The healthcare quality book pdf

Healthcare Management Search Questions

Introduction Healthcare

Quality Management

S e c o n d e d I t I o n

to

P a t r i c e L . S p a t h One North Franklin Street, Suite 1700 Chicago, Illinois 60606-3529 Phone: (301) 362-6905; Fax: (240) 396-5907 ache.org/HAP Order No.: 2242

i n t r o d u c t i o n to h e a lt h ca r e Q u a l i t y m a n ag e m e n t explains the basic principles and techniques of quality management in healthcare. this revised edition features a new chapter devoted to the use of high-reliability concepts that help organizations achieve safety, quality, and efficiency goals.

this reader-friendly book, complete with helpful charts and diagrams, examines a range of topics, from measuring performance to creating high-quality services that result in satisfied customers. Practical examples and case studies apply quality concepts and tools to real-life situations. each chapter contains a list of key words and defines important glossary terms to help you understand the vocabulary of healthcare quality management. As an added bonus to this edition, each chapter now includes an expanded list of websites that provides additional resources to customize and enhance your understanding of healthcare quality management.

Patrice L. Spath, RHIT, is a health information management professional with broad experience in healthcare quality and safety improvement. She is president of Brown-Spath & Associates, a healthcare publishing and training company. during the past 25 years, Spath has presented more than 350 educational programs on healthcare quality management topics. Spath is an adjunct assistant professor in the department of Health Services Administration at the University of Alabama, Birmingham.

} Quality characteristics most important to healthcare stakeholders, including payers and consumers

} Regulatory mandates and accreditation standards that influence healthcare quality activities } Proper techniques for gathering and effectively analyzing healthcare performance measurement data

} new technology-based services that improve the patient experience

} Key tactics and strategies that organizational leaders and improvement project teams must implement to accomplish quality goals

} Methods for redesigning healthcare processes to achieve more reliable performance

} Patient safety initiatives that reduce harmful medical errors } Resource management activities that improve continuity of care and prevent service overuse and

underuse

} organizational factors that affect quality management and performance reliability

Key discussions include the following topics:

in tr

o d

u c

tio n

h ea

lth c

a r

e Q u

a lity m

a n

a g

em en

t S

ec o

n d e

d itio

n

S p a t h

to

Spath (2242) COVER.indd 1 6/20/13 3:51 PM

INTRODUCTION HEALTHCARE

QUALITY MANAGEMENT

S E C O N D E D I T I O N

to

P a t r i c e L . S p a t h

AUPHA/HAP Editorial Board for Undergraduate Studies

Eric S. Williams, PhD, Chairman University of Alabama

Steven D. Berkshire, EdD, FACHE Central Michigan University

Stephanie L. Bernell, PhD Oregon State University

Rosemary Caron, PhD University of New Hampshire

Susan P. Casciani, FACHE Towson University

David E. Cockley, DrPH James Madison University

Tracy J. Farnsworth Idaho State University

Riaz Ferdaus, PhD Our Lady of the Lake College

Mary K. Madsen, PhD, RN University of Wisconsin–Milwaukee

Lydia Middleton AUPHA

John J. Newhouse, PhD St. Joseph’s University

Rubini Pasupathy, PhD Texas Tech University

Jacqueline Sharpe Old Dominion University

Daniel J. West, Jr., PhD, FACHE University of Scranton

Health Administration Press, Chicago, Illinois

AUPHA Press, Arlington, Virginia

INTRODUCTION HEALTHCARE

QUALITY MANAGEMENT

S E C O N D E D I T I O N

to

P a t r i c e L . S p a t h

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.

This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

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

Copyright © 2013 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.

18 17 16 15 14 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Spath, Patrice. Introduction to healthcare quality management / Patrice Spath. – Second edition. pages cm Includes index. ISBN 978-1-56793-593-6 (alk. paper) 1. Medical care–Quality control. 2. Quality assurance. 3. Medical care–Quality control– Measurement. 4. Quality assurance–Measurement. I. Title. RA399.A1S64 2014 362.1–dc23

2013005277

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. ™ Acquisitions editor: Carrie A. McDonald; Project manager: Joyce Dunne; Cover design: Marisa Jackson; Layout: Fine Print, Ltd.

Found an error or a typo? We want to know! Please e-mail it to hapbooks@ache.org, and write “Book Error” in the subject line.

For photocopying and copyright information, please contact Copyright Clearance Center at www.copyright.com or (978) 750-8400.

Health Administration Press A division of the Foundation of the American College of Healthcare Executives One North Franklin Street, Suite 1700 Chicago, IL 60606-3529 (312) 424-2800

Association of University Programs in Health Administration 2000 North 14th Street Suite 780 Arlington, VA 22201 (703) 894-0940

mailto:hapbooks@ache.org
http://www.copyright.com
This book is dedicated to all the health profession students who have taken

one of the university courses I teach in healthcare quality management.

While these students are learning from me, I am also learning a lot from them.

I thank all of my students for helping me to appreciate how best

to explain complex topics in understandable ways

and how not to overwhelm them with jargon.

Each book I write gets a little better because of what I learn

from practitioners and students of healthcare quality management.

v i i

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Chapter 1: Focus on Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Chapter 2: Quality Management Building Blocks . . . . . . . . . . . . . . . . . . . . . . . . . 13 Chapter 3: Measuring Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Chapter 4: Evaluating Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Chapter 5: Continuous Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Chapter 6: Performance Improvement Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Chapter 7: Improvement Project Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Chapter 8: Improving Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Chapter 9: Achieving Reliable Quality and Safety . . . . . . . . . . . . . . . . . . . . . . . . 210 Chapter 10: Managing the Use of Healthcare Resources . . . . . . . . . . . . . . . . . . . . 234 Chapter 11: Organizing for Quality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314

BRIEF CONTENTS

i x

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Content Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii Supplemental and Instructional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xx

Chapter 1: Focus on Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.1 What Is Quality? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.2 Healthcare Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

DETAILED CONTENTS

Chapter 2: Quality Management Building Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2.1 Quality Management Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.2 Quality Management Milestones in Industry and Healthcare . . . . . . . . . . . . . 16 2.3 External Forces Affecting Healthcare Quality Management . . . . . . . . . . . . . . 23 2.4 Quality Management Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Chapter 3: Measuring Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 3.1 Measurement in Quality Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 3.2 Measurement Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 3.3 Measurement Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 3.4 Selecting Performance Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 3.5 Constructing Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 3.6 Measures of Clinical Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 3.7 Balanced Scorecard of Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Chapter 4: Evaluating Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 4.1 Assessment in Quality Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 4.2 Display Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 4.3 Compare Results with Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 4.4 Determine Need for Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

x C o n t e n t s

Chapter 5: Continuous Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 5.1 Improvement in Quality Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 5.2 Performance Improvement Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Chapter 6: Performance Improvement Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 6.1 Qualitative Improvement Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

Chapter 7: Improvement Project Teams. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 7.1 Project Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 7.2 Team Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 7.3 Team Dynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Chapter 8: Improving Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 8.1 Safety in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 8.2 Preventing Mistakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 8.3 Measuring Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 8.4 Improving Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 8.5 Patient Engagement in Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

C o n t e n t s x i

Chapter 9: Achieving Reliable Quality and Safety . . . . . . . . . . . . . . . . . . . . . . . . . . 210

Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210 Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 9.1 Reliable Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 9.2 Applying Reliability Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 9.3 Monitoring Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224 9.4 Realizing Sustained Improvements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Chapter 10: Managing the Use of Healthcare Resources . . . . . . . . . . . . . . . . . . . . . 234

Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 10.1 Utilization Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 10.2 Defining Appropriate Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 10.3 Measurement and Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 10.4 Utilization Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 10.5 Discharge Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 10.6 Utilization Management Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258 For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260

Chapter 11: Organizing for Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264

Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 11.1 Quality Management System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 11.2 Quality Management Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 11.3 A Hospitable Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 For Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314

x i i C o n t e n t s

x i i i

FOREWORD TO THE SECOND EDITION

In my foreword to the first edition of this book, I commented on the number of Google hits for the search term healthcare quality books—19.3 million—and the impressive decrease by 98 percent when I refined the search term to healthcare quality textbooks. A new Google exercise for this second edition foreword presented an astounding 202 million hits for the broad term but a percentage decrease for the textbooks search similar to that in 2009 (resulting in 2.24 million hits). Although I am no longer surprised by the mag- nitude of references on the web, I was pleased to note that Patrice Spath’s Introduction to Healthcare Quality Management appeared third on the list of search results for textbooks. If the first edition holds this, albeit subjective, ranking of prominence, what can we expect from the second edition?

In health professions education, more so than in many other disciplines, textbook content is dynamic. The “who, what, when, where, why, and how” of healthcare are driven by technology innovations, policy and politics, economic models, and other societal and regulatory influences. For this reason, healthcare textbooks are supplemented with journal and news articles, research findings, and web-based resources to ensure that students are provided with essential current knowledge. A healthcare textbook is considered “good” if the foundational concepts remain sound and a significant amount of the application content is relevant to current practice for a reasonable period of time—ideally, three or more years. The tipping point when a new edition is warranted often is signaled by an

x i v F o r e w o r d t o t h e S e c o n d E d i t i o n

increase in the amount or a diversity in the type of supplemental resources required or by the emergence of important industry initiatives.

The first edition of Introduction to Healthcare Quality Management has maintained its relevance by way of its conceptual framework and its utility related to the application content. For this edition, the author reviewed each chapter and made appropriate revisions to ensure that the content is up to date. The inclusion of a new chapter and several new sections in the other chapters adds value for students and other purchasers.

Important additions to the conceptual base of this textbook are discussions of the human factors and reliability sciences. These principles are applied by an increasing number of healthcare organizations to improve the reliability of their performance. The criteria—and the expectations—by which healthcare organizations are measured with regard to their abil- ity to provide safe, effective, and high-quality patient care continue to evolve. The relation- ship between organizational performance and payment for services provided has become tightly coupled. Some healthcare organizations achieve success under a single evaluation framework but are unable to sustain their performance when regulatory or operational environments change. Thus, clinicians and managers must create a culture conducive to accountability, risk management, and corrective action that is effective and supports reli- able, high-quality performance in a dynamic environment.

Spath’s discussion of new technologies throughout the book will aid managers and leaders as they deploy technology-based services to improve the patient experience. Tech- nologies supporting communication and information capture, management, and analy- sis are progressively sophisticated, keeping pace with advances in clinical technologies. These rapidly evolving products enable patients, clinicians, and organizations to embrace e-health applications at the individual, community, and global levels. From her extensive knowledge in this area from a practice perspective, Spath demonstrates how new technolo- gies are creating innovative opportunities for data collection and more reliable healthcare performance.

Patients and their families are better informed than ever because of the communi- cation and information technologies now available to the general population. As a result, they are more confident in discussing their diagnoses and treatments with their healthcare providers. When these discussions cover personal and family preferences and constraints, clinicians are armed with information to guide patients in healthcare decision making. Spath’s textbook reflects this shift toward patient engagement by including a section on measuring a patient’s healthcare experience, adding an important component to the con- ceptual framework of healthcare quality.

As the knowledge in all domains of healthcare grows, so does the need to apply the knowledge to solve complex organizational problems—ideally by using a proactive (rather than reactive) approach and often by including teams of professionals from many academic and professional disciplines. Diverse teams bring the diverse skills needed to

F o r e w o r d t o t h e S e c o n d E d i t i o n x v

select and apply appropriate analytical tools for improvement. As the team concept of care delivery evolves, providers must emphasize the conceptual foundations of healthcare quality and embrace a culture of accountability for the quality and safety of the patient experience. This textbook provides health professions students with core knowledge that will enable them to adapt to organization-specific models as informed, educated, and valued employees.

Donna J. Slovensky, PhD, RHIA, FAHIMA School of Health Professions University of Alabama at Birmingham

x v i i

PREFACE

The old adage “The only constant is change” was true for the healthcare industry when I started my career many years ago, and it is true today. The pace of change has certainly picked up in the past few years, which brings unique challenges to staying well informed about new regulations, patient care recommendations, new tech- nologies, and innovations.

Mental overload is the new norm. How do individuals react when they are over- whelmed by too much information? Studies in the discipline of cognitive psychology indicate that overload causes people to develop tunnel vision. They lose their view of the big picture as their attention is narrowed to one issue or one task—seeing the world as if through a soda straw. Tunnel vision is the mind’s biological response to encountering too much information. Regardless of how good we presume ourselves to be at multitasking, our working memory can only concentrate on one thing at a time. This book provides readers with the opportunity to focus on one fundamental topic: how healthcare qual- ity is measured, evaluated, and improved. Once this learning has been assimilated into your long-term memory (your personal knowledge database), it will be there for retrieval whenever you need it.

This second edition of Introduction to Healthcare Quality Management is a cul- mination of my more than 30 years of experience as a hospital quality director, trainer, and consultant for other quality professionals and as an instructor of undergraduate- and

x v i i i P r e f a c e

graduate-level healthcare quality courses. Improvement fads, and the quality gurus who advocate their use, have come and gone; the cycle will surely repeat itself long after I’ve retired. In this book I’ve stuck to the basics—the foundational principles and techniques common to any healthcare quality initiative. Once they have mastered these basics, students of quality management will be able to adapt to whatever model of quality comes along. For individuals seeking advanced degrees, this book is a starting place for expanded learning.

This book is directed to people with little or no clinical healthcare experience. The case studies and illustrations focus primarily on the provision of health services rather than the diagnosis and treatment of patients. Clinical discussions are accompanied by explanatory text to clarify terminology or situations that may be unfamiliar to students. The websites listed at the end of each chapter point readers to advanced learning resources (up to date as of this writing), including additional clinical quality management examples.

Throughout my years of teaching quality management to beginners, I’ve found that vocabulary can be a barrier to learning. Simple concepts, such as measuring patient complication rates, may be tricky to understand if students have had little healthcare experience. To help overcome this barrier, the textbook introduces many of the concepts by using analogies from everyday life. Once students see the link between what they know and do almost every day and the basic quality concepts, they begin to understand related healthcare quality principles and techniques. While the analogies may seem simplistic, they often help the novice unravel the vagaries of healthcare quality management.

Content overview

The book begins with a chapter on the attributes of quality and factors that affect consumer perceptions of quality. The notion of value—quality at a reasonable cost—is introduced with an explanation of how perceived value influences purchasing decisions. Students learn the Institute of Medicine’s definition of healthcare quality and the quality characteristics expected in high-performing healthcare organizations. How these quality characteristics are measured and improved is reinforced throughout the remainder of the book.

Chapter 2 offers a description of the interrelated elements of quality management: measurement, assessment, and improvement. This trilogy provides a framework on which subsequent chapters build. The chapter continues with a discussion of the science of qual- ity and its application in healthcare organizations. Students are introduced to the work of Walter Shewhart, W. Edwards Deming, and other quality pioneers of the manufactur- ing industry. Healthcare organizations, which have been slow to adopt statistical process control techniques, are beginning to rival those in other industries in their application of quality management tools. The background behind these quality management advances is presented to help students grasp subjects covered in later chapters. Chapter 2 concludes with a summary of external forces that influence healthcare quality management activities.

P r e f a c e x i x

Chapters 3 through 7 provide step-by-step descriptions of how healthcare quality is measured, assessed, and improved. Chapter 3 begins with an overview of quality measure- ment. The three measurement categories—structure, process, and outcome—are intro- duced and explained through numerous examples from a variety of healthcare settings. Also covered are methods for choosing performance measures and constructing measures that yield worthwhile information. Most important, this chapter introduces students to a critical element of clinical quality management: measurement of clinical decision making using evidence-based guidelines.

Measurement is only the first step in quality management. The measurement results must be evaluated to determine whether performance is acceptable. Performance assessment, the second component of quality management, is covered in Chapter 4. Methods for effec- tive display and communication of data are introduced and two report formats—snapshot and trend—are discussed. Appropriate uses for each type of report and evaluation of results against performance expectations are demonstrated through case studies. Chapter 4 then provides an overview of statistical process control techniques, which are gaining popularity among healthcare organizations as a means of evaluating performance. The impact of unnec- essary process variation on quality, methods of measuring variation, and ways measurement can be used to control variation are also discussed. The chapter concludes with a discussion of the factors involved in the next step of quality management—assessing whether to proceed with an improvement initiative or to continue measuring.

The decision to improve performance sets in motion an improvement initiative. The next step is to determine which improvement process to follow. No standard pro- cess exists for improving performance. Shewhart’s Plan-Do-Check-Act (PDCA) cycle of improvement has been modified and adapted many times since its introduction in the 1920s. Chapter 5 acquaints students with the PDCA model and other frameworks com- monly used in improvement initiatives. It describes the primary purpose of each model and the differences between and similarities among them. Most important, this chapter emphasizes the need for a systematic approach to healthcare quality initiatives. Several project examples take students through the steps of methodical process improvement.

Throughout the steps of a process improvement initiative, many decisions must be made. How wide is the gap between expected and actual performance? What factors are causing undesirable performance? Which problems take priority? How can the process be changed to improve performance? The answers to these questions are gathered through the use of quality improvement tools. Some of these tools are quantitative—similar to the graphs and displays discussed in Chapter 4—and some are qualitative—for example, nom- inal group technique, cause-and-effect diagrams, and flowcharts. Chapter 6 introduces 14 qualitative tools commonly used in improvement initiatives. Practical examples and case studies provide students with the knowledge to apply these tools in real-life situations. In Chapter 7, students learn how improvement teams are formed and managed.

x x P r e f a c e

Two characteristics of high-quality patient care—safety and effectiveness—are particularly important in today’s performance-oriented, cost-conscious environment. A complete chapter is devoted to each subject. Chapter 8 begins with a discussion of the factors prompting increased public scrutiny of the safety of healthcare services. Using the measurement, assessment, and improvement framework, the chapter demonstrates how patient safety is evaluated and improved. Of particular importance are two safety improve- ment tools: (1) failure mode and effects analysis and (2) root cause analysis. Students of quality management should remember that they, too, are recipients of healthcare services; at the conclusion of this chapter, they discover what they can do as patients to protect themselves from potentially harmful medical mistakes.

Chapter 9 provides more detail on how to accomplish the important goal of achieving high-quality, reliable performance in healthcare. Because healthcare processes are not well designed, people’s vigilance and hard work are often relied on to ensure good performance. A better way to advance quality is to apply human factors and reliability science principles. In this chapter, students are introduced to techniques for improving processes—used for years in other industries and now being successfully applied in the healthcare environment—so that failures can be reduced and reliable quality can be realized.

Quality improvement and cost control depend on the organization’s ability to reduce underuse and overuse of healthcare services. Utilization management activities, described in Chapter 10, are undertaken by healthcare organizations to determine whether they are using resources appropriately. The chapter reveals tactics that purchasers and providers use to prospectively, concurrently, and retrospectively ensure effective use of healthcare services. A systematic approach is needed to control resource use without compromising the quality of patient care. This structured approach is also covered in Chapter 10.

Healthcare quality is not produced in a vacuum. Organization-wide commitment and an adequately supported infrastructure are essential to achieving performance excel- lence. Chapter 11 introduces the contributors vital to the success of a quality program, and it details elements of a planned and systematic improvement approach. Most impor- tant, Chapter 11 emphasizes the role of a supportive organizational culture in the quality process and concludes with a discussion of cultural factors that can advance or inhibit achievement of quality goals.

Supplemental and inStruCtional reSourCeS

Each chapter concludes with student discussion questions. Some questions encourage con- templation and further dialogue on select topics, and some give students a chance to apply the knowledge they have gained. Others promote continued learning through discovery and use of information available on the Internet. I hope that, on completion of each chap- ter, students feel compelled to address the discussion questions to expand their learning.

P r e f a c e x x i

Additional resources are available to students and instructors on this book’s companion website. For access information, visit www.ache.org/books/IntroHealthcareQuality2. The book companion features test banks, a PowerPoint presentation, and, for instructors, answers to discussion questions.

In keeping with my goal of sticking to the basics, some quality topics are not covered in depth or not covered at all. My decision to omit them should not be taken as a signal that they are unimportant to the study of healthcare quality management. Supplemental learning materials may be needed depending on course prerequisites and program curricula. The websites listed at the end of each chapter can be used to add topics or augment those insufficiently covered in the book. The information I have included on rapidly changing “hot topics,” such as pay for performance and meaningful use of information technology, is purposefully high level; current journal articles are students’ best resource for these subjects. A firm grasp of the basics—measurement, assessment, and improvement—better prepares students to address any quality management topic they encounter.

Patrice L. Spath, RHIT

http://www.ache.org/books/IntroHealthcareQuality2
1

Learning Object ives

After reading this chapter, you will be able to

➤ recognize factors that influence consumers’ perception of quality products and

services;

➤ explain the relationship between cost and quality;

➤ recognize the quality characteristics important to healthcare consumers,

purchasers, and providers; and

➤ demonstrate an understanding of the varied dimensions of healthcare quality.

C H A P T E R 1

FOCUS ON QUALITY

2 I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t

Key WOrds

➤ Cost-effectiveness

➤ Defensive medicine

➤ Healthcare quality

➤ High-value healthcare

➤ Institute for Healthcare Improvement (IHI)

➤ Institute of Medicine (IOM)

➤ National Quality Strategy

➤ Providers

➤ Purchasers

➤ Quality

➤ Quality assurance

➤ Reliability

➤ Value

C h a p t e r 1 : F o c u s o n Q u a l i t y 3

Since opening its first store in 1971, Starbucks Coffee Company has developed into an international corporation with more than 19,000 locations in more than 55 countries. The company’s dedication to providing a quality customer experience is a major contributor to its success. Starbucks’s customers expect to receive high-quality, freshly brewed coffee in a comfortable, secure, and inviting atmosphere. In almost every customer encounter, Starbucks meets or exceeds those expectations. This consistency does not occur by chance. Starbucks puts a lot of behind-the-scenes work into its cus- tomer service. From selecting coffee beans that meet Starbucks’s exacting standards of quality and flavor to ensuring baristas are properly trained to prepare espresso, every part of the process is carefully managed.

Providing high-quality healthcare services also requires much work behind the front lines. Every element in the complex process of healthcare delivery must be carefully managed. This book explains how healthcare organizations manage the quality of their care delivery to meet or exceed customers’ expectations. These expectations include deliv- ering an excellent patient care experience, providing only necessary healthcare services, and doing so at the lowest cost possible.

1.1 What is QuaLity?

In its broadest sense, quality is an attribute of a product or service. The perspective of the person evaluating the product or service influences her judgment of the attribute. No univer- sally accepted definition of quality exists; however, its definitions share common elements:

◆ Quality involves meeting or exceed- ing customer expectations.

◆ Quality is dynamic (i.e., what is considered quality today may not be good enough to be considered quality tomorrow).

◆ Quality can be improved.

reLiabiL ity

An important aspect of quality is reliability. From an engineering perspective, reliability refers to the ability of a device, system, or process to perform its prescribed function with- out failure for a given time when operated correctly in a specified environment (Meeker 2002). Reliability ends when a failure occurs. For instance, your laptop computer is con- sidered reliable when it functions properly during normal use. If it stops functioning— fails—you have an unreliable computer.

Quality

Perceived degree of

excellence.

LEARNING POINT Defining Quality*

A quality product or service is one that meets or exceeds expec-

tations. Expectations can change, so quality must be continu-

ously improved.

Reliability The measurable capa- bility of a process, procedure, or health service to perform its intended function in the required time under commonly occur- ring conditions.

4 I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t

Consumers want to experience quality that is reliable. Patrons of Starbucks pay a premium to get the same taste, quality, and experience at every Starbucks location (Clark 2008). James Harrington, past president of the American Society for Quality, cautioned manufacturers to focus on reliability more than they have in recent years to retain mar-

ket share. First-time buyers of an automobile are often influenced by features, cost, and perceived quality. Repeat buyers cite reliability as the pri- mary reason for sticking with a particular brand (Harrington 2009).

Reliability can be measured. A reliable process performs as expected a high proportion of the time. An unreliable process performs as expected a low proportion of the time. Unfor- tunately, many healthcare processes fall into the unreliable category (Amalberti et al. 2005). Healthcare processes that fail to consistently per-

form as expected a high proportion of the time contribute to medical errors that cause up to 98,000 annual deaths in the United States (Wachter 2010). Healthcare consumers are no different from consumers of other products and services; they expect quality services that are reliable.

cOst−QuaLity cOnnectiOn

We expect to receive value when purchasing products or services. We do not want to find broken or missing parts when we unwrap new merchandise. We are disheartened when we receive poor service at a restaurant. We become downright irritated when our banks fail to record a deposit and our checks bounce.

How you respond to disappointing situations depends on how you are affected by them. With a product purchase, if the merchandise is expensive, you will likely contact the store immediately to arrange an exchange or a refund. If the product is inexpensive, you may chalk it up to experience and vow never to do business with the company again. At a restaurant, your expectations increase as the price of the food goes up. Yet, if you are adversely affected—for example, you get food poisoning—you will be an unhappy customer no matter the cost of the meal. The same is true for banks that make mistakes. No one wants the hassle of reversing a bank error, even if the checking account is free. Unhappy clients tend move on to do business with another bank.

Cost and quality affect the customer experience in all industries. But in health- care, these factors are harder for the average consumer to evaluate than in other types

LEARNING POINT Importance of Reliability*

A necessary ingredient of quality is reliability, loosely defined as

the probability a system will perform properly over a defined

time span. It may be possible to achieve reliability without

quality (e.g., consistently poor service), but quality can never

be achieved without reliability.

Value

A relative measure that

describes a product’s

or service’s worth, use-

fulness, or importance.

C h a p t e r 1 : F o c u s o n Q u a l i t y 5

of business. Tainted restaurant food is easier to recognize than an unskilled surgeon is. As for cost, everyone agrees that healthcare is expensive, yet, if someone else is paying for it—an insurance company, the government, or a relative—the cost factor becomes less important to the consumer. If your surgery does not go well, however, you’ll be an unhappy customer regardless of what it cost.

In all industries, multiple dynamics influence the cost and quality of products and services. First, prices may be influenced by how much the consumer is willing to pay. For example, one person may pay a premium to get the latest and most innovative electronic gadget, whereas another person may wait until the price comes down before buying it. If prices are set too high, potential buyers resist purchasing it, thus affecting sales. Apple Inc. experienced this phenomenon in January 2007 with the launch of its newest iPhone. Within two months, lagging sales of this popular product led Apple to drop the price by $200 (Dalrymple 2007).

Second, low quality–say, poor customer service or inferior products—eventually causes a company to lose sales. The US electronics and automotive industries faced this outcome in the early 1980s when American consumers started buying more Japanese products (Walton 1986). Business and government leaders realized that an emphasis on quality was necessary to compete in a more demanding, and expanding, world market.

Consumer−Supplier Relationship

The consumer–supplier relationship in healthcare is influenced by different dynamics. For example, consumers may complain about rising healthcare costs, but most are not in a position to delay healthcare services until the price comes down. If you break your arm, you immediately go to a doctor or an emergency department to be treated. You are not likely to shop around for the best price or postpone treatment if you are in severe pain.

In most healthcare encounters, the insurance companies or government-sponsored payment systems (such as Medicare and Medicaid) are the consumer’s agent. When health- care costs are too high, they drive the resistance against rising rates. These groups act on behalf of consumers in an attempt to keep healthcare costs down. They exert their buying power by negotiating with healthcare providers for lower rates. In addition, they monitor billing claims for overuse of services and will not pay the providers—the suppliers—for

LEARNING POINT Cost–Quality Connection*

The cost of a product or service is indirectly related to its per-

ceived quality. A quality healthcare experience is one that

meets a personal need or provides some benefit (either real

or perceived) and is provided at a reasonable cost.

6 I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t

services considered medically unnecessary. If a doctor admits you to the hospital to put a cast on your broken arm, your insurance company will question the doctor’s decision to treat you in an inpatient setting. Your broken arm needs treatment, but the cast can be put on in the doctor’s office or emergency department. Neither you nor the insurance company should be charged for the higher costs of hospital care if a less expensive and reasonable treatment alternative is available.

The connection between cost and quality is value. Most consumers purchase a product or service because they will, or perceive they will, derive some personal benefit from it. Healthcare consumers—whether patients or health plans—want providers to meet their needs at a reasonable cost (in terms of money, time, ease of use, and so forth). When customers believe they are receiving value for their dollars, they are more likely to perceive their healthcare interactions as quality experiences.

1.2 heaLthcare QuaLity

What is healthcare quality? Each group most affected by this question—consumers, purchasers, and providers—may answer it differently. Most consumers expect quality in the delivery of healthcare services: Patients want to receive the right treatments and experi- ence good outcomes; everyone wants to have satisfactory interactions with caregivers; and consumers want the physical facilities where care is provided to be clean and pleasant, and they want their doctors to use the best technology available. Consumer expectations are only part of the definition, however. Purchasers and providers may view quality in terms of other attributes.

identifying the staKehOLders in QuaLity care

Purchasers are individuals and organizations that pay for healthcare services either directly or indirectly. If you pay out of pocket for healthcare services, you are both a consumer and a purchaser. Purchaser organizations include government-funded health insurance programs, private health insurance plans, and businesses that subsidize the cost of employees’ health insurance. Purchasers are interested in the cost of healthcare and many of the same quality characteristics that are important to consumers. People who are financially responsible for some or all of their healthcare costs want to receive value for the dollars they spend. Purchaser organizations are no different. Purchasers view quality in terms of cost-effectiveness, meaning they want value in return for their healthcare expenditures.

Providers are individuals and organizations that offer healthcare services. Pro- vider individuals include doctors, nurses, technicians, and clinical support and clerical staff. Provider organizations include hospitals, skilled nursing and rehabilitation facilities,

Healthcare quality Degree to which health services for individu- als and populations increase the likelihood of desired health outcomes and are con- sistent with current pro- fessional knowledge.

Purchasers Individuals and orga- nizations that pay for healthcare services either directly or indirectly.

Cost-effectiveness The minimal expendi- ture of dollars, time, and other elements necessary to achieve a desired healthcare result.

Providers Individuals and orga- nizations licensed or trained to give health- care.

C h a p t e r 1 : F o c u s o n Q u a l i t y 7

outpatient clinics, home health agencies, and all other institutions that provide care.

In addition to the attributes important to consumers and purchasers, providers are concerned about legal liability —the risk that unsatisfied consumers will bring suit against the organization or individual. This concern can influence how providers define quality. Suppose you have a migraine headache, and your doctor orders a CT (computed tomography) scan of your head to be 100 percent certain there are no physical abnormalities. Your physician may have no medical reason to order the test, but he is tak- ing every possible measure to avert the possibility that you will sue him for malpractice. In this scenario, your doctor is practicing defensive medicine—ordering or performing diagnostic or therapeutic interventions primarily to safeguard the provider against malpractice liability (Manner 2007). Because these inter- ventions incur additional costs, providers’ desire to avoid lawsuits can be at odds with purchasers’ desire for cost-effectiveness.

defining heaLthcare QuaLity

Before efforts to improve healthcare quality can be undertaken, a common definition of quality is needed to work from, one that encompasses the priorities of all stakeholder groups—consumers, purchasers, and providers. The Institute of Medicine (IOM), a non- profit organization that provides science-based advice on matters of medicine and health, brought the stakeholder groups together to create a workable definition of healthcare qual- ity. In 1990, the IOM committee charged with designing a strategy for healthcare quality assurance published this definition:

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.

In 2001, the IOM Committee on Quality of Health Care in America further clari- fied the concept of healthcare quality in its report Crossing the Quality Chasm: A New Health System for the 21st Century. The committee identified six dimensions of US healthcare quality (listed in Critical Concept 1.1), which influence the improvement priorities of all stake- holder groups.

Defensive medicine Diagnostic or thera- peutic interventions conducted primarily as a safeguard against malpractice liability.

DID YOU KNOW??

In a consumer message to Congress in 1962, President John F.

Kennedy identified the right to be informed as one of four basic

consumer rights. He said that a consumer has the right “to be

protected against fraudulent, deceitful, or grossly misleading

information, advertising, labeling, and other practices, and to be

given the facts he needs to make an informed choice” (Kennedy

1962). Consumers have come to expect this right as they purchase

goods and services in the marketplace.