Continuous Quality Improvement in Health Care Organizations

Prepared by: Dr. Alber Paules

Definition
Quality Improvement (QI): the sum of all activities which create desired change in the quality. An effective QI system results in a stepwise increase in quality of care. QI approach emphasizes reducing the variability in the entire process and shifting the process in the desired direction; rather than just taking actions whenever thresholds are exceeded. Continuous Quality Improvement (CQI): implies the continuity of the improvement efforts (i.e.) whenever an improvement is achieved, we might seek another opportunity to achieve further improvement.

Why Healthcare Organizations Adopt CQI Strategies/Initiatives?

1. To maximize their quality of care as defined in both technical and customer preference terms. 2. To gain more competitive advantages and increase their share in the local health care market through excelling in the service they provide. 3. To gain or maintain an accreditation status with bodies such as the JCAHO (JCI), NCQA, and others. 4. To respond to the pressures imposed on them by the patient advocacy groups, employers, payers, and regulatory bodies.

Why Should Health Care Organizations adopt CQI?

1. To maximize their quality of care as defined in both technical and customer preference terms. 2. To gain more competitive advantages and increase their share in the local health care market through excelling in the service they provide. 3. To respond to customer requirements/expectations which change over time because of changes in education, economics, technology, and culture; in addition to changes in the competitors performances. Such changes require continuous improvements in the administrative and the clinical methods that affect the quality of care.

Elements of CQI
1. Philosophical elements 2. Structural elements

Philosophical Elements of CQI

1. Strategic Focus--Emphasis on having a mission, vision, values, and goals that performance improvement processes are designed, prioritized, and implemented to support. 2. Customer Focus--Emphasis on both customer satisfaction (whether external or internal ones) and health outcomes as performance measures. 3. Processes ViewEmphasis on analysis of the system processes. 4. Continuing Improvementemphasis on continuing the process analysis even when a satisfactory solution to the presenting problem is obtained.

Philosophical Elements of CQI

4. Top Management Commitment. 5. Emphasis on avoiding personal blame. The initial assumption is that the process needs to be changed and that the persons already involved in that process are needed to help identify how to approach a given problem. 6. Encouraging participative management (through encouraging the involvement of all personnel associated with a particular work process to provide a contribution and share in solving the problem) and decentralization (through placing responsibility for ownership of each process in the hands of its implementers).

Philosophical Elements of CQI

7. Increasing the pride and the morale of the employees by recognizing their important role when they become members in a process improvement team and become involved in the re-design of a relevant process. 8. Data-driven AnalysisEmphasis on gathering and use of objective data on process performance with subsequent fact-based decision making.

Structural Elements of CQI

(elements which structure, organize, and support the CQI process) 1. Process Improvement TeamsEmphasis on forming and empowering team of employees to deal with existing problems and opportunities. 2. Seven Toolsuse of one or more of these seven quality tools: flow charts, cause-and-effect diagrams, histograms, Pareto chars, run charts, control charts, and correlational analysis (e.g.) scatter diagram. 3. Quality Councildevelopment of the quality council, which is an organizational structure formed from the top institutional leaders, to set priorities for and monitor CQI strategy and implementation.

Structural Elements of CQI

4. Development of a comprehensive set of indicators to monitor our performance. 5. Benchmarkinguse of benchmarking to identify best practices in similar settings to use as performance targets.

The Iceberg Model of QI

Tip
Tools (what we can see and do)

Systems, Frameworks, and Models (shaped by theories and assumptions; unseen)

Base

Theories and Assumptions (deep under the surface; we are largely unaware of)

Foundation of the Iceberg Model: Theories and Assumptions

These include the contributions of the quality leaders, like:
1. 2. 3. 4. Walter Shewhart Edwards Deming Joseph Juran Philip Crosby, and others.

Middle of the Iceberg Model: Systems, Frameworks, and Models

They are derived from the ideas and theories developed by the thought leaders; they include:

1. FOCUS-PDCA:
o o o Designed by a healthcare QI consulting group in the 1980s . Uses the Demings Cycle (PDCA cycle). FOCUS-PDCA is an acronym for the following:
Find an opportunity for improvement Organize a team that knows the process Clarify current understanding of how the process works Understand the process variation Select a strategy for improvement The PDCA cycle tests the strategy to determine its effectiveness (i.e., if it results in improvement)

FOCUS-PDCA
Find a process to improve
This is relatively easy when the organization first begins performance improvement activities. A comparison has been made to a fruit tree. When you first begin to harvest the fruit, it is very easy since it probably is lying about the ground; however, the more harvested the more difficult it becomes to obtain. Selected improvement opportunities should be approved by the quality council.

FOCUS-PDCA
Find a process to improve
Because of this increasing difficulty in identifying opportunities, there are many ways for finding opportunities than simply picking one up from the ground. The following references may suggest opportunities for improving performance: Standards of Care Customer Satisfaction Surveys Incident Reports Action/Recommendation Sections of Committee Minutes Employee Suggestions Accreditation Surveys

FOCUS-PDCA
Find a process to improve
Mistakes to avoid while searching for improvement opportunities: Selecting a System to study instead of a Process: (e.g., selecting a phase on the medication management system rather than addressing the whole system) Selecting a desired Solution instead of a Process: Frequently managers will already have a desired solution to the problem in mind and will convene this solution to the team to study. Teams must be free to select whatever interventions they think are best. Sure, the suggested solution may be the best, but this is determined only after thorough analysis of the process.

FOCUS-PDCA
Organize a team that knows the process
The Team Leader: o Chairs the team o It is better if he/she is the owner of the process under study (i.e., has direct control over the process) since his/her managerial responsibility over the process under study will make it easier and less time-consuming to improve the process. o The team leader should be a good group leader with knowledge of consensus building skills. o Examples of responsibilities: schedule meetings, lead team when using PI tools, resolve problems that may arise for team members (e.g., contact the manager/supervisor of a team member to allow him/her sufficient time for the work of the team)etc.

FOCUS-PDCA
Organize a team that knows the process
The Facilitator: o Assigned by the quality council to assist the team. o Attends the meetings. o Not a team member. o He/she facilitates not dictates. o He/she is more concerned with how decisions are made rather than with what the decisions actually are. o Responsibilities include: assist team in using PI tools, assist team in preparation of presentations to management, assist team in measurement and understanding of statistics, assist team leader in dealing with divisive members..etc.

FOCUS-PDCA
Organize a team that knows the process
The Recorder: o A team member. o Assigned by the team leader. o Responsible for keeping the minutes of the team and for documentation of the progress of the team. o A single team member may serve for the duration or this responsibility may rotate among all team members. o If one team member is a secretary, he/she should not be automatically chosen to serve as the recorder.

FOCUS-PDCA
Organize a team that knows the process
The Time Keeper: o A team member. o Assigned by the team leader. o Responsible for periodically reminding the team of the assigned time remaining for agenda items and the meeting as a whole, aiming at keeping the team on track and focused.

FOCUS-PDCA
Organize a team that knows the process
Team Members: o They are usually the process experts (i.e., those who best understand the process to be improved). Sometimes, the team member may be a supervisor of the expert (i.e., does not have direct knowledge of or experience with the process). o Chosen by the leader and approved by the quality council. o Responsibilities include: attending team meetings on a regular basis, full participation in team activities, and conducting the in-between meeting assignments in a timely manner.

FOCUS-PDCA
Clarify current understanding of how the process
works
Ensure that all members understand the whole scope of the process to be improved. Frequently, members are familiar with only a few steps of the process and are not aware of what might be occurring on either side of their activity segment. A frequent problem that occurs at this stage is the temptation to prematurely think about suggestions for process improvement. Interjecting fragmented solution suggestions at this point only makes it more difficult for the team to arrive at a complete process analysis.

FOCUS-PDCA
Clarify current understanding of how the process
works
Another barrier to good process analysis is the failure to drive out fear. For example, a team member may be afraid to tell that a process does not follow an existing policy. Clearly, if this information is not available to the team, the process improvement efforts will fail. The team leaders political-sensitive approach towards encouraging the team member to share his/her opinion is crucial. Several tools are available to assist the team in driving out fear and facilitating the free and open communications necessary to the project. One of the most important tools used during the clarification (C) phase is flowcharting.

FOCUS-PDCA
Understand causes of process variation
In this stage, the team strives to understand why the existing process is not working well, i.e., what are the reasons for process variation. Cause-and-effect diagram, also known as "fishbone" diagram, is an excellent aid in the (U) understanding phase of the FOCUS-PDCA cycle. A cause-and-effect diagram is actually only a graphic presentation of a list.

FOCUS-PDCA
Understand causes of process variation
While brainstorming may be used anywhere in the FOCUSPDCA cycle, the first need for it will likely be encountered in the (U) understanding phase. Brainstorming is effective because it is free form and does not restrict people in offering ideas. It encourages responses from team members who may for a variety of reasons be reluctant to participate. Brainstorming can be followed by a multivoting technique. At this point, it may become necessary to use the Pareto analysis to determine what is causing most of the problems.

FOCUS-PDCA
Select the strategy for improvement
At this point in the cycle the team should be ready to select the improvement or improvements that will be made in the process. It may be necessary to use a structured approach that results in a precise statement of the planned improvements that was reduced down from a thorough study of the alternatives (e.g., prioritization matrix).

FOCUS-PDCA
Plan the improvement
Here, the team should outline how the improvements will be accomplished, i.e., the who, what, where, and when. Consideration should be given to developing a pilot project for the selected changes. Considering what resources, training, etc., shall be needed is crucial.

FOCUS-PDCA
Do the improvement
Implement the planned improvement. Usually, the implementation is the responsibility of the team.

FOCUS-PDCA
Check the results
After the implementation of the improvements, it will be necessary to continue data collection to determine if the improvements have proven successful in bringing the process to the desired direction. If continued checks indicate that the desired outcome has not occurred, it may be necessary to return to the selection stage and take another look at the alternative improvements. If all is going well, the team should perform a self analysis of their performance with emphasis on how the team process could have been improved. This team self-analysis can be reported to the quality council to benefit future teams.

FOCUS-PDCA
Act to maintain the gains
There is often a tendency for things to reverse to their previous state if well-planned controls are is not in place. It is very important to ensure that initial gains are not lost due to subsequent satisfaction, failure to stick to on implemented changes, etc. Now after the new improvements have proven success, the team should consider revising and modifying the relevant policies and procedures, etc. Additionally, performing regular internal audits is crucial to ensure the compliance to such new or modified policies and procedures. Control charts are usually used to monitor the maintenace of such gains.

Middle of the Iceberg Model: Systems, Frameworks, and Models

2. ISO 9000:
o o o o o The ISO 9000 Quality Management System was created in 1987 In 1994, ISO 9001 standards were released. The most recent version of ISO 9000 is ISO 9001:2008 Applicable to both manufacturing and service sectors. Emphasizes: documentation and recording. conduction of internal audits on a regular basis. taking corrective and/or preventive actions, whenever needed. listening to customers. continuous improvement.

Middle of the Iceberg Model: Systems, Frameworks, and Models

3. Lean Thinking:
o Lean focuses on the removal of waste or the non-value added activities from the system processes. An important waste to be eliminated is the inventory. o After the WWII, Japanese industry needed to rebuild and grow, and its leaders wanted to copy the assembly lines and the mass production systems found in the US. However, they had limited resources and limited storage space. o At Toyota Motor Corporation, top management sought to reduce inventory by various means. This lead to reduction of the production cost.

Middle of the Iceberg Model: Systems, Frameworks, and Models

4. Six Sigma:
o A system for improvement that was developed over time by GE and Motorola in the 1980s. o The aim of Six Sigma is the to reduce variation/eliminate defects in key business processes. o Methodology follows the following five steps: Define, Measure, Analyze, Improve, and Control (DMAIC).

Middle of the Iceberg Model: Systems, Frameworks, and Models

o All of the pre-mentioned are systems or frameworks for performance improvement, and each has a slightly different focus, tools, and techniques associated with it. o However, all these programs emphasize customerfocus, process analysis, and teamwork. o The compatibility of any of them within any organization depends on the organizational culture and infrastructure, the top management support (both ideologically and financially), and the employees buy-in and support (which is again dependant on the top management commitment).

Tip of the Iceberg Model: Methods, Procedures, and PI Tools

Tools, methods, and procedures are analogous to the tip of the iceberg. We can observe people using tools and methods for improvement. We can see them making a flowchart, plotting a control chart, or using a checklist.