hospitals, all with different protocols, which can result in confusion. One solution is to create a standardized method of collecting information, as the Joint Commission recommended. Discussion Questions 1. What steps should Harry’s healthcare providers have taken to prevent the amputation of his good leg? 2. How can the Plan-Do-Study-Act model be used to reduce the occurrence of wrongsite surgery? 3. The Joint Commission recommended a “standardized method of collecting information” to prevent wrong-site surgery. What do you think should be involved in such a process? fin81226_01_c01_001-018.indd 15 10/29/14 8:46 PM Summary & Resources Key Terms continuous quality improvement (CQI) The process-based, data-driven approach to improving the quality of a product or service. quality The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. quality improvement (QI) A process using quantitative and qualitative methods to improve the effectiveness, efficiency, and safety of, as well as human resources’ performance in, healthcare delivery. Critical Thinking Questions 1. How can the Joint Commission help prevent wrong-site surgeries and improve the performance of healthcare organizations? 2. How do medical staff contribute to the problem? What about non-medical staff? 3. Despite all efforts, wrong-site surgeries continue to occur. Why do you think that is the case? In your opinion, what is the best way to prevent this medical error? Suggested Websites • • • • • • fin81226_01_c01_001-018.indd 16 Infectious Diseases Society of America (IDSA): http://www.idsociety.org/ An organization that represents physicians, scientists, and other healthcare professionals who specialize in infectious diseases. The World Health Organization (WHO): http://www.who.int/en/ The directing and coordinating authority for health within the United Nations system, providing leadership on global health matters. U.S. Centers for Disease Control and Prevention (CDC): http://www.cdc.gov U.S. government agency responsible for protecting America from health, safety, and security threats, both foreign and domestic. The Joint Commission (TJC): http://www.jointcommission.org An independent, non-profit organization that provides accreditation and certificates to healthcare organizations and programs in the United States and overseas. National Committee for Quality Assurance (NCQA): http://www.ncqa.org A non-profit organization making efforts to improve healthcare quality through accrediting and certifying a wide range of healthcare organizations. Data.Medicare.gov: https://data.medicare.gov/ Medicare website includes data that allow consumers to compare hospitals, home health agencies, nursing homes, physicians, and dialysis facilities. 10/29/14 8:46 PM Summary & Resources • • • • • fin81226_01_c01_001-018.indd 17 The Leapfrog Group’s Hospital Ratings: http://www.leapfroggroup.org/cp?form=cp_start The Leapfrog Group Hospital Ratings provide comparative information about several quality indicators for hospitals. Healthgrades: http://www.healthgrades.com/ A private company that provides online information, including ratings, on hospitals and physicians. Council on Health Research for Development (COHRED): http://www.cohred.org/ A global, non-profit organization whose goal is to maximize the potential of research and innovation to deliver sustainable solutions to solve the health and development problems of people living in low and middle income countries. National Institute for Health and Care Excellence (NICE): http://www.nice.org.uk/ A public body that provides national guidance and advice to improve health and social care in the United Kingdom. The Network for Regional Health Improvement (NRHI): http://www.nrhi.org/ A national organization representing over 30 members; each member is a regional health improvement collaborative working in its region to improve healthcare delivery. 10/29/14 8:46 PM fin81226_01_c01_001-018.indd 18 10/29/14 8:46 PM What is Special Education? An Overview of Quality Improvement and Accreditation 1 2 LISSAC/BSIP/SuperStock iStockphoto/Thinkstock Learning Objectives Pre-Test After reading this you should behandicap able to dointerchangeably. the following: T/F 1. You can use thechapter, terms disability and 2. • The history specialofeducation began in Europe. T/F Examine theofhistory healthcare quality improvement. 3. • The firstthe American legislation students withindisabilities Outline concepts of qualitythat andprotected quality improvement healthcare.was passed in the 1950s. T/F 4. All students with disabilities should be educated in special education classrooms. T/F • Show how quality is assessed, including structure, process, and outcome measures in quality 5. Special education law is constantly reinterpreted. T/F improvement. Answers can be at the of the chapter. • Examine thefound purpose of end accreditation. 19 fin81226_02_c02_019-040.indd 19 10/29/14 8:48 PM Introduction Introduction The Hippocratic Oath was written thousands of years ago but is still recited by physicians and other healthcare providers before they are allowed to practice medicine. “Never do harm,” expressing the concept of beneficence, is heavily emphasized by this oath, which continues to resonate in the medical field. As mentioned in the introductory chapter, the groundbreaking report from the Institute of Medicine (IOM) in 1999 titled To Err Is Human: Building a Safer Health System also touches on this theme. The report emphasized the urgency of decreasing medical errors and improving patient safety. One of its key components was that errors happen because they are part of human nature (in other words, we are not robots or machines). Even reputable healthcare facilities can make mistakes in both the clinical and administrative sides of healthcare delivery. For instance, Jesica Santillan, a 17-year-old girl who came to the United States seeking medical treatment for a life-threatening heart condition, died on February 23, 2003, after surgeons at Duke University Hospital in Durham, NC, transplanted a heart and lungs from a person whose blood type did not match hers on February 7. Her death followed a second transplant operation in which doctors attempted to fix the error by transplanting organs that were a match, but the damage to her body was too great and she was declared brain dead. Her transplant surgeon, who said he was “devastated” by the mistake, blamed human errors, including the assumption that the blood type match was confirmed by the transplant agency. Miscommunication between the surgeon and the organ transplant coordinating agency that provided the heart and lungs resulted in a failure to check the compatibility of the donor organs with the patient. The hospital reviewed the events leading up to the mismatch and revised its procedures to prevent such an error in the future. As a result of the new procedures, additional physicians are involved in the compatibility process and there is a system for double-checking blood types and organ suitability before organ acceptance and transplant. Changes were also made in the nation’s organ transplant system to strengthen its safety. Duke University Health System and Jesica’s family reached an undisclosed legal settlement. Errors in healthcare commonly have a number of contributing factors, as it is complex and made up of many components, including people, processes, and organizations. Healthcare delivery is not as simple as manufacturing, in which a product may be moved slowly down an assembly belt as parts are added one by one. Yet there are key lessons in quality improvement from the manufacturing world that have been embraced in healthcare organizations and are helping to reshape the quality of care that patients receive in the United States. We will explore those specific quality improvement methods in future chapters. But just how does a healthcare organization determine what an acceptable error rate is and where it needs to focus its quality improvement efforts? One way is benchmarking, where a healthcare organization compares itself to other organizations in its local area, region, state, or country. Knowing what a normal error rate is for different procedures, types of organizations, and organizational processes is part of the process that organizations use to determine how to prioritize the resources allocated to quality improvement projects. For example, what is the mortality rate for major metropolitan hospitals that conduct triple bypass surgery? What is the fall rate for nursing homes in Iowa or the vaccination rate at Indian Health Service clinics across the country? How does an organization stack up against competing facilities when it comes to a customer needs assessment? fin81226_02_c02_019-040.indd 20 10/29/14 8:48 PM Section 2.1 History of Quality Improvement in Healthcare Benchmarking is a way to determine where an organization is not measuring up to other similar organizations. How does one facility benchmark against others? For instance, if a hospital has three medication errors in a year, those may result in lawsuits from the patients who were injured and, therefore, costs to the organization. However, the hospital will not really know how big of a problem it has until it compares itself with, for instance, national data on medication errors in other comparable organizations. If the national benchmark is an average of five medication errors per year, then the hospital is doing comparatively well from a quality standard. Every hospital strives to have zero medication errors, but that may not be a realistic goal. And granted, while improvement is desired to try to eliminate medication errors, it may not necessarily justify the purchase of an electronic medication distribution system that might cost the hospital $3 million or more. On the other hand, if the medication rate is much higher than the average, the hospital may be justified in purchasing such a system to cut the number of errors. Before we get started looking at how quality improvement works in the healthcare system, let’s provide some historical perspective. 2.1 History of Quality Improvement in Healthcare Improving the quality of products and services has been a goal for centuries, but was really emphasized in the mid-nineteenth century. Most healthcare organizations have a long history of trying to improve care for their patients. They may not have thought about it as quality improvement per se or used the continuous quality improvement methods developed by modern industry, but physicians and nurses have always been trying to save more lives and improve the care of their patients. Photos.com/Thinkstock Florence Nightingale initiated one of the first quality improvement projects in healthcare. fin81226_02_c02_019-040.indd 21 During the Crimean War (1854–1856), Florence Nightingale, who became known as the founder of modern nursing, began what was essentially one of the first “quality improvement” projects, although it is unlikely she thought about it in those terms. She helped increase the quality of care provided to patients by trying to improve sanitation in medical facilities. During the 1860s in Europe, Louis Pasteur’s germ theory gained support; it stated that diseases are caused by the presence of specific microorganisms that later came to be known as bacteria. Nightingale proved the need for proper sanitation through statistical analysis. She was able to correlate proper hygiene with healthy recovery from various illnesses and wounds. Her research resulted in a major reform of the entire military hospital system (Chassin & O’Kane, n.d.). 10/29/14 8:48 PM History of Quality Improvement in Healthcare Section 2.1 1900–1950 As the twentieth century approached, sanitation and proper hygiene gained support and compliance in the healthcare system. In 1906, President Theodore Roosevelt signed the first Food and Drug Act, which was an effort to bring quality standards to food and drugs (also discussed in Chapter 3). This new law was designed to protect the consumer and brought national awareness to the importance of safe products and goods used for human consumption. Shortly after the regulations of the Food and Drug Act were enforced, Dr. Ernest Codman, a physician from Massachusetts General Hospital in Boston, proposed instituting standards that could assess the effectiveness and success rate of various hospital treatments and procedures. In 1910, Dr. Codman’s methodology of measuring effectiveness came to be known as the “end result system of hospital standardization.” His methodology consisted of tracking the progress of hospital patients to assess how successful the treatment was. In 1913, Dr. Codman’s colleague, Dr. Franklin Martin, founded the American College of Surgeons (ACS). Inspired by Dr. Codman’s end result system of hospital standardization, the ACS developed the Minimum Standards for Hospitals in 1918. As the emphasis on quality standards took shape, the first official quality manual was published in 1926, totaling only 18 pages. A few decades later in 1945, Joseph Juran and W. Edwards Deming became well-known figures in the field of quality management within the healthcare industry. More complex than Dr. Codman’s end result method, quality improvement became a primary method to assess the performance of organizations in various industries, such as healthcare, government, manufacturing, and education. In the manufacturing industry, quality improvement was used to reduce human error by reorganizing the production process. Some quality improvement methods to reorganize processes are through standardization, decisions based on data and science, and responsiveness from staff to uphold the mission of improving the quality of products and services. The quality improvement approach was successful in manufacturing and business, and therefore was applied to the U.S. healthcare system in hope of similar results. 1951–2001 In the mid-twentieth century, organizations were created in an effort to enforce quality standards in the healthcare industry. In 1951, the ACS, the American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association established what is now known as The Joint Commission or TJC (also formerly known as JCAHO). Originally, this group was focused only on hospitals and was called the Joint Commission on Accreditation of Hospitals (JCAH). This non-profit organization started to provide accreditation for hospitals that met the minimum quality standards. Congress passed the Social Security Act Amendments in 1965, which allowed hospitals accredited by the original JCAH to receive reimbursement payments for treating Medicare and Medicaid patients. In 1987, the JCAH, which had widened its scope to accredit more than just hospitals, changed its name to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In 2007, the accreditor shortened its name to simply The Joint Commission, the name which most people use for the organization. fin81226_02_c02_019-040.indd 22 10/29/14 8:48 PM History of Quality Improvement in Healthcare Section 2.1 After the establishment of The Joint Commission, other organizations formed to ensure the well-being of healthcare organizations in the United States. In 1970, the National Academies of Science established the Institute of Medicine (IOM), which has become an essential advisor to health regulation and expectations. Almost a decade later, in 1979, the Accreditation Association for Ambulatory Health Care (AAAHC) was established, focusing exclusively on the quality of care received in ambulatory care settings, such as surgical centers and kidney dialysis centers. The Department of Health and Human Services (HHS) recognized the need for accountability and efficiency in healthcare research and overall quality. Therefore, the Agency for Healthcare Research and Quality (AHRQ) was formed in 1989 to ensure safe and effective care in the United States. Every organization created its own methods of measuring performance. In 1990, the National Committee for Quality Assurance (NCQA) developed what is now known as the Healthcare Effectiveness Data and Information Set (HEDIS), which is widely used by healthcare employees to evaluate the quality of managed care organizations, as well as physician credentialing agencies and physician groups that can include independent physician associations (IPA), physician-hospital organizations (PHO), and management services organizations (MSO). HEDIS was uniquely created with six primary categories for measuring performance. These categories include access and availability, effectiveness of care, utilization of services, member satisfaction, cost of care, and health plan stability. In response to the increases in mortality from medical errors and the lack of initiative in addressing flaws in the healthcare system, the IOM published various works. The two most influential were To Err is Human: Building a Safer Health System (1999) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001). As mentioned previously, To Err is Human focused on bringing awareness to the mortality rates from medical errors, specifically errors in medication order entry and administration. Some of its staggering statistics indicated that between 44,000 and 98,000 Americans die annually as a direct or indirect result of medical errors, costing from $17 billion to $29 billion in additional healthcare expenses. The results of medication errors revealed approximately 7,000 deaths annually, which is 1,000 more deaths than workforce injuries. However, it is important not to fixate solely on inpatient hospital statistics. Errors also occur in an outpatient setting, such as surgery centers, as well as in physician offices and long-term care or nursing home facilities (Schilli, 2007). Every safety and quality inspection organization continues to amend the minimum standards of care as new problems appear in the fight for optimal quality. 2002–2014 During this time, quality healthcare has become a high priority for the government, employers, insurance companies, and healthcare providers, whose work is highly scrutinized and publicized. The Centers for Medicare & Medicaid Services (CMS) began to closely monitor the quality of care delivered to Medicare beneficiaries and thus assured quality healthcare for all Americans through accountability and public disclosure. Most initiatives focused on publicly fin81226_02_c02_019-040.indd 23 10/29/14 8:48 PM History of Quality Improvement in Healthcare Section 2.1 reporting quality measures for nursing homes, home health agencies, hospitals, and kidney dialysis facilities. Consumers can use the quality measures information that is available on the Official U.S. Government Site for Medicare (http://www.medicare.gov/) for these healthcare settings to assist them in making healthcare choices or decisions. In 2003, President George W. Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act (the Medicare Modernization Act or MMA), which produced the largest overhaul of Medicare in the public health program’s 38-year history. Medicare Part D, also called the Medicare prescription drug benefit, was established under this law. It provides prescription drug coverage, subsidizing the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries. Individuals on Medicare are eligible for prescription drug coverage under a Part D plan if they are signed up for benefits under Medicare Part A and/or Part B. This improved the overall quality of care because Medicare patients no longer worried about how they would pay for prescription drugs and no longer needed to skip pills or reduce the dosages of their prescription drugs to save money. The Patient Safety and Quality Improvement Act was enacted in 2005, demonstrating efforts to improve patient safety and quality of care. The act created patient safety organizations (PSOs) to collect and analyze information from voluntary and confidential reporting of events that adversely affected patients. As a result, PSOs came up with measures to eliminate patient safety risks and hazards. On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA), which primarily expanded health insurance coverage to about 30 million uninsured people in the United States. This insurance expansion covers several areas that include: (1) requiring uninsured individuals to purchase insurance, (2) requiring employers to provide coverage if they have 50 or more employees, (3) expanding Medicaid to a large number of people with certain eligibility conditions, (4) mandating that states establish a health insurance exchange so that individuals and small employers can purchase insurance, and (5) making it illegal to deny health insurance to people with pre-existing conditions. The PPACA not only increased the scrutiny on healthcare providers and insurance carriers in terms of quality care but also helped these providers and health plans take advantage of economies of scale, or cost advantages, and produce better quality of care through specializations, as well as vertical and horizontal integration (strategies where organizations create or acquire competitors or integrate them under common ownership), which would eventually result in formation of accountable care organizations. Table 2.1 displays major significant events and laws passed in the twentieth century to improve the quality of care in the United States. After this overview of history, let’s move on to look at quality improvement in healthcare. fin81226_02_c02_019-040.indd 24 10/29/14 8:48 PM History of Quality Improvement in Healthcare Section 2.1 Table 2.1: Key dates for quality improvement in healthcare Date Description 1906 President Theodore Roosevelt signed the Food and Drug Act, regulations established to protect the consumer. Led to national awareness of the quality of food and drugs that Americans consumed. 1910 1918 1926 1945 1951 1954 1965 1966 1970 1979 1989 1990 1991 1996 1998 fin81226_02_c02_019-040.indd 25 Dr. Ernest Codman proposed the measurement of effectiveness of hospital treatments. He was a physician at Massachusetts General Hospital who wanted to track every patient to determine whether the particular treatment was effective. Onsite inspections of hospitals began. Dr. Codman influenced the founding of the American College of Surgeons, which developed the Minimum Standards for Hospitals. Only 13% of hospitals surveyed met the standard. The first quality manual was published. Joseph Juran and W. Edwards Deming became prominent figures in the field of quality management within the healthcare industry. Quality improvement became an official method to assess performance of public and private organization in industry, healthcare, government, and education. The Joint Commission on Accreditation of Hospitals (JCAH) was established as a non-profit organization to provide accreditation to hospitals that met the minimum quality standards. It later broadened its scope and became the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and today is referred to as The Joint Commission (TJC). Juran and Deming were invited to Japan, where they influenced the Japanese to embrace total quality concepts. Congress passed the Social Security Act Amendments, which allowed hospitals accredited by what was known then as JCAH to participate in treating Medicare and Medicaid patients. Avedis Donabedian, MD, published “Evaluating the Quality of Medical Care,” (2005) which built on the foundation of Juran and Deming and defined quality of healthcare services through three parts: structure, process, and outcome. The National Academies of Science established the Institute of Medicine (IOM), which is a nonprofit scientific advisor to improve the United States’ health. The Accreditation Association for Ambulatory Health Care (AAAHC) was formed, which assisted ambulatory care organizations in improving the quality of care provided to patients. The Agency for Healthcare Research and Quality (AHRQ) was created, which is a public health service agency in the Department of Health and Human Services. The purpose of the AHRQ is to improve the quality, safety, efficiency, and effectiveness of healthcare for the United States. The National Committee for Quality Assurance (NCQA) was given a mandate to offer accreditation programs for managed care organizations. The NCQA utilizes what is now known the Healthcare Effectiveness Data and Information Set (HEDIS) as performance measures to assist employees in analyzing the quality of HMOs. The Institute of Health Care Improvement (IHI) was founded as a non-profit organization that campaigns for healthcare changes worldwide. The National Patient Safety Foundation (NPSF) was established to provide more voice for the patient as a consumer. The Quality Interagency Coordination Task Force (QuIC) was established by a presidential directive to ensure all federal agencies were working toward the common goal of improving quality care. continued 10/29/14 8:48 PM Quality and Quality Improvement in Healthcare Section 2.2 Table 2.1: Key dates for quality improvement in healthcare (continued) Date Description 1999 The IOM published To Err is Human: Building a Safer Health System (1999), based on the magnitude of mortality due to medical errors. 2002 JCAHO (now TJC) announced the Shared Vision—New Pathways program that was designed to sharpen the focus of the accreditation process to the safety and quality of patient care. 2001 2003 2003 2005 2010 2013 2014 The IOM published Crossing the Quality Chasm: A New Health System for the 21st Century (2001), stating marginal reforms would be inadequate to address the systemic flaws. JCAHO (now TJC) announced the first set of National Patient Safety Goals, which included: Improve the accuracy of patient identification, improve the effectiveness of communication among caregivers, improve the safety of using high-alert medications, eliminate wrong-site, wrong-patient, and wrong-procedure surgery, improve the safety of using infusion pumps, and improve the effectiveness of clinical alarm systems (Duke University Medical Center, 2005). In the same year, President George W. Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act (the Medicare Modernization Act or MMA), which provided prescription drug coverage to Medicare beneficiaries under Medicare Part D. The Patient Safety and Quality Improvement Act was enacted, which created patient safety organizations (PSOs) to collect and analyze information from voluntary and confidential reporting of adverse events. As a result, many measures were developed to eliminate patient safety risks and hazards. President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA), which primarily expanded health insurance coverage to a large number of uninsured people in the United States. In October, a marketplace was launched in which Americans have broad access to compare and choose the insurance health plan that meets their needs. By January 1, most Americans were required to have a basic level of health insurance. Questions to Consider 1. In your opinion, what three events and dates were the most influential in quality improvement history? Why? 2. In which time period or decade did the most quality improvement efforts take place? Why do you think this is? 2.2 Quality and Quality Improvement in Healthcare The quality of a product describes how good or bad it is, such as if the product meets the customer’s needs and is free of errors. Quality improvement (QI) is taking a product or a process and improving upon it. These concepts are easily applied to healthcare. The quality of healthcare describes how good or bad the direct care of a patient is, and quality improvement can mean improving the care a patient receives. fin81226_02_c02_019-040.indd 26 10/29/14 8:48 PM Quality and Quality Improvement in Healthcare Section 2.2 Consumers often base value on the quality and reliability of a good or service. As quality has become an expectation, businesses and organizations have made it a primary objective to continuously improve their services. In the United States’ healthcare system, continuous quality improvement has become a requirement for sustainability and growth. With rising competition, healthcare organizations are continuously trying to understand their strengths and improve areas of weakness or inefficiencies. Probably the most important take-home message is that improving quality in healthcare is critical because patient lives are always at stake. In the next sections, a detailed look at quality, the definition of quality in healthcare, and the approach to quality improvement will be discussed. Background on Quality In 1951, as previously mentioned, Joseph Juran, an advocate of quality control and quality management, provided two views of quality. First, quality can identify characteristics of a specific product or service based on its ability to satisfy the needs of customers. An increase in customer satisfaction often correlates with an increase in the use of a service, or an increase in the number of products sold. In this case, higher quality can be revenue generating. There are several healthcare facilities in the nation that are recognized for their quality of care and services. The Mayo Clinic, Sloan Kettering Center in New York, Johns Hopkins Medical Center in Baltimore, and the Geisinger Health Center in Pennsylvania are known for providing a high quality of care and boast higher success rates with many healthcare procedures and treatments. Simply, patients seek care at these facilities because they receive higher satisfaction or “better results,” providing overall superior quality of care. Quality can also characterize a product or service that is free of error. When quality products or services lack deficiencies, it allows for less failure and modification. Therefore, high quality products can be perceived as having cost-saving benefits. Viewing quality as a character of having fewer errors or flaws reduces inefficiencies, attracts new customers, and retains existing ones for products and services. The opposite occurs when a product or service has many defects that cost customers more money, time lost for repeat work, or, worse yet, recalls. For instance, a hospital may purchase blood pressure cuffs from a manufacturer that costs three times less than another brand. However, if the blood pressure cuff is 10 times more likely to fail than the more costly brand, then the rational decision is to purchase the more expensive brand because it is cost effective and quality enhancing. A more dramatic example of this view of quality is related to the Martin Luther King Jr./Drew Medical Center (King/Drew) that had been a champion healthcare provider for Los Angeles’s south side since the 1970s. A series of reports by the Los Angeles Times in the early 2000s showed that King/Drew had provided poor quality of care to patients, including the preventable death of a homeless woman. The December 5, 2004, issue of the Los Angeles Times reported several examples of failures in King/Drew Medical Center that eventually led to its closure in 2007 (Weber, Ornstein & Landsberg, 2004). This is an extreme example of what can happen in a healthcare organization as a result of poor quality. Most hospitals are not shut down. However, all hospital and healthcare organizations are prone to errors and must make the provision of the highest quality of patient care a top priority. fin81226_02_c02_019-040.indd 27 10/29/14 8:48 PM Quality and Quality Improvement in Healthcare Section 2.2 Defining Quality in Healthcare The IOM has developed a working definition of quality in healthcare. It is defined as the extent to which the healthcare delivered improves the health outcomes of individuals and nations (Institute of Medicine, 2012). This definition incorporates patient satisfaction and benefit. Healthcare quality must be considered a priority so that everyone within the healthcare organization is focused on providing the best care possible. In 2001, the IOM brought public awareness to the importance of patient safety in the United States and produced six aims for improving quality of care. Healthcare must be safe, effective, patient-centered, timely, efficient, and equitable (Institute of Medicine, 2001). These are similar to the seven ‘pillars of quality’ as set out by the physician Avedis Donabedian, one of the early proponents of quality assurance in healthcare. Donabedian listed seven attributes of healthcare that define its quality, including: 1) efficacy: the ability of care, at its best, to improve health; 2) effectiveness: the degree to which attainable health improvements are realized; 3) efficiency: the ability to obtain the greatest health improvement at the lowest cost; 4) optimality: the most advantageous balancing of costs and benefits; 5) acceptability: conformity to patient preferences regarding accessibility, the patient-practitioner relation, the amenities, the effects of care, and the cost of care; 6) legitimacy: conformity to social preferences concerning all of the above; and 7) equity: fairness in the distribution of care and its effects on health (Donabedian, 1990, p. 1115). Let’s look at the six aims of healthcare defined by the IOM (Institutes of Medicine, 2012): 1. Safe care should include minimizing the risk of injury. In many research studies, lower staffing levels are associated with heightened risk of poor patient outcomes, such as higher mortality and complications. For example, nurse-to-patient ratios are critical for better patient outcomes (Shekelle et al., 2013). If nurse-to-patient ratios are too low, patients may receive inadequate care because they are not being attended to as frequently as needed. 2. Effective care means providing services that are based on scientific knowledge. Healthcare organizations should apply that knowledge to clinical practice; for example, they should prescribe beta-blockers to every elderly heart patient who would benefit from them. Data and information gathered from patients and providers must be truthful and accurate, and that data must remind patients and providers that there is a cost associated with the care and services provided. Medioimages/Photodisc/Thinkstock In some cases, patients preferring to take many prescription drugs harm themselves with the toxicity that results from combining certain medications. It is important to note that more care does not mean more effective or better quality care. Patients with generous health plans prefer more tests, more drugs, and, in fin81226_02_c02_019-040.indd 28 10/29/14 8:48 PM Quality and Quality Improvement in Healthcare Section 2.2 some cases, more procedures, but this does not always result in better outcomes. For example, a patient with a virus will receive no benefit from a prescription for antibiotics, since antibiotics can fight bacterial infections but are not useful to treat a virus. In some cases, patients preferring to take many prescription drugs can harm themselves with the toxicity that results from combining certain medications. 3. Patient-centered care includes understanding patient demographics, promoting patient self-empowerment, and encouraging accountability for the patient’s health. In simple terms, patient-centered care supports the active involvement of patients and their families, particularly when it comes to decisions about individual options for treatment. Patient-centered care promotes active participation, which leads to improved outcomes for patients and providers, given the improved effectiveness of care. For instance, a physician can explain why a patient needs to take an antibiotic being prescribed for bronchitis and that the full prescription must be taken. A patient who does not take medication as prescribed can prolong symptoms, which can lead to more costly office visits. The IOM report defines patient-centered care as care that is “respectful of and responsive to individual patient preferences, needs, and values,” and ensures that patient values guide all clinical decisions (Institute of Medicine, 2001, p. 6). Care should be customized according to those patient needs and values, responding to individual patients’ choices and preferences. Patients should be the source of control, the IOM report says. Healthcare providers should give patients the necessary information and opportunity to make healthcare decisions that affect them. Systems need to be able to accommodate differences in patient preferences and encourage shared decision making between providers and patients. Patients should have access to their own medical information and to clinical knowledge, with effective communication between clinicians and patients. For instance, an 81-year-old patient who has been diagnosed with bone cancer in her jaw may decide she does not want possibly disfiguring surgery that will be followed by more reconstructive surgery and intense chemotherapy and radiation. She may decide she wants to live out her life without these medical interventions, asking her physician to keep her as pain free as possible and opting for hospice care at the end of life. After physicians explain the medical options, the patient chooses which care she wants. 4. Timely care should strive to reduce waiting times and be attentive to the needs of the patient. For instance, when a cancer goes untreated, it can metastasize and cause greater risk and discomfort. Therefore, it is important not to delay treatments and diagnostic efforts as much as possible. 5. Efficient care should decrease costs, limit the waste of supplies and equipment, and improve future opportunities for better quality care. The IOM report said healthcare organizations should strive to continuously reduce the waste, with the healthcare system not wasting resources or patient time (Institute of Medicine, 2001). For instance, in most cases patients will first seek care for any health problem from their primary care provider’s (PCP) office. For routine healthcare, there may not be a need to seek higher levels of care. By first consulting the PCP, the patient may receive a diagnosis and treatment without seeing a specialist, which can be more costly. Perhaps a patient’s sore knee can be treated with physical therapy or a set of exercises, without the patient seeing an orthopedic surgeon or ordering x-rays or MRIs. fin81226_02_c02_019-040.indd 29 10/29/14 8:48 PM Quality and Quality Improvement in Healthcare Section 2.2 6. Equitable care should promote equal access to care among various social and ethnic groups. Care should not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, or socioeconomic status, according to the IOM report (2001). Care should be blind to race, gender, and income to ensure unbiased, equal quality of care. Patients should receive care based on the best available scientific knowledge, which, unless there is a reason for it, should not vary from doctor to doctor or from place or place. Patients covered by private health insurance and those covered by government insurance programs such as Medicaid or Medicare should receive the same quality of care. A woman who suffers a heart attack should receive the same standard of care as a man who does. Quality Improvement in Healthcare Quality improvement involves the use of quantitative and qualitative methods to improve processes, systems, and the performance of human resources in delivering products and services. Quantitative methods are strongly based on numerical and statistical data, while qualitative methods focus on the meaning and significance of research observations. Quality improvement has also been defined as a distinct management process by which organizations use a set of tools and techniques to ensure various departments’ commitment to their communities’ health needs, through better service delivery and process improvement (Riley, Moran, Corso, Beitsch, Bialek, & Cofsky, 2010). The Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention (CDC) support the Accreditation Coalition, a collaborative of the key national organizations supporting accreditation. The coalition is an organization that acknowledges the importance of a uniform definition of QI to ensure the opportunity for quality improvement. In response to this need, a subcommittee was established to create a uniform definition that could be used universally among providers and public health departments. After researching previous definitions, in 2009 the subcommittee created the following definition of QI: Quality improvement in public health is the use of a specific improvement process that focuses on community needs and improving population health, such as Deming’s Plan-Do-Study-Act (PDSA), in a continuous effort to reach measurable improvements in all quality indicators in services or processes that achieve equity and improve the health of the community (Public Health Quality Improvement Exchange, n.d.). With Deming’s PDSA model, a healthcare organization will plan improvements to address a problem it has uncovered, put actions in place, study how effective the steps were, and act to revise the plan if needed. This particular definition focuses on the application of quality improvement on public and community health while using a specific process, including any of the methods that will be discussed throughout the book. Although there are slight variations in the exact definition of quality improvement in healthcare, all definitions address the IOM’s six pillars of quality. Simply, the message is that a network of health providers should work to be mindful of their patients, analyze their current methods and processes of care, test and improve their methodologies, and continuously redesign and monitor results to improve performance. While quality improvement often focuses fin81226_02_c02_019-040.indd 30 10/29/14 8:48 PM Quality and Quality Improvement in Healthcare Section 2.2 on patient care and safety, it is not limited to direct patient care. Quality improvement has been implemented across many healthcare settings, involving many different areas of the organization. Quality improvement often requires a working partnership between clinicians, managers, and other workers across the healthcare system. For instance, while quality improvement strategies have long been the domain of patient safety and risk management, the techniques can also help hospital safety officers tackle adverse events. Quality improvement can focus on facilities issues such as preventing fires, electrical outages, water failure, or facility damage—events that not only affect one patient, but everyone in the hospital or healthcare facility. Patient safety officers, risk managers, facility managers, and safety officers are teaming up at some organizations to prevent safetyrelated adverse events that affect facility management operations, which can most definitely have an adverse effect on patient care. Quality Improvement Methodologies Quality improvement methodologies typically focus on a step-wise approach that includes a combination of quantitative and qualitative methods to obtain desired outcomes such as efficiency, effectiveness, performance, and accountability. This systematic approach generally includes the following steps: • • • • Set a goal for performance or quality improvement; Collect data and analyze current practices; Revise or completely change current practices; and Measure outcomes and determine success. These are commonly shared features among the many quality improvement methodologies currently available. Some of the most common examples used in healthcare are Plan-DoStudy-Act (PDSA) (formerly PDCA; see Chapter 1), Six Sigma, and lean theory. You will find more on Deming’s PDSA in Chapter 5 and more on Six Sigma and lean theory in Chapter 7. PDSA involves a sequence of four steps that are intended to provide a structured process that is to be continuous, or repeated in successive cycles. This method is covered in great detail in Chapter 5. Six Sigma was developed by the Motorola Company in the 1970s to reduce defects in the production process, aiming for less than 3.4 defective parts per one million opportunities. Lean theory was developed by Toyota and focuses on elimination of waste. Questions to Consider 1. How do the six pillars of healthcare quality play a role in today’s quality efforts? 2. Are delays in treatments and diagnoses considered a quality problem in today’s healthcare system? If so, why? If not, why not? 3. What are some of the main characteristics of QI? Which do you think are most important? 4. What do the different QI definitions have in common? What qualities do they promote? 5. What are the common themes in all quality improvement models? fin81226_02_c02_019-040.indd 31 10/29/14 8:48 PM Assessing Quality Section 2.3 2.3 Assessing Quality The healthcare industry has many stakeholders, including patients, purchasers, health plans, regulators, clinicians, and care delivery systems. Improving the overall quality of care in the United States requires that these stakeholders work together to improve patient outcomes. However, it is important to recognize that the pursuit of quality is a continuously moving target and that there is always room for improvement. How the quality of healthcare is assessed is an important question for all stakeholders. Assessing Healthcare Quality Quality measures have become a standard for assessing the quality of service at healthcare organizations. Some quality measures collected by CMS include whether healthcare organizations order statin medications for patients with coronary artery disease, monitor patients on the blood thinner Warfarin, or prescribe mood stabilizers for patients with bipolar disorder. In general, quality measures are used for (1) quality improvement, (2) accountability, and (3) research. Quality improvement within an institution or system of care is called internal quality improvement, while improvement across institutions or systems of care is called external quality improvement. In the internal quality improvement model, healthcare organizations must: 1. 2. 3. 4. Identify problems or opportunities; Select proper quality measures; Obtain current measures of quality indicators as a threshold; and Re-measure the indicators to determine if there is improvement as a result of quality efforts (National Quality Measures Clearinghouse, 2014). One movement in healthcare that has coincided with all of these quality improvement efforts is that of patient-centered care, as discussed above. As the name implies, patient-centered care revolves around the patient. In fact, patient-centered care is a core component of healthcare quality recognized by the IOM. Effective care is defined by each patient and his or her satisfaction with that healthcare. Such questions as “What was the patient’s experience with triple bypass surgery [or hip replacement or other aspect of their medical care]?” explore this concept. Good care reflects overall satisfaction or outcome from the viewpoint of the patient. Patient-centered care supports the active involvement of patients and their families in decision-making about treatment options. If patients are not happy with the care they receive, it’s up to healthcare organizations to improve that experience. For instance, consider a patient who undergoes hip replacement surgery. There is a problem healing from the surgery. An infection is discovered. That patient needs to undergo further surgery to clean out the infection that has occurred. Is it likely that patient will give the surgery center high satisfaction ratings? Can the surgery center take action to reduce infections that occur after the surgery takes place? Or was there a problem with the hip replacement device itself? Quality measures are used for external quality improvement in programs operated by outside agencies such as the state and federal government, accreditation and quality improvement organizations, and professional organizations. This type of quality improvement model allows fin81226_02_c02_019-040.indd 32 10/29/14 8:48 PM Section 2.3 Assessing Quality healthcare organizations to compare themselves to their competitors and provides incentives for quality improvement to catch up with organizations ahead of them. These organizations frequently collect performance measurement data and report quality performance results among providers of care in a format that allows for their direct comparison. Exactostock/SuperStock Part of the accreditation process is recording and collecting specific data in order to demonstrate that specific health outcomes (or processes) have been met. Quality measures are also used for accountability by consumers, health plans and providers, and provider organizations. Using quality measures, individual providers or provider organizations receive certification or recognition to attract additional patients and, in some cases, even obtain bonus payments. For example, the Diabetes Recognition Program is offered by the NCQA to provide clinicians with tools to deliver and recognize high quality care for diabetic patients. The program has 11 measures that cover areas such as blood sugar control, eye examinations, and smoking cessation advice. The NCQA publicly recognizes those organizations that exceed or maintain a composite score above the minimum threshold as achieving program “recognition” for providing high-level diabetes care, which may be highly beneficial for additional financial composition and a competitive edge. The American Diabetes Association also offers an Education Recognition Program that assesses whether applicants meet the National Standards for Diabetes Self Management Education and Support, which can be used in many healthcare settings, from physician offices to health maintenance organizations and outpatient settings. Lastly, quality measures can be used to produce new knowledge about the healthcare system that is generalizable to a wide range of settings and provides valuable input in setting health policy. Quality-of-care research is often conducted to evaluate programs and assess the effect of policy changes on healthcare quality. Research also allows policymakers and managers to identify best practices in their field or unit of work and test existing practices against best practices. Structure, Process, and Outcome In 1966, Avedis Donabedian developed a three-measure framework for assessing quality of care: structure, process, and outcome (Donabedian, 2005). All three measures of quality can be concurrently used to assess quality of the healthcare system. In the next section, each of these will be reviewed. Structure The National Quality Measures Clearinghouse (NQMC) defines a structure as the platform (or place) for where and how goods and services are produced and delivered (National fin81226_02_c02_019-040.indd 33 10/29/14 8:48 PM Assessing Quality Section 2.3 Quality Measures Clearinghouse, 2014). The structure of an organization or clinician practice includes physical plant, medical supplies and materials, and employees, as well as organizational arrangements, policies, and protocols. These elements are related to the capacity to provide high quality healthcare. Measuring the environmental structure of the organization is useful to determine the competence of administrative leadership, the quality of the facility and equipment, and the overall structure and flow of operations in the institution (Donabedian, 2005). The Agency for Healthcare Research and Quality (AHRQ) has identified recent measures of structural quality based on the use of health information technology or a hospital specializing in a specific surgical procedure. Structure can also include patient volume. Process Most process measures are related to the delivery of medical care by healthcare professionals, who are often guided by evidence-based clinical guidelines and best practices. For example, the percentage of heart attack patients who receive an aspirin prescription on discharge is a process measure based on strong evidence that aspirin can prevent future cardiovascular events. Process measures have many advantages over outcome measures, including being easier and less costly to measure than outcomes and more useful when outcomes of interest are rare or sample sizes are small. Measuring the healthcare process is an accurate method to gain insight into the appropriateness of care received and the level of performance on services or procedures, and it provides data on the accessibility of care (Donabedian, 2005). For example, therapeutic procedures or diagnostic tests can be monitored and analyzed to detect possible quality barriers before negative health outcomes can occur, as in the measurement of the number of women who use preventative mammography screenings (process) compared to the number of women who develop breast cancer (outcome). Patient outcome is not the major unit of measure for healthcare quality. The following are common organizational processes: • • • • • • • • • • • • • • • • • fin81226_02_c02_019-040.indd 34 Quality management Resource management Regulatory research Market research Product design Purchasing Production Service provision Product protection Customer needs assessment Customer communications Internal communications Document control Record...
Purchase answer to see full attachment