Ethical subjectivism is a recipe for moral anarchy.

Elizabeth R. Ransom, Maulik S. Joshi, David B. Nash, and Scott B. Ransom, Editors

HEALTHCARE QUALITY BOOK

THETHETHE

SECOND EDITION

“Some of the best minds in healthcare” Nancy M. Schlichting, President and CEO, Henry Ford Health System

VISION, STRATEGY, AND TOOLS Revis

ed

and

Upda ted

QUALITY BOOK

(from the foreword)

HEALTHCARE QUALITY BOOK

THE

SECOND EDITION

AUPHA HAP Editorial Board

Sandra Potthoff, Ph.D., Chair University of Minnesota

Simone Cummings, Ph.D. Washington University

Sherril B. Gelmon, Dr.P.H., FACHE Portland State University

Thomas E. Getzen, Ph.D. Temple University

Barry Greene, Ph.D. University of Iowa

Richard S. Kurz, Ph.D. Saint Louis University

Sarah B. Laditka, Ph.D. University of South Carolina

Tim McBride, Ph.D. St. Louis University

Stephen S. Mick, Ph.D. Virginia Commonwealth University

Michael A. Morrisey, Ph.D. University of Alabama—Birmingham

Dawn Oetjen, Ph.D. University of Central Florida

Peter C. Olden, Ph.D. University of Scranton

Lydia M. Reed AUPHA

Sharon B. Schweikhart, Ph.D. The Ohio State University

Nancy H. Shanks, Ph.D. Metropolitan State College of Denver

Health Administration Press, Chicago

AUPHA Press, Washington, DC

HEALTHCARE QUALITY BOOK

THE

SECOND EDITION VISION, STRATEGY, AND TOOLS

Elizabeth R. Ransom, Maulik S. Joshi, David B. Nash, and Scott B. Ransom, Editors

Your board, staff, or clients may also benefit from this book’s insight. For more information on quantity discounts, contact the Health Administration Press Marketing Manager at (312) 424- 9470.

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The statements and opinions contained in this book are strictly those of the author(s) and do not represent the official positions of the American College of Healthcare Executives, of the Foundation of the American College of Healthcare Executives, or of the Association of University Programs in Health Administration.

Copyright © 2008 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher.

12 11 10 09 08 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

The healthcare quality book : vision, strategy, and tools / [edited by] Elizabeth R. Ransom ... [et al.].—2nd ed.

p. ; cm. Includes bibliographical references and index. ISBN 978-1-56793-301-7 (alk. paper) 1. Medical care—United States—Quality control. 2. Health services administration—

United States—Quality control. 3. Total quality management—United States. I. Ransom, Elizabeth R. [DNLM: 1. Quality of Health Care—organization & administration—United States. 2. Health Services Administration—United States. 3. Total Quality Management—organization & admin- istration—United States. W 84 AA1 H443 2008]

RA399.A3H433 2008 362.11068—dc22

2008017268

The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences-Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984. ∞™

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One North Franklin Street Arlington, VA 22201 Suite 1700 (703) 894-0940 Chicago, IL 60606 (312) 424-2800

CONTENTS IN BRIEF

FOREWORD..............................................................................................xiii

PREFACE...................................................................................................xv

III Science and Knowledge Foundation

1 Healthcare Quality and the Patient, by Maulik S. Joshi and Donald Berwick............................................................................3

2 Basic Concepts of Healthcare Quality, by Leon Wyszewianski ...................................................................................................25

3 Variation in Medical Practice and Implications for Quality, by David J. Ballard, Robert S. Hopkins III, and David Nicewander ...................................................................................................43

4 Quality Improvement: The Foundation, Processes, Tools, and Knowledge Transfer Techniques, by Kevin Warren ....................63

III Organization and Microsystem

5 Milestones in the Quality Measurement Journey, by Robert C. Lloyd .........................................................................87

6 Data Collection, by John J. Byrnes ..........................................109

7 Statistical Tools for Quality Improvement, by Jerod M. Loeb, Stephen Schmaltz, Linda S. Hanold, and Richard G. Koss ......131

8 Physician and Provider Profiling, by David B. Nash, Adam Evans, and Richard Jacoby ..................................................................169

9 Measuring and Improving Patient Experiences of Care, by Susan Edgman-Levitan .............................................................187

10 Dashboards and Scorecards: Tools for Creating Alignment, by Michael D. Pugh ......................................................................217

v

11 Patient Safety and Medical Errors, by Frances A. Griffin and Carol Haraden..........................................................................243

12 Information Technology Applications for Improved Quality, by Richard E. Ward .......................................................................269

13 Leadership for Quality, by James L. Reinertsen .......................311

14 Organizational Quality Infrastructure: How Does an Organization Staff Quality?, by A. Al-Assaf..............................331

15 Implementing Quality as the Core Organizational Strategy, by Scott B. Ransom, Thomas J. Fairchild, and Elizabeth R. Ransom .................................................................................................349

16 Implementing Healthcare Quality Improvement: Changing Clinician Behavior, by Valerie Weber and John Bulger ............377

IIII Environment

17 The Quality Improvement Landscape, by Jean Johnson, Ellen Dawson, and Kimberly Acquaviva ...................................407

18 Accreditation: Its Role in Driving Accountability in Healthcare, by Greg Pawlson and Paul Schyve............................................433

19 How Purchasers Select and Pay for Quality, by Francois de Brantes ..................................................................457

INDEX...................................................................................................475

ABOUT THE AUTHORS ...............................................................................491

C o n t e n t s i n B r i e fvi

DETAILED CONTENTS

FOREWORD..............................................................................................xiii

PREFACE ..................................................................................................xv

III Science and Knowledge Foundation

1 Healthcare Quality and the Patient, by Maulik S. Joshi and Donald Berwick............................................................................3 Important Reports........................................................................4 A Focus on the Patient .................................................................6 Lessons Learned in Quality Improvement....................................7 Case Study..................................................................................17 Conclusion .................................................................................21 Study Questions .........................................................................22 Notes ..........................................................................................22 References ..................................................................................23

2 Basic Concepts of Healthcare Quality, by Leon Wyszewianski...25 Definition-Related Concepts ......................................................25 Measurement-Related Concepts.................................................33 Implications................................................................................39 Study Questions .........................................................................39 Note ...........................................................................................40 References ..................................................................................40

3 Variation in Medical Practice and Implications for Quality, by David J. Ballard, Robert S. Hopkins III, and

David Nicewander ...............................................................43 Background and Terminology ....................................................45 Scope and Use of Variation in Healthcare..................................47 Clinical and Operational Issues ..................................................48 Keys to Successful Implementation and Lessons Learned from

Failures ................................................................................51 Case Study..................................................................................53 Conclusion .................................................................................56 Study Questions .........................................................................56 References ..................................................................................59

vii

4 Quality Improvement: The Foundation, Processes, Tools, and Knowledge Transfer Techniques, by Kevin Warren ....................63 The Quality Foundation.............................................................63 Quality Improvement Processes and Approaches .......................67 Quality Tools..............................................................................73 Knowledge Transfer and Spread Techniques ..............................76 Conclusion .................................................................................81 Study Questions .........................................................................81 Note ...........................................................................................82 References ..................................................................................82

III Organization and Microsystem

5 Milestones in the Quality Measurement Journey, by Robert C. Lloyd .........................................................................87 The Measurement Challenge......................................................88 Milestones Along the Quality Measurement Journey.................88 Conclusion ...............................................................................105 Study Questions .......................................................................105 Notes ........................................................................................105 References ................................................................................106

6 Data Collection, by John J. Byrnes ..........................................109 Categories of Data....................................................................109 Considerations in Data Collection ...........................................109 Sources of Data ........................................................................112 Case Study in Clinical Reporting .............................................123 Conclusion ...............................................................................127 Study Questions .......................................................................127 Acknowledgments ....................................................................127 Notes ........................................................................................128 References ................................................................................129 Suggested Reading ...................................................................129

7 Statistical Tools for Quality Improvement, by Jerod M. Loeb, Stephen Schmaltz, Linda S. Hanold, and Richard G. Koss ...........131 Fundamentals of Performance Measurement ...........................131 Control Chart Analysis .............................................................138 Comparison Chart Analysis ......................................................142 Using Data for Performance Improvement ..............................147 Conclusion ...............................................................................149 Study Questions .......................................................................150 Appendix 1: Control Chart Formulas ......................................150

D e t a i l e d C o n t e n t sviii

D e t a i l e d C o n t e n t s

Appendix 2: Comparison Chart Formulas................................154 Appendix 3: Case Studies .........................................................158 Notes ........................................................................................166 References ................................................................................166

8 Physician and Provider Profiling, by David B. Nash, Adam Evans, and Richard Jacoby ..................................................................169 Background and Terminology ..................................................169 Scope and Use of Profiling in Healthcare ................................171 Keys to Successful Implementation and Lessons Learned ........178 Case Study................................................................................179 Study Questions .......................................................................183 References ................................................................................184

9 Measuring and Improving Patient Experiences of Care, by Susan Edgman-Levitan .............................................................187 Regulatory and Federal Patient Survey Initiatives....................188 Using Patient Feedback for Quality Improvement...................190 Scope and Use of Patient Experiences in Healthcare ...............197 Keys to Successful Implementation .........................................204 Lessons Learned, or “The Roads Not to Take” .......................206 Case Study................................................................................210 Conclusion ...............................................................................212 Study Questions .......................................................................212 Notes ........................................................................................212 References ................................................................................213 Other Useful Resources............................................................214

10 Dashboards and Scorecards: Tools for Creating Alignment, by Michael D. Pugh ......................................................................217 Background and Terminology ..................................................217 Scope and Use of Dashboards and Scorecards in Healthcare ...219 Clinical and Operational Issues ................................................225 Keys to Successful Implementation and Lessons Learned ........230 Case Study: St. Joseph Hospital ...............................................236 Conclusion ...............................................................................238 Study Questions .......................................................................241 Notes ........................................................................................242 References ................................................................................242

11 Patient Safety and Medical Errors, by Frances A. Griffin and Carol Haraden..........................................................................243 Background and Terminology ..................................................243 Scope and Use in Healthcare Organizations ............................247

ix

Clinical and Operational Issues ................................................258 Case Study: OSF Healthcare System ........................................261 Conclusion ...............................................................................266 Study Questions .......................................................................267 References ................................................................................267

12 Information Technology Applications for Improved Quality, by Richard E. Ward .......................................................................269 Background and Terminology ..................................................269 Taking a Lesson from Other Industries....................................272 The Emerging Field of Medical Informatics ............................274 Two Tiers of Clinical Information Technologies......................274 Technologies for Different Types of Clinical Care

Management Initiatives .....................................................278 Requirements and Architecture Framework for Clinical

Information Technology....................................................279 Workflow Automation Technology Applied to

Clinical Processes...............................................................284 Other Clinical Information Technology Components .............286 Information Needed for Practice Improvement on a

National Level....................................................................289 Case Examples ..........................................................................291 Overall Return on Investment of Clinical

Information Systems..........................................................295 Key Strategy Debates................................................................301 The Challenge ..........................................................................306 Study Questions .......................................................................309 References ................................................................................309

13 Leadership for Quality, by James L. Reinertsen .......................311 Background ..............................................................................311 Scope and Use of Leadership Concepts in Healthcare .............315 Clinical and Operational Issues ................................................319 Keys to Successful Quality Leadership and Lessons Learned ...320 Case Study of Leadership: Interview with

William Rupp, MD ............................................................322 Conclusion ...............................................................................327 Study Questions .......................................................................327 Notes ........................................................................................327 References ................................................................................328

14 Organizational Quality Infrastructure: How Does an Organization Staff Quality?, by A. Al-Assaf..............................331 Quality Assurance, Quality Improvement, Quality Control, and

D e t a i l e d C o n t e n t sx

D e t a i l e d C o n t e n t s

Total Quality Management................................................331 Management Commitment ......................................................332 Allocation of Resources ............................................................335 Organizational Structure ..........................................................336 Increasing Awareness of Healthcare Quality ............................338 Mapping Quality Improvement Intervention...........................338 Challenges, Opportunities, and Lessons Learned for Sustaining

QA/QI ..............................................................................342 Case Example ...........................................................................345 Study Questions .......................................................................346 References ................................................................................346 Suggested Reading ...................................................................347

15 Implementing Quality as the Core Organizational Strategy, by Scott B. Ransom, Thomas J. Fairchild, and

Elizabeth R. Ransom .........................................................349 Implementing Quality in Healthcare Organizations ................352 Case Study: An Academic Medical Center’s

Quality Journey .................................................................363 Conclusion ...............................................................................373 Study Questions .......................................................................373 Notes ........................................................................................374 References ................................................................................374

16 Implementing Healthcare Quality Improvement: Changing Clinician Behavior, by Valerie Weber and John Bulger ............377 Understanding Change Management in Healthcare ................377 Active Implementation Strategies.............................................384 Addressing the Cost of Implementation...................................391 Keys to Successful Implementation and Lessons Learned ........393 Case Studies .............................................................................394 Conclusion ...............................................................................399 Study Questions .......................................................................399 Note .........................................................................................399 References ................................................................................400

III Environment

17 The Quality Improvement Landscape, by Jean Johnson, Ellen Dawson, and Kimberly Acquaviva ...................................407 Quality Improvement Organizations........................................407 Drivers of Quality.....................................................................408 Measurement Development Process.........................................413

xi

Trends in Quality Improvement...............................................415 Trends and Initiatives in Specific Healthcare Sectors ...............419 Case Studies .............................................................................425 Conclusion ...............................................................................428 Study Questions .......................................................................429 References ................................................................................429

18 Accreditation: Its Role in Driving Accountability in Healthcare, by Greg Pawlson and Paul Schyve............................................433 Background and Terminology ..................................................433 Scope and Use of Accreditation in Healthcare:

Successes and Failures........................................................436 The Future of Accreditation: Challenges and Changes ............443 Conclusion ...............................................................................452 Study Questions .......................................................................452 Notes ........................................................................................452 References ................................................................................453 Other Useful Resources............................................................454

19 How Purchasers Select and Pay for Quality, by Francois de Brantes ...............................................................457

Background and Terminology ..................................................458 Case Study: Bridges to Excellence: Building a Real Business

Case for Better Quality Care .............................................460 Defining the Program Specifications—Measures, Specific

Incentives, and Consumer-Focused Elements ...................464 Designing the Program’s Implementation ...............................470 Program Evolution ...................................................................471 Conclusion and Key Lessons ....................................................471 Study Questions .......................................................................472 Notes ........................................................................................472 References ................................................................................472

INDEX ..................................................................................................475

ABOUT THE AUTHORS ....................................................................................

D e t a i l e d C o n t e n t sxii

FOREWORD

Nancy M. Schlichting

There has never been a more important and exciting time in the journey to achieve excellence in healthcare quality. After more than eight years since the Institute of Medicine released its groundbreaking report, To Err Is Human: Building a Safer Health System, on the poor state of healthcare quality in the United States, there is significant momentum for fundamen- tal change to improve quality. The momentum is being felt in a number of important venues:

• In the government world, as legislators and administrators are working to increase the incentives for quality in governmental programs

• In the business world, as companies are redesigning health benefit plans to encourage more involvement of the employees in their choice of health- care providers based on performance

• In the insurance world, as health plans are evaluating providers based on quality indicators

• In the provider world, as hospitals and physicians are investing in new infor- mation technology to provide more consistent and safer quality of care for their patients

• In the consumer world, as individuals are seeking out information about quality before choosing a physician, a hospital, or a health plan

The importance of this momentum cannot be overstated. It will cre- ate enormous opportunities for learning that can be spread across the coun- try, more alignment of incentives among all stakeholders, more informed consumers, and greater availability of accurate and useful information for decision making.

The second edition of The Healthcare Quality Book is a resource for all learners and participants in this critical process of change. It is a guide for quality improvement that incorporates both theoretical models and practical approaches for implementation. The editors have brought together some of the best minds in healthcare to offer insights on leadership strat- egy, tools, organizational design, information technology, legal and reg- ulatory issues, and, most important, the patient experience. The Healthcare Quality Book will serve all who have a passion for changing the quality

xiii

paradigm and creating an ideal patient and family experience. Now is the time for action! The editors of The Healthcare Quality Book are providing the necessary resources. I am confident the readers will be part of the healthcare quality solution.

Nancy M. Schlichting President and CEO

Henry Ford Health System Detroit, Michigan

F o r e w o r dxiv

PREFACE

Change is constant, and no statement is more appropriate for the health- care industry. Since the first edition of this textbook, healthcare costs have increased beyond the rate of inflation, the number of uninsured individu- als has grown dramatically, employers and consumers are facing a greater share of healthcare expenses, and navigation of the complex and compli- cated healthcare system has become a burden on the public. Our health- care crisis permeates every aspect of the industry—the delivery of medical care, the financing of our system, and the quality of healthcare we receive.

In our fragmented, unsustainable, and uncertain healthcare system, one element remains steadfast—healthcare quality is paramount. Healthcare that is safe, effective, efficient, equitable, patient centered, and timely is fundamen- tal to all potential healthcare reform plans—big or small, national or regional.

This textbook provides a framework, a context, strategies, and prac- tical tactics for all stakeholders to understand, learn, teach, and lead health- care improvement. We have assembled an internationally prominent group of contributors for the best available current thinking and practices in each of their disciplines.

This edition has evolved from the first. New case studies have been added, up-to-date content has been included, new study questions have been posed, and a new chapter has been added. The framework of the book remains constant. Chapters 1 through 4 discuss foundational healthcare quality principles. Chapters 5 through 16 discuss critical quality issues at the organizational and microsystem levels. Chapters 17 through 19 detail the influence the environment has on the organizations, teams, and indi- viduals delivering healthcare services and products.

In Chapter 1, Maulik Joshi and Donald Berwick center on the patient and articulate key findings from national, sentinel reports of healthcare qual- ity over the last ten years. In Chapter 2, Leon Wyszewianski discusses the fundamental concepts of quality. In Chapter 3, David Ballard and colleagues discuss medical practice variation and provide an updated case study, and Kevin Warren has revised Chapter 4 to reflect the latest quality improvement tools and programs.

In Chapter 5, Robert Lloyd discusses measurement as a building block in quality assessment and improvement. John Byrnes focuses on data collection and its sources in Chapter 6, and Jerod Loeb and colleagues discuss analytic opportunities in quality data in Chapter 7. In Chapter 8, David Nash and col- leagues detail a physician profiling system. In Chapter 9, Susan Edgman-Levitan tackles an often discussed but less understood area of patient satisfaction—expe- riences and perspectives of care—and includes an update on the latest surveys. In Chapter 10, Michael Pugh aggregates data into a management tool called the Balanced Scorecard. Frances Griffin and Carol Haraden in Chapter 11 and

xv

Richard Ward in Chapter 12 dive deeper into two evolving subjects essential to driving performance improvement—patient safety and information technology, respectively. Chapters 13 through 15, by James Reinertsen, A. Al-Assaf, and Scott Ransom and colleagues, provide a triad of keys for change in organiza- tions seeking to become high performers. The triad represents leadership, infra- structure, and strategy for quality improvement. Chapter 16, by Valerie Weber and John Bulger, is a compilation of strategies and tactics necessary to change staff behavior.

Chapter 17, by Jean Johnson and colleagues, a new chapter, pro- vides examples of many of the recent national quality improvement initia- tives and an overview of the quality improvement landscape. In Chapter 18, Greg Pawlson and Paul Schyve collaborate to summarize the work of the two major accrediting bodies within healthcare—the National Committee for Quality Assurance and The Joint Commission—and cover the latest changes in the accreditation process. The book concludes with an impor- tant chapter by Francois de Brantes on the power of the purchaser to select and pay for quality services, which he has updated to provide the latest information on pay for performance.

Several of these chapters could stand independently. Each represents an important contribution to our understanding of the patient-centered organizations and environment in which healthcare services are delivered. The science and knowledge on which quality measurement is based are changing rapidly. This book provides a timely analysis of extant tools and techniques.

Who should read this book? The editors believe all current stakeholders would benefit from reading this text. The primary audiences for the book are undergraduate and graduate students in healthcare and business administration, public health programs, nursing programs, allied health programs, and programs in medicine. As leadership development and continuing education programs proliferate, this textbook is a resource for executives and practitioners at the front line. We hope this book will break down the educational silos that currently pre- vent stakeholders from sharing equally in their understanding of patient-cen- tered organizational systems and the environment of healthcare quality.

This textbook and the accompanying instructor manual are designed to facilitate discussion and learning. There are study questions at the end of each chapter in the textbook. The instructor manual contains answers to the study questions and a PowerPoint presentation for each chapter as a teaching aid. For access information, e-mail hap1@ache.org.

Please contact us at doctormaulikjoshi@yahoo.com. Your feedback, your teaching, your learning, and your leadership are essential to raising the bar in healthcare.

Elizabeth R. Ransom Maulik S. Joshi David B. Nash Scott B. Ransom

P r e f a c exvi

I PART

SCIENCE AND KNOWLEDGE FOUNDATION

HEALTHCARE QUALITY AND THE PATIENT Maulik S. Joshi and Donald Berwick

Quality in the U.S. healthcare system is not what it should be. Peoplewere aware of this issue for years from personal stories and anec-dotes. Around the end of the last century, three major reports revealed evidence of this quality deficiency:

• The Institute of Medicine’s (IOM) National Roundtable on Health Care Quality report, “The Urgent Need to Improve Health Care Quality” (Chassin and Galvin 1998)

• To Err Is Human (Kohn, Corrigan, and Donaldson 2000) • IOM’s Crossing the Quality Chasm (IOM 2001)

These three reports made a tremendous statement and called for action on the state of healthcare, its gaps, and the opportunity to improve its quality in the United States to unprecedented levels.

Before we begin discussion of these reports, however, let us begin by defining quality, its evolution, and its implications on our work as health- care professionals.

Avedis Donabedian, one of the pioneers in understanding approaches to quality, discussed in detail the various definitions of quality in relation to perspective. Among his conceptual constructs of quality, one view of Donabedian’s (1990) rang particularly true: “The balance of health bene- fits and harm is the essential core of a definition of quality.” The question of balance between benefit and harm is empirical and points to medicine’s essential chimerism: one part science and one part art (Mullan 2001).

The IOM Committee to Design a Strategy for Quality Review and Assurance in Medicare developed an often-cited definition of quality (Lohr 1990):

Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. . . . How care is provided should reflect appropriate use of the most current knowledge about scientific, clinical, technical, interpersonal, manual, cognitive, and organization and management elements of health care.

In 2001, Crossing the Quality Chasm stated powerfully and simply that healthcare should be safe, effective, efficient, timely, patient centered,

1 CHAPTER

3

and equitable. This six-dimensional aim, which will be discussed later in this chapter, provides the best-known and most goal-oriented definition, or at least conceptualization, of the components of quality today.

Important Reports

In 1998, the Journal of the American Medical Association’s National Roundtable report included two notable contributions to the industry. The first was its assessment of the state of quality. “Serious and widespread quality problems exist throughout American medicine. These problems . . . occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed.” The second contribution to the knowl- edge base of quality was a categorization of defects into three broad cate- gories: overuse, misuse, and underuse. The classification scheme of underuse, overuse, and misuse has become a common nosology for quality defects.