Third Edition

Q Solutions: Essential Resources

for the Healthcare Quality Professional

Quality and Performance I mprovement

Susan V. White, PhD RN CPHQ NEA-BC FNAHO

Series Editors
Luc R. Pelletier, MSN PMHCNS-BC CPHO FNAHQ FAAN
Christy L. Beaudin, PhD LCSW CPHQ FNAHQ

NAF{:q
NATIONAT ASSOCIAIION TOR HEALTHCAR-E QUAIITY

Glenview, IL
Other titles in the Q So/utions Suite

L e ader ship and Management

Healthcare Safety
I nfo r matio n Manage ment
Regulation, Accreditation, and Continuous Readf ness

Copyright @ 2Ol2 by the National Association for Healthcare Quality. All rights reserved.
Except as permitted under the United States Copyright Act of 1976, no part of this
publication may be reproduced or distributed in any form or by any means, including but
not limited to the process of scanning and digitization, or stored in a database or retrieval
system without the prior written permission of the publisher.

Copyright @ 2005,2008, 2Olzby the National Association for Healthcare Quality.

All rights reserved. First edition published in 2005. Second edition published in 2OO8.
rsBN 978-O-9858336-1-9

National Association for Healthcare Quality

47OO W. Lake Avenue
Glenview,IL 60025
www.nahq.org

For the National Association for Healthcare Quality

Stacy Sochacki, Executive Director
Beth Zemach, Senior Programs and Product Analyst
Karen Schrimmel Practice Content Manager
June Pinyo, MA, Managing Bditor
Monica Piotrowski, Associate Editor
Sonya Jones, Senior Graphic Designer

Printed in the United States of America

ThirdEdition
Contents
l.EstablishingPrioritiesforQualityandPerformancelmprovement(QPl)Activities............,
A. Definition andlmportance. ...........1
B. Strategic Management Process ........2
l.Whatthe Organization Wants to Do ...... ..............2
a. Mission and Vsion . . - . . . ..........2
b. Guiding Principles and Core Values. . . .. ... ..3
c. Goalsand Objectives. .............3
2. What the Organization Should Do; Assessment of the ExternalEnvironment .............. .4
l. What the Organization Can Do, Assessment of the lnternal Environment. . . . . . . . . . . . . . . . .5
4. Strateqy Formulation....... ..........5
5. Strategy lmplementation . ..........7
ll. Translating Strategic Goals into Quality Outcomes. . . . . . ....... . 8
A. The Governing Body! Role in QPI . ... .... .... . .. 8
B. Fundamental Principles of Leadership . . . . . . ........8
C. Leadership Framework. ....... 8
lll. Aligning Cukure to Suppo* Quality. ..........1o
A. Definition and lmportance of Culture...... ......10
....
B. Elements of Culture. ..... ...... .. 10
C. Assessing Culture.. ..........10
D. Strengthening Culture for GPl.. . ... . . ..11

lV Aligning Structure to Support0uality. ........11

A. Definition and lmportance. .......... . . . .I 1
1. Survey Preparation ...... .. ..........13
l. Facil;tating the Credentialing and Privileging Process... .............13
3. Overview of QPI ......... . -..... -...17
B. Retrospective Audits . . . . --..-........ - 17

C. Quality Assurance . . . . . . ............. . 17

D. QPI Method .......17

E. Performance Management ... ......... '18
F. Setting Priorities forQPl .. ............l9
G. Priorities for QPl. . . . . . . . . ...........19
l. Reengineering or System Redesign -. - -. .. .. -. -23
H. Facilitate Development of QPI Action Plans and Pro.iects . .............24
l. Facilitate Program Development Evaluation Planning, Projects, and Activities ..... .25
l. Decision-Making Methods and Tools ........ ...25
J. Selection of Process and Outcome Measures.. -- . . .. .. 3l
-- , ..
1. Comparative Data.. ... . ... .. . .. .. . ..34
2. Benchmarking -.. -.....- -..34

V Decision Support, Risk Adjustment, Data lnterpretation, and Benchmarking ....... 58

A. Decision Support . . . . . . . .............38
1. Evaluation and Selection of Evidence-Based Practice Guidelines.. -. -. - -. -.....39
:. QPI Research Continuum . - . -. -. -.. 40
vt Q SoluUions

3. Development of Clinical and Critical Pathways or Guidelines.... . '

4. External Quality Awards. .

B. QPI Teams.
1. Types of QPI Teams . . .

z. When Should Teams Be Used?

3. How Do Teams Develop or Grow?
4. Characteristics of Effective Teams.
C. Evaluating Team Performance
D. Coordinating and Participating in QPI Projects
E. Organizational Reviews and Audits
F. lnfection Prevention and Control Processes
G. Departmental Reviews. .

H. Health Records .

1. lnformation Covered by Privilege

l. Medical Peer Review
J. PatientAdvocacy........
1. Recognition of lnternal Customers

K. Risk Management.......
1. Risk ldentification ..........
2. Risk Evaluation and Prevention
L. Organizational QPI Tiaining.
1. Determining Education and Tiaining Needs
2- Fundamentals of QPI Cuniculum
3. What Skills Do Healthcare Quality Professionals Need? . .. .

M. Tiaining on QPl, Program Development, and Evaluation ' ' ' '
N. Effectiveness Evaluation of QPI Tiaining. .
1. Framework for Evaluating the Results of Tiaining
2. Aligning Rewards to Support Quality .

a. Basics of Motivation. . . . .
1.) Need Theories .. .

2.) Expectancy Theory . ' .

3.) Equity Theory

+.) Procedural Justice.....
b. What Do Employees Say?. .

3. Setting Up a Reward SYstem

O. Communicating Successes

Vl. Summary. ......

References .

95
SuggestedReading. . . . . . .

Online Resources

107
lndex .
 vI

Tables
Table 1. Example of Mission, Goals, and Objectives . . . . .........4
Table z. AHAk Principles of Accountability for Hospitals and Healthcare Organizations:
Governance/ Leadership . . . .......9
Table 3. Healthcare Accreditation Organizations. . . . . . . .........12
Table +. ComparisonofDependentandlndependentPractitionersforCredentialingandPrivileging........ls
Table 5. Types ofWaste in Lean Production Systems .. .. ......24
Table 6. Evidence to Support the Focus of Measurement. ..... . 35

Table 7. Examples of Benchmarking Projects -.... ... ' .37

Table e. Levels of Certainty About Net Benefit ......4o
Table 9. USPSTF Updated Definitions . . . . . . . . . . . . . .41

Table 1o. Research Process Versus Guality lmprovement Process. ..........41

Table 11. Common Quality Awards or Designations. . . . . . . . ............. 45
Table 12. Sample Framework for Performing a GapAnalysis. .............46
Table l3. Team Roles ............51
Table 14. Team Characteristics . . . . . . ..... '. 52
Table 15. Medication Monitoring..... .............. 58
Table 16. Blood Usage Monitoring. . . . ............'' 58
Table 17. Restraint Use Monitoring ... ... ........... 59
Gble 18. Operative and lnvasive Procedure Monitoring. ....... ' 59
Table 19. Cardiopulmonary Resuscitation (CPR) Monitoring. ... ....... ...61
Table 2o. Customer Service Standards and Pledge .. .......... .68
Table 2'1. Evolution of Healthcare Risk Management . .. . . .. '.... 75

Table 22. National Quality Forum Consensus Standards for Quality of Hospital Care. ..... -.. -..76
Table 23. Suggested Substantive lssues for QPI Education and Tiaining . . . . . . . . . . . . . . 80

Figures
Figure l. Strategic Management Process .......... '.. 2
Figure 2. Potential Environmental lnfluences on GPI ..... ........ 5
Figure 5. Organizational SystemsModel .......'.....6
Figure 4. Core Hoshin Planning Process. . .. '...... . -. 7

Figure 5. Framework for Leadership of lmprovement . . . . .........! ......20

Figure 6. Detailed Framework for Leadership for lmprovement. ............20
l-rgure /. Leadership Framework as an lntegrated System . . . '.. -21

Figure 8. Cascading Series of Goals and Drivers.. . ..........21

Figure 9. Prioritization Matrix: Clinical lmprovement Priorities ..... ....-.23
Figure 1o. Framework for Execution . . . -. -........ 25

Figure 11. Brainstorming. -......26

Figure 12. Multivoting ... --....26
Figure 13. Nominal Group Technique . . -............27
Figure 14. Healthcare Failure Mode and Effects Analysis (HFMEA) .. .......27
Figure'15. Prioritization Matrix: Decision Example.. . ' . . . . . . . . . . . . 28
Figure 16. Spaghetti Diagram (or Layout Diagram) ... .... ..'.... 50
Figure u Checklist. ....'.30
Figure 18. s_s .. ... ............51
Figure 19. Value Stream Mapping. ......32
Figure 20. Voice of the Customer . . . . . ..... . 32
vlii Q SoluEions

Figure 21. Supplier lnput Process Output Customer (SIPOC) ......... -...33
ltgute 22. Baldriqe National Health Care Criteria for Performance Excellence Frameworkzo'l't-zo'tz. . . . . . . . . 44
Figure 23. Classification of Teams ..... .... -.. -. -.. 47
Figure 24. The TeamSTEPPS' Model . . ...........s4
rrqure 15. Patients'Bill of Rights and Responsibilities . . . . . .... .. . -71
Figure 26. Sources
Professional Liability -.. ... 7a
Figure 2z Elements for a Tort ... .. . 7a
Figure 28. Levels of Knowledge . . . . . . . . ............81
Figure 29. Framework Linkage .... ... .'........... 84
Figure 30. Motivation Equation . ..... .. .... 86
 ix

Foreword to the Third Edition

Healthcare is at a transformative and exciting time as we embark on new models of deliv-
ering care. Prominent focal points during this essential time are quality, safery innovation,
and the technology needed to bring higher levels of performance with lower costs. During
2Ol1 and 2OL2, the National Association for Healthcare Quality (NAHQ) has been prepar-
ing for the transition by reenergizing our purpose and vision and solidifying our strategies
for meaningful work that benefits our stakeholders. Our challenge is determining how to
provide the greatest value to our members, certificants, and consumers of NAHQ products
while continuing to expand our reach.
We believe it to be of primary importance to coordinate the work of the NAHQ Board
of Directors, staff, and teams, as well as the Healthcare Quality Certification Commission
(HQCC) to ensure NAHQ products are ready for the market previous to when programs are
offered. A prime example of the effort is the third edition of Q Solutions.
I take this opportunity to personally thank Luc R. Pelletier; MSN PMHCNS-BC CPHQ
FNAHQ FAAN, and Christy L. Beaudin, PhD LCSW CPHQ FNAHQ, for leading this major
revision to Q Solutions with the most current information available. By providing continuity,
intellectual capital, and fortitude to this important NAHQ goal, we have the product ready
to deliver to you. The NAHQ Board called on a number of key people throughout the coun-
try to support the writing and review of the content, which coordinates with the Certified
Professional in Healthcare Quality (CPHO content outline's main divisions. I thank each of
them and the NAHQ staff for helping to bring this valuable resource to market.
This edition of Q Solutions features a new approach to presentating content. By placing
the information within individual modules, purchasers may obtain a module specific to his
or her needs. The availabiliry of the first four modules (and fifth module soon after) of the
third edition coincides with updates to the United States regulation and accreditation con-
tent HQCC will begin using in January of zOtA. I am certain all of you will want to share this
updated resource with your colleagues in the field of healthcare qualiry. These resources
will motivate you to excel even further.
My career development and leadership style have been enriched by many individuals,
especially those who have brought their best into this wonderful organization. NAHQ con-
stituents are my network for identifying, learning about, and understanding changes that
are happening rapidly and continuously within care delivery. They enhance their work-
places, and patients benefit from their commitment to achieving healthcare improvement.
Promoting safe, effective, and efficient practices through education, certification, and ad-
vocacy are key components. I encourage each of you to identify the strengths in the people
and the products of NeHq. Enjoy the third edition of Q Solutions.

Betty Brown, MBA MSN RN CPHQ FNAHQ

NAHQ President, 2Oll-2OL2
x Q SoluEions

Preface
Healthcare is complex and at times confusing to customers. Delivery systems, health plans,
solo and group practitioners, employers, and government agencies seek ways to achieve the
Triple Aim-ensure quality of care for the individual, improve the health of the population,
and control costs. Developing, deploying, and sustaining appropriate quality strategies
pose challenges and opportunities for healthcare qualiry professionals. Thoughtful
strategies employ effective, efficient, and evidence-based approaches to measure, monitor,
and determine outcomes. Did the actions and interventions yield intended goals and
objectives for improved quality and performance excellence? The healthcare quality
professional must successfully navigate the system to demonstrate quality and safety. The
application of sound theoretical and methodological practices is imperative. Q Solutions
covers the breadth and depth of critical areas for professional development and leadership,
including frameworks for quality management, the linking of science with practice, and
the translation of data into practical information that can be used and understood by any
customer, whether it is a practitioner, third-party payer, or consumer.
The development of the third edition of Q Solutfons was informed by the most recent
Healthcare Quality Certification Commission's (HQCC's) practice analysis. The practice
analysis assesses the current functions and competencies for certified professionals in
healthcare quality. Organized under the HQCC detailed content outline, the following
modules were created:
. Leadership and Management
. quality and Performance Improvement
. Heakhcare Safety
. lnformationManagement
. Regtlation, Accreditation, and Continuous Readiness.
These modules feature critical components of healthcare quality, the science and art
of quality and performance management, and environmental considerations such as
healthcare reform. In addition, Q Solutions was developed using feedback from healthcare
quality professionals and academic and policy experts in the field.
In our world of teeming technology, rapid innovation, and continuously expanding
science, we also rely on hope day in and day out. We hope that political agendas will reflect
the needs of patients, families, and other stakeholders; that resources will be available for
the work to be done; and that fear will not result in barriers to uncovering mistakes, flaws,
and failures. For healthcare qualiry to permeate the healthcare landscape, the cultures of
silence that still exist in institutions must be eradicated.
In addition to emerglng technologies and techniques, the foundation of our work
involves the collaborative relationships we form and develop with various stakeholders.
Our work, after all, is relationship based. Mutual respect and accord lead to mutual
understanding and a sense of camaraderie as we face complex healthcare quality
challenges. This is accomplished in many ways including affiliations with professional
groups such as the National Association for Healthcare Qualiry (NAHO.
Q Solutions is targeted to audiences across the care continuum and provides critical
knowledge to develop and enhance essential leadership skills in healthcare quality. In
effect, these tools and techniques are universal to any healthcare setting. The basic
principles can be adapted to your organization. When we embarked on the third edition
journey, there was no question about who the right people were to make these publications
 xi

happen. We were humbled by-the company we kept. Fortunately, these individuals made
time for what proved to be a fruitful endeavor. The product you hold in your hands would
not have been possible without the unceasing efforts of our esteemed authors-Cathy E.
Duquette, PhD RN CPHQ NEA-BC; Robert Rosati, PhD; Susan V. White, PhD RN CPHQ
NEA-BC FNAHQ; and Diane S. Brown, PhD RN CPHQ FNAHQ FAAN. Their vision
for NAHQ is depicted on every page. We thank them all for their thoughts and ideas
throughout the development process. In addition, we appreciate the thorough content
examination by our external review panel members-James B. Conway, MS LFACHE;
Gerald N. Glandon, PhD; John Hansen, MD MPH; Bernard J. Horak, PhD FACHE CPHQ;
and Barbara G. Rebold, MS RN CPHQ. As always, we acknowledge the continuous support
of the NAHQ Board of Directors, which has resulted in the successful launch of the third
edition of Q Soluaons.
The work of healthcare quality professionals is noble indeed. Armed with a set of
advanced skills and practical tools, we are a force that can be boundless. Our nobility comes
from the fact that we are truth seekers. We are constantly challenged to tell a quality story
that is cogent, accurately depicts healthcare circumstances, and is understood by varying
audiences. To be able to tell the truth, we must demand that healthcare organizations
o provide resources necessary to conduct investigations and to maintain reporting
systems that use state-of-the-art information technologies ;
. allow and support a solid infrastructure for continuous readiness, including health
information technology that supports the continuous quality improvement paradigm
and doesn't disappear after an accreditation survey or regulatory audit;
. ensure that all organizations are educated on the science of discovery (i.e., data,
methods, analysis, and application); and
. contribute to the growingbody of healthcare quality science by sharing evidence-
based, outcomes-oriented quality techniques making a difference in the safety, care,
and service embraced by forward-thinking highly reliable organizations.
Our primary goal for this suite of Q Solutions modules is to provide NAHQ members
and other qualiry and patient safety professionals with a product that is reliable, valid,
innovative, and timely. These updated modules reflect recent changes in hational
healthcare safety as well as the transformation of healthcare as we know it. In the future,
NAHQ plans to supplement these modules with other relevant topics and learning
opportunities.

Luc R. Pelletier, MSN PMHCNS-BC CPHQ FNAHQ FAAN

San Diego, CA

Christy L. Beaudin, PhD LCSW CPHQ FNAHQ

Los Angeles, CA
xii Q SoluEions

About the Editors

Luc R. Pelletier, MSN PMHCNS-BC CPHQ FNAHQ FAAN, is an administrative liaison
at Sharp Mesa Vista Hospital, a core adjunct faculty member at National Universiry, and
a healthcare consultant in San Diego, CA. He received a Master of Science degree in
nursing from Yale University and a bachelor of science in nursing from Fairfield University.
A healthcare quality professional for almost 25 years, Pelletier has participated in local
and national initiatives that ensure safe and equitable care for behavioral health patients
and has helped to shape systems of care and national standards of performance. He has
published several books and written numerous chapters and peer-reviewed articles. He
has delivered presentations on various nursing and healthcare quality topics and given
writing seminars to aspiring authors. He was the editor in chief of the Journal for Healthcare
Quality from 1998 to 2OO7. During his tenure, the
journal grew in prominence as a leading
healthcare quality publication and was the recipient of various publishing awards. He has
served as a nurse expert with the U.S. Department of Justice and as a scientific consultant
to the National Institutes of Health. His current research focus is on nurse residency
programs in behavioral health and patient engagement. He is also a Fellow of the American
Academy of Nursing and NAHQ.

Christy L. Beaudin, PhD LCSW CPHQ FNAHQ is national director of qualiry for AIDS
Healthcare Foundation in Los Angeles, CA. In her current role, Dr. Beaudin is responsible
for healthcare safery accreditation, infection prevention and control, public reporting, and
education. At the executive level, she led healthcare safety efforts at Children's Hospital
Los Angeles, PacifiCare Behavioral Health, and Value Behavioral Health, and served as
vice president of research and deveiopment at Magellan Behavioral Health. Dr. Beaudin
supported hospitals and managed care organizations in preparing for and maintaining
state licensure and accreditation compliance including the National Committee for
euality Assurance (NCQA), URAC, Accreditation Association for Ambulatory Health
Care 6eeHC), and The Joint Commission. Dr. Beaudin earned her doctorate in health
services from the UCLA School of public Health, master's degree in social work from San
Diego State Universiry and bachelor's degree in criminal justice from California State
Universiry San Bernardino. Dr. Beaudin is adjunct faculty at the University of Redlands
and participates in state- and national-level quality initiatives for NAHQ, SNP Alliance, and
the California HealthCare Foundation. She is widely published, serves on several editorial
boards and review panels, and is a national subject matter expert on healthcare quality,
behavioral health, and managed care.
 xllt

About the Autlior

Susan v. white, PhD RN CPHQ NEA-BC FNAHQ, is the chief of qualiry management at
the Orlando VA Medical Center in Orlando, FL. Her areas of responsibiliry include qualiry
management, performance improvement, accreditation and continuous survey readiness,
patient safety, risk management, peer review, infection control, and credentialing and
privileging. Prior to this role, she was the associate chief nurse and quality improvement
and magnet coordinator at the James A. Haley Veterans'Hospital in Tampa, FL, in addition
to serving as the vice president of quality management of the Florida Hospital Association.
She has an extensive career in healthcare in administrative and clinical roles. She was the
associate executive director and director of nursing in a community hospital and developed
the quality management program for a hospital within a large network. Dr. White received
her master's degree in nursing as well as her doctorate in philosophy from the University
of Florida. She is a member of multiple professional organizations including the Florida
Association for Healthcare Quality (FAHQ), NAHQ, Florida Nurses Association (FNA),
American Nurses Association (ANA), Florida Organization of Nurse Executives (FONE),
American Organization of Nurse Executives (AONE), and Sigma Theta Tau. She is also
the interviews editor for the Journal for Healthcare Quality (JI{Q). She obtained status as a
NAHQ Fellow in 2003 and received the NAHQ Claire Glover Quality Award in 2004, the
state FAHQ Qualiry Award in 2OO4, and the FAHQ Author Award in 2OO7. Dr. White served
as vice chair on the board of directors for the Florida Center for Nursing from its inception
in 2001 until 2009, and was an initial member on the Florida Patient Safety Corporation,
serving as vice chair. She has published widely and coedited Patient Safety: Principles and
Practices, published by Springer Publishing in 2OO4.

External Review Board

This project could not have been completed without feedback from expert thought leaders
in the healthcare quality industry. We thank Dr. Bernard J. Horak for providing feedback for
this module.

Bernard J. Hot'ak, PhD FACHE CPHQ

Professor and Program Director :

Health Systems Administration

Georgetown Universiry
Washington, DC
Quality and Performance lmprovement 1

LEARNING OBJECTIVES
t. Establish priorities for quality and performance improvement (QPl) activities and develop action plans and
projects.
2. Develop and provide survey preparation training (i.e., accreditation, licensure, or equivalent) and evaluate
organizational readiness for external quality awards and recognition.
3. Develop evaluation planning, projects, activities, and selection of process and outcome measures.
4. Select and implement evidence-based practice guidelines (e.g., for standing orders or as guidelines for
physician ordering practice) and critical pathways, ,

5. Design organizational QPI training (e.g., quality, patient safety) and provide training on QPl, program
development, and evaluation.
6. Participate on QPI teams (i.e., as a team member, leader; or facilitator) and evaluate team performance.
7. Promote effective enterprise risk management strategies and leadership through organizational safety

8. Communicate success (e.g., presentation, storyboards, and publications).

I. Establishing Priorities for Quality and Performance lmprovement (OPl)

Activities
The road to QPI begins with strategic planning. Through strategic planning, leaders iden-
tify priorities for the organization as well as potential areas for improvement, reflecting an
integration of the strategies, resources, and performance goals. By narrowing the focus of
the vision, leaders refine broad oppoffunities into specific priorities most amenable to ac-
tion and change.
A. Definition
and lmportance
The environment surrounding healthcare organizations is dynamic (changes frequently) and
complex (with many constituents). Since the mid-1990s, external forces in healthcare have
become increasingly important with the focus on reform efforts and reduction in healthcare
costs. The significant growth of managed care and its organizational entities (e.g., preferred
provider organizations [PPOs], health maintenance organizations [UVtOs], and preferred
health organizations [PHOs]) and most recently accountable care organizations (ACOs), ac-
companied by a significant shift from the acute care hospital to subacute and ambulatory set-
tings as a focus for delivery of care, has made strategic planning even more important. The
most recent trend with "medical homes' has continued to shape healthcare, with more focus
on health prevention, primary care, and care coordination. l

Strategy is defined as 'the plans and activities developed by an organization in pursuit of

its goals and objectives, particularly in regard to positioning itself to meet external demands
relative to its competition" (Shortell, Morrison, & Robbins, 1985, p.22O), Strategic planning is
one way of coping with a dynamic and complex environment. The goals of strategic manage-
ment (Ginter, Swayne, & Duncan,2OO2) are to
. provide a framework for thinking about the business;
. create a fit between the organization and its external environment;
. provide a process for copingwith change and organizational renewal;
. foster anticipation, innovation, and excellence;
.
facilitate consistent decision making; and
.
create organizational focus.
Quality has received a great deal of industry attention in recent years because organiza-
tions have come to realize that quality must be an integral part of the strategic plan.
2 Q SoluEions

B. Strategic Management Process

The strategic management process includes all the decisions and actions needed to meet the
strategic goals. Figure I shows the steps in the strategic management process. Before a strat-
egy is-for-ulated, leaders consider what they want to do, what they should do, and what they
can do (Luthans, Hodgetts, & Thompson, 1990). Consideration of these three issues leads to
the development of a strategic plan.

What the Organization Wants to Do

Define and Formulate Goals

Strategy Formulation

Strategy lmplementation

Measure and Control Progress

L Pierce, 1989, Glenview,/L: Scott Foresma n and Company. Copyright Das. Reprinted with permission'
From Management, by R. B. Dunham and J.

1. What the Organization Wants to Do

a. Mission and Msion
mfssion is the or-
Organizations must define what they want to accomplish in the future. The
ganization's purpose or reason for existing. It answers questions such as,_"Why are we
here?"
,,Whom do we serve?" and "What do we do?" For example, the mission of SSM Health Care, a
Malcolm Baldrige National euality Award recipient, is "Through our exceptional healthcare
respect, ex-
services, we reveal the healing presence of God." Its core values are compassion,
cellence, stewardship, and communiry (SSM Health Care,2005). This provides a
long-term di-
rection for the organization.
Quality and Performance lmprovement 3

Vision is an organization's sqatement of its goals for the future, described in measurable
terms that clarify the direction for everyone in the organization. An organization's direction is
built on its mission and guided by its vision.
b. Guiding Principles and Core Values
Guiding principles define the organization's attitudes and policies for employees and thereby
help to direct the vision. Customer focus is a core value central to any improvement initia-
tive. The customer is the person or entify that receives the process, product, or service and
therefore defines the qualiry of products or services received. The key to performance im-
provement is knowing and understanding the customer. The following list includes other
core values contained in the Baldrige Health Care Criteria for Performance Excellence (Bald-
rige Performance Excellence Program, 2Oll-2OI2, p. 49) :
. visionaryleadership,
. patient-focusedexcellence,
. organizational and personal learning,
. valuingworkforce members and partners,
. agiliry
. focus on the future,
. managing for innovation,
. management by fact,
. societal responsibility and community health,
. focus on results and creating value, and
. system perspective.
c. Goals and Objectives
Goals and objectives are essential components of any planning process; they guide actions
and serve as a yardstick for measuring the organization's progress and performance. Bill
Hewlett, cofounder of Hewlett-Packard, once observed, "You cannot manage what you cannot
measure . . . and what gets measured gets done" (House & Price, 1991, p. 93). There sometimes
is confusion over the terms goal and objective; they differ with respect to scope and specific-
ity. In general, goals are broad, general statements specifying a purpose or desired outcome
and may be more abstract in nature than objectives (one goal can have several objectives).
Establishing goals is the initial step in the strategic planning process and sets the direc-
tion for the activities to follow. In general, goals need to be
. observable,
. measurable,
. challengingbutattainable,
. controllable,
. visible, and
. time limited.
Objectives are specific statements that detail how the goals will be achieved; they there-
fore are more narrow and concrete. Objectives represent the organization's commitment to
achieving specific outcomes. They should be written as action-oriented statements, outlining
specific activities to be carried out and measurable and observable qualitative or quantitative
performance outcomes. Examples of a mission statement, strategic goals, and strategic objec-
tives can be found in Table L
4 Q SoluEions

of Mission, Goals, and

Mission We are a teaching hospital and critical member of the community, and our mission is to provide
statement high-quallry innovative healthcare services to all members of our community regardless of race,
reiigion, naiion"lity, or ability to pay. We are dedicated to educating clients, with an emphasis on
preventive healthcare.

Strategic . Be recognized as one of the top healthcare providers in the community.

goals . Establish an outreach program for management of chronic illness.
. Develop a state-of-the-art program for breast cancer detection and treatment.
. Reduce projectcosts by15%.

Strategic . Hire highly skitled nursing staff and set minimum nurse-to-patient ratios to reduce staff turnover.
objectives . Obtain communication technology to allow distance education of clients and providers.
. Provide education and time reimbursement for physicians to train in innovative breast cancer
technology.
. Control -tttby using computerized planning tools (e.g., Program Evaluation Review Technique
[PERrD.

The following are some general guidelines to use when writing objectives (Fisher &
Samways, f985):
. Keep the statements short and simple.
. State the end results or desired outcome and not just an activity.
. Specify the action to be taken, the condition under which the action is to be performed,
and the criteria for successful completion.
. Write precisely to determine to what extent the objectives have been accomplished and
what remains to be accomplished.
. Prioritize the objectives.
When goals are developed at the executive level, there must be corresponding goals and
level
objectives ior other levels in the organization, such as the business level and functional
(eg., human resources, research and development) and the unit or depaftmental level (e.g',
goals
nuising, radiolory, pharmacy). Alt levels should have both long-term and short-term
(Specific, Mea-
and objectives. Another mnemonic for writing objectives is the SMART way
surabl;, Attainable, Relevant, and Time Bound; Centers for Disease Control and Prevention,
2011), which provides clear focus for developing a comprehensive way to ensure that
objec-
tives have all the necessary elements to be implemented and provide the guidance for the
action plans needed for implementation.
What the Organization Should Do: Assessment of the External Environment
2.
Once the objectives have been established (or revised), the organization must look at
the
external environment. on the roadmap, the environment is shown to influence what the or-
ganization wants to do. Because all organizations must adapt to the forces of the external
environment to suryive, stretch, and grow. In other words, the organization is one system
among a variety of other systems in the external environment. Adaptation includes main-
taining good relationships with key constituents who can influence its ability to meet the
stated-objectives. fig.rr" 2 depicts the various constitLtents whose needs must be met
and
balanced with the needs of other stakeholders. The outer ring represents the overall
envi-
ronment in which the organization exists. A variety of factors, including sociocultural, polit-
ical and legal, economic,tchnologlcal, global, and demographic forces, indirectly influence
the organization. For example, economic forces can influence the amount of resources avail-
general
able to organizations (e.g.,1abor, capital). This is why organizations must scan the
Quality and Performance lmprovement 5

Figure 2. Potential Environ-.i'tt"l tnfluences on QPt

Govemmental

Religious

Economic

Research

Technological

Copyright zotz by NAHQ. All rights reserved.

external environment looking for threats to, or opportunities for, meeting strategic goals
and objectives. The second ring represents the immediate environment in which the orga-
nization operates. With respect to QPI, the key constituent is the customer. However, other
constituents also are important. For example, the entity through which the patient acquires
healthcare insurance (typically an employer), payers, and regulatory agencies also are key
stakeholders.
3. What the Organization Can Do: Assessment of the lnternal Environment
When the organization has established what it wants to do and what it should do based on
assessment of the external environment, it needs to know what it can do. This requires an
examination of the internal environment that looks at the resources, capabilities, and core
competencies of the organization. Resources can be tangible (human, financial, physical) or
intangible (reputation). For example, if an organization wants to be a leader in breast can-
cer detection and treatment, it must have qualified staffand equipment.
4. Strategy Formulation
Based on the strategic goals, objectives, and evaluation of external and internal environments,
strategic opportunities and threats are identified. Generally, organizations perform a gap anal-
ysis to evaluate the extent to which the present strategy would have to be changed to meet
the goals and objectives. Stratery formulation clearly stipulates actions to be taken to achieve
goals. In the systems model (Figure 3), this is indicated by the arrows pointing to the lower
half of the rectangle, describing the various subsystems in the organization that will under-
take these actions to help the organizationreach its goals.
6 Q SoluEions

Figure 3. Organizational Systems Model

se
:i
a
o
o{
E
....., N
e
Environment o
'v'
E
E
I
Whatthe E
orgarization ci
slpuld do to

Structure
7 \
Culture People
sS
*G
Subsystems o
d
of the _;,-.1
EI

Organization .' t.
E
o
t
6
Resources Renewal :s
st
,/
Reward

Copyright zotz by NAHQ. All rights reserved.

The organizational systems model depicted in Figure 3 builds on simpler models, further
breaking down the elements and showing relationships between structure, process, and
outcomes. The model begins at the top of the rectangle with formulation of mission, guiding
principles, stratery, goals, and objectives; these give the organization direction and are the ba-
sis for strateg'y formulation. The "environment" box represents the multitude of stakeholders
that must be satisfied, and the arrow demonstrates that the environment can influence the di-
rection of the healthcare organization. Leadership is a critical process variable that influences
the extent to which the structures (inputs) lead to desirable outcomes. The lower half of the
Quality and Performance lmprovement 7

diagram depicts subsystems of the organization or, in Donabedian's (1980) terms, structuralvari-
ables. The lines connecting the various subsystems are meant to demonstrate that subsystems
are interdependent. Changes in one subsystem typically mean that changes must also occur in
other subsystems to keep them aligned. This conceptualization of subsystems was suggested by
Peters and Waterman (fgSZ) more than 3O years ago but remains just as applicable today.
5. Strategy lmplementation
The various programs and departments develop their own strategies that will contribute to
the overall goals and objectives of the organization. Top management can take a number of
approaches to integrate QPI with strategic planning and to ensure that plans and strategies
are being carried out. Hoshin planning (a Japanese term that means "policy deployment') is
one approach for integration.
Hoshin planning is a component of the QPI system used to ensure that the vision set
forth by top management is being translated into planning objectives and actions that both
management and employees will take to accomplish long-term organizational strategic
goals (Figure 4). "The primary reason to undertake Hoshin planning is to focus effort and
resources on those few strategies and processes that will best achieve the organization's

Figure 4. Core Hoshin Planning Process

Strategy implementation

Deployment or rolldown Heart of Hoshin

to departments to develop !-r.
planning process
plans including targets and means

lmplementation of departmental plans

PIAN
'/ \
/\

Regular process review

.L-/
CHECK

(monthly + quarterly)

Annual
review

Copyright zotz by NAHQ. All rights reserved.

8 Q SoluEions

survival and vision, and to develop an effective process to align the goals and efforts of the
organization" (Gaucher & Coffey, 1993, p. +92). The planning fypically is performed at three
levels: general (senior management), intermediate (middle management), and detailed
(implementation teams). Furthermore, the Hoshin concept is based on the principle that
high-performance organizations are those that harness the creative-thinking power of all of
its employees. In this model, each employee is regarded as the expert at their own job and
their contributions are consistently acknowledged (Hutchins, 2008).

ll. Tianslating Strategic Goals into Gluality Outcomes

A. The Governing Bodyi Role in QPI
The organization's governing body bears ultimate responsibility for seffing policy, financial
and strategic direction, and the quality of care and service provided by all of its practitioners.
Together with the organization's management and medical staff leaders, the governing body
sets priorities for QPI activities.
The development of meaningful governingbody involvement in QPI requires assessment
of the governing body's knowledge of QPI. This is a key role of healthcare quality profes-
sionals, who are responsible for organizing and coordinating quality management and
performance improvement activities for the organization and its medical staff. Healthcare
quality professionals can promote the governingbody's commitment to qualiry by providing
useful information in a format easily understood by members who may lack familiarity with
healthcare terminology and procedures.
The American Hospital Association (AHA, Lggg) has outlined Principles of Accountabil-
ity for Hospitals and Healthcare Organizations, with specific directives for governing board
and leadership. These government and leadership directives are described in Table 2.
For practical purposes, day-to-day leadership is delegated to the CEO and senior man-
agement, elected or appointed members of the medical staff (e.g., chairs), and administra-
tive and clinical staff (e.g., healthcare quality professionals).
B. Fundamental Principles of Leadership
Leadership is the ability to influence an individual or group toward achievement of goals
(Robbins, 2001). Leadership and management are not identical. Leadershrp is determining
the correct direction or path, whereas management is doing the correct things to stay on that
path. Kotter (1990) notes that management is about coping with complexity through plan-
ning and budgeting; setting goals; organizing, staffing, and creating a structure to foster goal
attainment; setting up mechanisms for monitoring; and controlling results. In contrast, lead-
ers are responsible for coping with change by developing a vision for change and aligning
the subsystems of the organization. Both strong leadership and management are necessary
for high performance. Some people are great leaders but poor managers and vice versa; in
some cases, a person maybe successful in both roles.

C. Leadership Framework
There are many frameworks for leadership. As is true with the system framework, often it is
less important to choose a particular framework than simply to have one to guide behavior.
Deming (2000) believed that managers were responsible for optimizing the system. Accord-
ing to the model in Figure 3, "optimizing" would involve aligning the subsystems of the or-
ganization. What types of leadership practices are essential to this process?
Quality and Performance lmprovement 9

Tabte 2. AHAs Principles of Accountability for Hospitals and Healthcare Organizations:

Governance/ Leadersh ip
Mission and Vision. The organization's governing body and leadership should articulate clearly defined mission
and vision statements. With these statements as a foundation, the organization's leadership should develop an
action plan with specific goals, time frames for accomplishment, and linked measures of performance for a regular
assessment of achievement, with oversight by the governing body. As part of this development process, the
organization's governing body and leadership should seek input from relevant stakeholders concerning their needs
and interests relative to the organization. The plan and the results should be widely communicated to all individuals
who are employed by or affiliated with the organization.
Executive Management Oversight. The organization s governing body is responsible for the oversight of
the organization's leadership performance and should periodically evaluate that performance relative to the
organization's achievement of its stated strategic aoals. As part of the process of evaluating the organization's
leadership, the governing body should periodically and systematically assess its own performance relative to
defined goals and measures of performance.
Quality Oversight. The organization's governing body and leadership, in conjunction with the clinical staff
are responsible for developing and implementing, in a comprehensive manner, systems and procedures for
safeguarding and enhancing the quality of patient care and services. The governing body and leadership, in
conjunction with the clinical staf[ are also responsible for actively monltoring and immediately acting upon, where
appropriate, the results derived from those systems and procedures such that patient and staff safety is ensured or
improvements in patient care occur.
Financial Stabillty. The organization! governing body is responsible for ensuring the financial well-being of the
organization and, in conjunction with the organization's leadership, for overseeing the appropriate and most optimal
allocation of financial and physical resources for the improvement of patient care. The organizationi mission and
duty to improve patient care and community health must not be obstructed by (and must take precedence over) the
financial interests of individuals or groups employed by or affiliated with the organization.

1t-12,19g9, by the American HospitalAssociation, Chicago, lL, AHA. Copyright t999. Reprinted with permission.

Practices of exemplary leaders were explored by Kouzes and Posner Q.OO2),who identi-
fied five important general practices: inspire a shared vision, challenge the system, enable
others to act, model the way, and encourage the heart. These principles are generic and
therefore applicable to any rype of organization.
Inspire a Shared Vision. For any change to be successful, leaders must provide a vision for
QPI and influence people to share that vision. This means getting people to accept the core
values underlying QPI by developing a strong culture.
Challenge the System. Challenging the system means acting as a change agent for that vision. It
also means recognizing good ideas and demonstrating a willingness to stretch and grow to im-
prove the qualiry of care. This, too, involves adoption of core values as a learning organization.
Enable Others to Act. The third leadership practice is enabling others to act by sharing
decision making and power. Along with sharing power, enabling involves having an appro-
priate structural design and resources to support QPI initiatives.
Model the Way. Much behavior is learned through role modeling. Leaders who expect em-
ployees to make changes to support QPI must model those desired behaviors; actions speak
Iouder than words.
Encourage the Heart. The last practice is critical. Change is difficult, even if it is done for
the right reasons. Encouraging the heart means recognizing contributions employees make
and celebrating the core values and victories. The most important point of any reward sys-
tem is to re\^rard the desired behaviors.
Leaders use these five practices to keep subsystems aligned. However, leaders must first
get people to support a vision of qualiry. One way this occurs is through a strong culture of QPI.
10 Q Soluuions

lll. Aligning Culture to Support Quality

A. Definition and Importance of Culture
Culturehas been defined as the social glue that holds people together (Siehl & Martin, 1981).
At the heart of culture is the notion of shared values (what is important) and behavioral
norms (the way things are done; Rokeach, lg73). Cultures are described as strong when the
core values are intensely held and widely shared. Strong culture
. provides a sense of identiry for employees and commitment to something larger than
themselves;
. enhances cooperation;
. creates a system of informal rules spelling out how people are expected to behave; and
. creates distinctions between organizations, allowing a definite competitive advantage
to develop.

B. Elements of Culture
Culture has both hidden and visible elements. Hidden elements are values and norms, where-
as visible elements include s).mbols; language, slogans, and brands; ritual
and ceremonies; sto-
ries,legends, and myths; and heroes.
Pro-
Values and Norms. The core values reflected in the Baldrige Performance Excellence
gram are one example. The role of leaders is to inspire commitment to these underlying
quality values.
dv-Uhr. Symbols are things that represent an idea. The purpose of symbols is to reflect the
culture, trigger values and norms, and help people make sense of their organization. For ex-
do this,
ample, o.re hospital wanted to strengthen the value for reporting adverse events. To
staffwore buttons that said, "We care, We report, We learn"'
Language, Slogans, and Brands. Language and slogans are intended to convey cultural mean-
(e.g.,
ing to and stakeholders. They should be easy to learn, remember, and repeat
"Quality "*p1oy."r
is Job 1," "Thrive'). Brands help build loyalty to a product or service'
Rituals and Ceremonies. Rituals and ceremonies reinforce an organization's core values and
goals, thereby strengthening culture.
6tori"r, Legends, rr,a nnyttrs. Stories, legends, and myths a-re narrative examples repeated by
employees to inform (often new) employees about culture. Stories are based on fact; legends
are
on fact.
based on facts but embellished; myths are consistent with the culture but are not based
Heroes. Heroes are company role models whose ideals, character, and support of the or-
ganizational culture highlight the values and norms a company wants to reinforce. Heroes
provide a role model for success. By design or default, an organization develops a culture.
It is better to actively direct the evolution of that culture than to try to change a strong cul-
ture that is not aligned with the goals of QPI.
C. Assessing Culture
How can it be determined whether performance improvement (PI) is a core value in an orga-
nization? In a model proposed by Schein (L992) and Schneider (rggo), the following questions
can assess the culture of PI:
. Does the leader pay attention to, measure, and control quality on a regular basis?
. Are scarce resources allocated to PI?
. Are behaviors supporting PI rewarded?
. Do staffknowledge, skills, and behaviors important for PI figure into decisions about re-
cruitment, selection, and promotion?
Quality and Performance lmprovement 1t

. Is active involvement in Pl"activities one measure of status in the organization?

a Are people spending time on PI?
a Does stafffrequently discuss PI?
a Is the prevailing attitude toward PI positive or negative?

D. Strengthening Culture for QPI

Many actions for strengthening a quality culture flow from the aforementioned questions.
First, leaders must showvisible support through such actions as
. making QPI everyone's responsibiliry
. having an annual budget for QPI,
. making QPI part of the strategic planning process, and
. rewardingbehaviors that support QPI.
Second, the visible elements of culture must receive attention. For example, the following
must be accomplished.
. Old, negative stories about QPI that are acting as barriers to cultural change must be re-
placed with new, positive ones.
. Symbols to reinforce values critical to qualiry must be created. Rituals that reinforce val-
ues critical to quality must be established.
. Leaders must celebrate Successes relating to QPI.
Finally, leaders must be persistent. Culture takes a long time to change (see Q Solutions:
Healthcare Safety).
Although inspiring people to a vision is critical, leaders must also enable others to achieve
goals and objectives. One way to enable others is to structure or design the organization in a
way that supports QPI.

lV. Aligning Structure to Support Quality

A. Definition and lmportance
Designing an organization is similar to designing a house.
Like the physical structure of a house, organizational structure identifies and distin-
guishes the individual parts of an organization and ties these pieces together to define an
integrated whole. Organizational structure dffirs from the physical structure of a house,
however, in that it encompasses more th.an inanimate characterfstics of walls, doors, and
windows. Organizational structure includes the interaction patterns that link people to
people and people to work, and unlike a house, structural dimensions of organizations
frequently change and eyolve. (Dunham & Pierce,1989, p.399)
Choices for applying resources for performance improvement and quality measurement
are based on organizational priorities, available resources, and other drivers such as social, po-
litical, and regulatory requirements. As a matter of policy and practical considerations, accredi-
tation standards alone do not address outcomes directly. First, there were problems with the
way quality was measured. Second, no professional consensus existed on systematic measures
of patient outcomes. Finally, uniform and comparable clinical databases were nonexistent.
The problem of measuring and interpreting patient outcomes precluded practical use
in accreditation. As a consequence, the accreditation process was necessarily built on an
implicit assumption that if proper structures and processes \Mere in place, good outcomes
\Mere likely to follow. The Joint Commission and other accreditation organizations have
12
Q SoluEions

since moved into using other mechanisms for assessing processes and outcomes, such as
individual patient tracers and second-generation tracers, which focus on specific areas such
as disinfection and sterilization, credentialing and privileging, information systems, and
radiation dosing. Although the Joint Commission is the largest healthcare accreditation
organization, it is not alone; other organizations provide accreditation to healthcare organi-
zations for general care and specialry care (Table 3)'

Table 3. Healthcare Accreditation O tions

Accreditation Body Primary Focus of Accreditation

Accreditation Association for Ambulatory Ambulatory healthcare organizations, including ambulatory

Health Care (AAAHC) surgery centers, office-based surgery centers, endoscopy centers,
anJ college student health centers, as well as managed care
organizations, such as health maintenance organizations and
preferred provider organizations

Accreditation Commission for Health Care Home care, hospice and durable medical equipment,
(ACHC) prosthetics, orthotics, and supplies (DMEPOS)

American Board for Certification in Comprehensive orthotics and prosthetics, pedorthics, ocular
Orthotics, Prosthetics & Pedorthics (ABC) prosthetics, mastectomy, noncustom therapeutic footwear,
DMEPOS

American College of Radiology (ACR) Breast magnetic resonance imaging, breast ultrasound, computed
Accreditation tornogr"phy, mammography, magnetic resonance imaging, nuclear
medic-ine and positron emission tomography, radiation oncology,
stereotactic breast biopsy, ultrasound

American Osteopathic Association (AOA) Healthcare facilities, predoctoral and postdoctoral training programs,
Healthcare Facilities Accreditation Program hospitals and clinical laboratories

CARF lnternational Aging services; behavioral health; business and service management
networks; CARF/Continuing Care Accreditation Commission
(CCAC); child and youth services; DMEPOS;employment and
community services; medical rehabilitation; oPioid treatment
programs; vision rehabilitation services

College of American Pathologists Laboratory services, biorepository program, reproductive Program'

Accreditation and Laboratory lmprovement forensic drug testing

Community Health Accreditation Program Community-based healthcare organizations

(cHAP)
Det Norske Veritas (DNV lnternational Healthcare organizations (clinical, management, and environmental
Accreditation) National lntegrated safety); leading accreditor of U.S. hospitals integrating ISO soot
Accreditation for Healthcare Organizations quality compliance with the Medicare Conditions of Participation.
(NrAHo)
Healthcare Quality Association on Home and durable medicalequipment
Accreditation (HAAA)
National Committee for Quality Assurance lndividual physicians, health plans' medical groups, disease
(NCAA) management (uses Healthcare Effectiveness Data and lnformation
Set [HEDIS] and Consumer Assessment of Healthcare Providers
and Systems [CAHPS] data)

American Society of Health-System Residency accreditation, pharmacy technician accreditation

Pharmacists (ASH P) Accreditation

The Joint Commission Healthcare organizations: hospitals, critical access hospitals,

ambulatory care, long-term care, behavioral health, home care,
laboratory services, special diseases and conditions

URAC Health plan, health network and utilization management

Quality and Performance lmprovement 13

1. Survey Preparation '

Continuous survey readiness (CSR) is the goal rather than ramp-up process, although
there is often final preparation for any survey. However, because most surveys are unan-
nounced, the CSR model is ideal. First, one must clearly understand the applicable stan-
dards, criteria, or survey requirements. Then training preparation begins, with a focus
on the audience. Content experts need ongoing training and education to lead the survey
readiness process and train others. Management staff need education and training to en-
sure that their department or service is ready by developing policies, processes, and other
organizational guidance. Staff members need very specific training to ensure that they im-
plement the standards, policies, and processes into daily work.
Because CSR must be an ongoing process, a variety of approaches and learning methods
should be used, including the following:
. face-to-faceeducation,
. rounds of work areas with environment assessment and staffknowledge assessment,
. questions and ans\Mer tools (daily, weekly, and monthly),
. resource books of common standards updated at least annually,
. self-assessment tools to identify gaps in comparison to standards and education and oth-
er action plans to address the gaPs,
. visual tools or cognitive aids such as posters on safety goals or performance improve-
ment model,
. content experts to respond one-on-one to questions or interpretation of standards,
. tools for tracer activities, and
. mock surveys to assess compliance with standards in an ongoing manner.
An extensive discussion on regulation, accreditation and continuous readiness can be
found in Q Solutions: Regulotion, Accreditation, and Continuous Readiness.
2. Facilitating the Credentialing and Privileging Process
Medical staff members of an organization provide patient care and fulfill other professional
responsibilities through rules and defined policies. The bylaws and rules of the medical staff
are documents that delineate how the medical staff will organize and govern its affairs. The
essential components include the following:
. structure and membership of the medical staff;
. credentialingfunction;
. processes for appointment and for granting clinical privileges;
o provisional period for initial appointment;
. reappraisal or reappointment process;
. responsibilities of department chairpersons, department, and chief of staff;
. fair hearings and due process; and
. mechanisms for corrective action.
The two components of allowing members of the medical staff to practice and provide
patient care within an organization are credentialing and privileging. These fwo components
will be described separately.
Credentialing Process. The term credentialing refers to the systematic process of screening
and evaluating qualifications and other credentials, including licensure, required education,
relevant training and experience, and current competence and health status of a member of
the medical staff. This applies to licensed independent practitioners (ttps) as well as certain
14
Q SoluEions

other professionals who may or may not be LIPs but are members of the medical staff with
ei-
ver-
ther piivileges or a scope of practice. The credentials of the licensed professional must be
from
ified through primary rorrr.. verification. Primary source verification is documentation
the original source oia specific credential that verifies the accuracy of a
qualification reported
docu-
by an individuat healthcare practitioner. This can be documented in the form of a letter,
source. The
mented telephone contact, or secure electronic communication with the original
patient care truly
organization is responsible for this process to ensure that anyone providing
has the credential, pr"r"rr,.d and that there are no adverse actions against
the provider.
The following items are minimally verified for each LIP:
. current licensure, which is the official or legal permission to practice in an occupation,
as evidenced by documentation issued by a state, territory commonwealth,
or the Dis-
trict of Columbia in the form of a license, registration, or certification;
. education from an accredited program with evidence of successful graduation;
. board certification (if required);
. training (any specialized training such as fellowships);
. references from peers;
. medical malpractice claims;
. reports to the National practitioner Data Bank (NPDB) and Healthcare Integrity
and
Protection Data Bank (HIPDB); and
. current competence.
in-
The credentialing (and privileging) process is repeated every 2 years with updated
to
formation to ensure that the practitioner maintains current credentials and competence
provide safe, high-qualitY care.
rririt"girrgprocess. The privilegrng process is based on the services provided at the organiza-
for privileg-
tion and approved by the medi.rirtrf. The practitioner's qualifications and request
es are considered based on the procedures and rypes ofservices
and care that can be provided by
training,
the organization. The practitioner requests privileges based on his or her education'
to the medical staff
and experience, and then the clinical iepartment makes recommendations
through the medical executive committee. Privileges are granted by the organizationthrough
defined
the committee,s recommenclations to the governingbody. The term clinicalprivflegrngis
as the process bywhich a practitioner,licensed for independent
practice (e.g., without supervi-
permitted by law
sion, direction, required sponsor, preceptor, mandatory collaboration), is
patient care
and the faciliry to practic. irrd"p"ndently to provide specified medical or other
services within the scope of the practitioner's license, based on his or
her clinical competence
train-
as determined by peei references, professional experience, health status, education,
and
ing, and licensure. clirricrl privileges must be facility- and provider-specific. Credentialing
pri.,rit"ging of depend.rr, independent practitioners are outlined in Table 4. Clinical priv-
"r,d
il"g"t may be defined several ways and categorized by
o practitionerspecialry
. level of training and exPerience,
. patient risk categories,
. lists of procedures or treatments, and
' any combination of the above'
At the time of the initial appointment to the medical staff, the practitioner must
complete a Focused professional Practice Evaluation (FPPE). The FPPE is a time-limited
pro.L* whereby the organization evaluates and confirms the current competence of the
Quality and Performance lmprovement 15

Table 4. Comparison of Dependent and lndependent Practitioners for Credentialing

and Privileging
Aspect Dependent Practitioner lndependent Practitioner
Credentials Required licensure, education, and Required licensure, any action against
certification if applicable licensure, education from accredited
program, special training (such as fellowship),
board ehgibility or certification if required,
peer references, malpractice history

Description of function Job description Privileges (or scope of practice)

Brought on to the Hired Appointed

organization

Probationary period lnitial competence assessment (often a lnitial competence is assessed by Focused
skills checklist) Professional Practice Evaluation (FPPE).

Ongoing development Education and training within profession Education and training within profession

Reassessment of Regular ongoing competence Competence is reassessed by Ongoing

competence assessment (period defined by Professional Practice Evaluation (OPPE).
the organization and accreditation
standards)

Evaluation Annual performance evaluation OPPE for consideration of

is used
reappointment (time frame is every 2 years).

PerFormance issues A personal improvement plan to correct An OPPE or other triggers may require an
(clinical) deflciencies FPPE for cause.

Ongoing.review Continued employment with the Reappointment to the medical staff

organization

practitioner's performance for all initially requested privileges or when issues affecting the
provision of safe, effective patient care are identified. This process usually includes an as-
sessment for proficiency in the following six areas of general competencies developed by the
Accreditation Council for Graduate Medical Education (ACGME) and the American Board of
Medical Specialties (ABMS) joint initiative:
. patient care,
. medical or clinical knowledge,
o practice-based learning and improvement,
. interpersonal and communication skills,
. professionalism, and
. systems-basedpractice.
After the initial FPPE is completed, the practitioner's performance is monitored in an
ongoing manner through the Ongoing Professional Practice Evaluation (OPPE). The OPPE
is a process that continuously evaluates a practitioner's professional performance to iden-
tifu problems that may affect quality of care and patient safety. Ongoing provider evaluation
is an evidence-based privilege renewal process and is part of a decision-making process that
is used on a biennial basis to continue a provider's existing privileges or scope of practice or
to limit or revoke existing privileges or scope of practice before or at the time of renewal.
This process includes an assessment of proficiency in the six ACGME areas of general com-
petency. Other criteria that may be used by an organization depending on services provided
include the following:
 Q SoluEions
16

o pxtt€ills of blood and pharmaceutical usage,

. use oftests and procedures,
. length-of-staypatterns,
. morbidity and mortalitY data,
. use of consultants,
. performancemeasures,
. medical record management,
. periodic and retrospective chart reviews,
. direct observation,
. monitoringofdiagnostic andtreatmenttechniques,
. compliahce with Policies,
. review of operative and other clinical procedures performed and their outcomes,
and

. other service-specific items.

The reprivileging process occurs simultaneously with recredentialing every 2
years
staff or
during a reapprairrt. I.t ir is conducted at the time of reappointment to medical
renewal or revision of clinical privileges. Renewal is based on ongoing
monitoring of
-in-
formation-oppE-and includes confiimation of adherence to medical staff membership
medical staff leaders
requirements, rules and regulations, and policies. Through the OPPE'
consider relevant practitioner-specific information, results of peer review,
and other per-
formance evaluations. The governing body is ultimately responsible for the credentialing
and privilegrng process and the qualiry olcare provided by members of the
medical staff'
The processes are usually managed by staff in the medical staff office or QPI department'
negardless of where the function is housed, it must include the following
processes:
. initialappointments;
' reappointments;
o granting, renewing, and expanding clinical privileges; and
. fair hearing and appeal in the event of an adverse decision on granting, revoking,
revis-
clinical
ing, or renewingclirrical privileges for medical staffmembers or others holding
p.irii"g", in accordance with afphcable statutes, rights of the individuals, and bylaws.
privileges.
The organization maintains a credential file for each person requesting clinical
staff
A separate oppE file includes performance data reviewed by the department medical
chair. credential files contain clear evidence that the fulI range of
privileges has been includ-
ed in the initial and subsequent reappraisals, particularly privileges for
performing high-risk
procedures and treating hlgh-risk conditions. Information is substantive and practitioner-
documen-
specific. The effectiveness of the reappraisal process may be measured by objective
tation that the indiviclual's privileger *"r" increased, reduced, or terminated because
of
. assessments of documented performance,
. nonuse of privileges for high-risk procedures or treatments, and
. emergence of newtechnologies.
Under specific situations, temporary privileges for a defined period of time may
be

granted afteiminimal criteria are verified. Also, disaster privileges may be granted if the-orga-
nization determines it will allow them and specific criteria are met'
The healthcare quality professional must abide by the standards set by accrediting agen-
cies and state professional boards regarding credentialing and privileging
processes.
Quality and Performance lmprovement 17

3. Overview of QPI
Definitions and requirements for quality in healthcare have evolved over the past decades. In
the early 195os, quality care review was conducted exclusively by individual physicians using
an unstructured and subjective process that relied on the practitioner's knowledge and experi-
ences. Between 195O and 1960, the responsibility for qualiry of care expanded beyond the phy-
sician to include both the hospital and the board of directors. Two significant legai decisions
marked this transition period:
' Bingv.Thunig (1957). In this case, the New York Court ofAppeals ruled that the doctrine
of charitable immunity no longer applied to hospitals; hospitals are liable for patient in-
juries sustained through negligence of employees.
' Darlingv. CharlestonCommunity MemorialHospital (1965). In this important corporate
negligence case, the court ruled that the hospital had a legal responsibility to protect a
patient from harm by others by overseeing the qualiry of patient care.

B. Retrospective Audits
A shift from physician review to medical audits occurred in 1955. Medical audits included a
systematic procedure using objective, valid criteria with an orientation on outcomes. InL966
there \Mas a major change whereby the Joint Commission on Accreditation of Hospitals (as
it was called then; now the Joint Commission) focused on optimal, not minimal, standards
of care. In 1975, the Joint Commission on Accreditation of Hospitals published the qualiry of
professional services standards, requiring hospitals to demonstrate optimal care using valid
and reliable measures. Although optimalwas never defined, this new focus led to one-time au-
dits of care, known as performance evaluation programs audits.
C. QuahtyAssurance
Audits soon led to a preoccupation with meeting audit number requirements. As a result, in
1980 the Joint Commission on Accreditation of Hospitals developed the first qualiry assur-
ance standards requiring a problem-focused approach to measuring quality. This approach
required organizations to identify and monitor problem areas.
The combined strengths of criteria-based audits and the epidemiological approach
used in infection control in the l98os resulted in a new focus on systematic monitoring and
evaluation in 1985. From this, a lo-step process for QPI evolved in 1986 requiring organiza-
tions to evaluate important aspects of care and then use the results to identify opportunities
for improvement.
D. QPI Method
By the early 1990s QPI methods were becoming common in healthcare facilities. In 1994,
the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced
the new standards for improving organizational performance, requiring a collaborative cul-
ture that focuses on processes by elucidating how customers define quality, how processes
work, and the importance of reducingvariation in those processes (JCAHO, 1994).This repre-
sents a shift in focus from the performance of individuals to the performance of the organiza-
tion's systems and processes. There is no longer any department-specific review (e.g., no ancil-
lary services review for QPI); QPI is reviewed for the entire organization (JCAHO, 1994). The
standards also required a shift from improving only clinical quality to improving nonclinical
care, value, and patient satisfaction.
The following discussion on performance management centers on the organizational
level in the context of meetingthe organization's strategic goals and objectives.
 Q SoluEions
18

E. Performance Management
performance management has been defined as "the use of performance management informa-
processes by helping to set
tion to effect positive change in organizational culture, systems, and
informing managers to
agreed-upon performance gorls, allocating and prioritizingresources,
those goals, and sharing
either confirm or change .irr"rr, policy oip.ogtr- direction to meet
(U.S. Department of Energy' Office of Manage-
results of performrrr."i, pursuin! those goals"
.I.he goal of a performance management system is to make certain that the vision of
ment, n.d).
reflected in that vision.
the organization is being met by defining and measuring outcomes
the Baldrige
Although there are a variety of quality performance programs' including
performance Excellence program and the European Foundation for Quality Management, a
1000 companies use the balanced
significant percentage of government agencies and Fortune
compat-
scorecard (BSC) ,, f, approach to periormance management. BSCs are completely
such programs by embedding
ible with other quality performance programs but go beyond
of the organization (Kaplan & Bower,2OOl)'
QPI in the strategi. frr-"*ork
in the early 1990s' The
The BSC was developed by ors. oaiid Norton and Robert Kaplan
provide a comprehensive view of organiza-
basic idea is that performance measures should
indicators. Unlike other per-
tional performance and not be overly dependent on a few choice
formance models, the BSC helps organizations better
link long-term strategy with short-term
activities (Kaplan & Norton, 1996)'
perspectives or categories:
The BSC approach views the organization from four different
customer ("How do our
financial (,How.do we look to proiid"., of financial resources?"),
customers see us?'), internal business processes
(At what must we excel?"), and learning and
Answers to these
growth Ccan we continue to improve and create value for customers?').
that are set and, ultimately
questions influence the nature of the strategic goals and objectives
performance indicators is that
what performance measures are used. rhe critical aspect of
they must reflect the organization's strategic goals and objectives'
There are likely to" be several rr.r,"gi. objectives corresponding
to each of the four
measure, and the principles
perspectives. Each of ,h.r. objectives stroutd have at least one
measure precision, reliabiliry
described in Q solut ions: Leadership and Management regarding
here. In addition, data can be
validity, and mixture of qualitative and quantitative all hold true
gloups, patient chart reviews)'
collected through a variety of means (e.!., srrueys, focus
of measures (i'e" struc-
Kelly (2003) suggests that developrn"nt and use of different types
approach' Examples of the
ture, proc.rr, o.r,.oil"s) in each of the categories is an important
goals and objectives discussed
four categories and measures in the .orrt"rt of the strategic
earlier (Table 1) are presented next'
The foundation fbr an organization's strategic success begins
with its people, who must be
they must' for example'
willing to learn and grow. To meet the changing needs of customers,
be able to learn new technology and acquir. .r.* skills
in order to take on ne\M responsibili-
program for breast cancer detection and
ties. For the strategic goal "De.,relop a staie-of-the-art
treatment" (see Table 1), measures could include
. structure: quantityofimagingequipment;
o pfoc€sS: number of patients diagnosed with imagingtechnologS';
and
. outcome higher percentage of early diagnoses, due to use of imaging
technology'
to convert
It is necessary to monitor and improve key processes so that employees are able
"Be recognized as one
Iearning ,rra gro;h into products and services or qualiry outcomes.
goal (see Table 3)'
of the top fr""ttt .r." proriders in the community" was another strategic
Measures could include
Quality and Performance lmprovement 19

. structure: resources available for care delivery (e.g., nurse-patient ratio);

. process: care (how patients are diagnosed and treated); and
. outcomes: results of care (e.g., satisfaction,length and quality of life, turnover rates).
Just as different organizational levels and units develop goals and objectives based on
corporate strategJ, different levels and units also can use BSC. AIso, note that for the same
strategic goal (e.g., be recognized as one of the top healthcare providers in the communiry)
there are several measures of performance across different perspectives.
F. Setting Priorities for QPI
The road to QPI begins with strategic planning to guide the organization in focusing on the
most important aspects or priorities. Priorities for performance or QPI activities are based on
several standard approaches. The first approach is that the priorities should be aligned with
the organization's strategic priorities in order to maximize resources for improvement, and
the second is a criteria-based approach considering risk, volume, problem proneness, patient
safety, cost, customer satisfaction, and other criteria established specifically by the organiza-
tion. The pillars identified by Quint Studer are also often used as the categories of improve-
ment priorities: Service, Quality, Financial, People, and Growth (Studer Group, 2OL2).
A framework for leadership of improvement is the first step in turning the strategic plan
into an operational plan for improvement. In this framework leaders apply the mission, vi-
sion, values, and strategic plan to set direction. This framework is built on a foundational
leadership team to support improvement capability. The three components of will to prepare
for change, ideas to generate new ways of performf4g and execution of change contribute to a
leadership system for improvement. This model is depicted in Figure 5. A detailed view of
this framework is presented in Figure 6. Finally, this framework is presented as an integrated
system in Figure 7.

G. Priorities for QPI

Prioritizing evaluates key processes against key business drivers to identify the most impor-
tant processes to improve and measure in evaluating performance. Applying priorities de-
termines the initiation of an improvement action, based on the analysis of data collection.
The goals and drivers of the system are depicted in Figure 8. Leaders identify a priority list
of processes or services for improvement (Provost, Miller, & Reinertsen, 2006). Healthcare
quality professionals facilitate development of priorities by
. establishing criteria for priority assessment (e.g., volume, risk, problem proneness),
. using data on past performance to assess gaps (internal performance),
. using external drivers for consideration (new regulations, standards),
. providing information to leaders with a basis for recommendations,
. using tools to create a matrix for priorities for decision making,
. involving key stakeholders for input, and
. identifuing internal and external requirements that influence priorities.
In addition, healthcare qualiry professionals and their QPI teams use the described crite-
ria to prioritize QPI activities based on the quantitative and qualitative data available to them.
By using past performance, aligned with the criteria and strategic initiatives, the team is able
to determine the priorities for action. A plan should be established that is approved by the
clinical leaders to ensure success of the activities, especially in applying resources for the ef-
fort required for the team. The initiatives that have the most opportunity for improvement
are often tackled first. Usually, the initiatives selected will focus on core clinical processes,
 Q SoluEions
20

5. Framework for LeadershiP of

Set Direction: Mission, Vision, and Strategy

+
PUSH
Making the status quo comfortable
Making the future attractive
D
PULL

\
ldeas
Execution
,( \will
Foundation
in Health Care (znd Edition), by J' L Reinertsea M. Bisognano, and M.
From Seven Leadership Leverage Points for organization-Level lmprovement
pugh, Copyright zooe. Reprinted with permission'
D. Cambridge,lrly'l- lnsdite for Healthcare lmprovement.

6. Detailed Framework for

+
PUSH
1. Set Direction: Mission, Vislon, and StrategY

Make the status quo uncomfortable Make the future attractlve

+
PULL

3. Build Will 4. Generate ldeas 5. Execute Ghan$e

. o Read and Scan Widely, . Use Model for lmprovement
Plan for lmprovement
Learn from Other for Design and Redesign
. Set Aims and Allocate lndustries and DisciPlines . Review and Guide KeY
Resources
o Benchmark to Find ldeas lnitiatives
. Measure System
. Spread ldeas
Performance o Listen to Customers
o Provide Encouragement . lnvest in Research . Communicate Results
. Make Financial Linkages and DeveloPment . Sustain lmproved Levels
. Manage Knowledge of Performance
. Leam Subject Matter
. Understand Organization
. work on the Larger System as a System

2. Establish the Foundation

. Reframe Operating Values ' Prepare Personally ' Build Relationships
. Build lmprovement capability . choose and Align the senior Team . Develop Future Leaders

ffiintsforor9anization-LevellmprovementinHealthCare(zndEdition),byJ.L.Reinettsen,M.Bisognano'andM.
permission'
2OO8. RePrinted with
D. pugh, Cambridge MA lnstiite for Healthcare lmprovement. Copyright
Quality and Performance lmprovement 21

Figure 7. Leadership Framework as an lntegrated System

PUSH Changing the old ancl communicating the directiotr PULL

+

Building Cooperative Building }nprovement

Relationships Capability

Cltoosing and Aligning Personal

the Senior'feam Preparation

From "Buildinga System of Leadership for lmprovemenr,"in A Framework for Leadership of lmprovement (p.4), by lnstitute for Heakhcare
lmprovement, February 2006, Cambridge, MA: lHl. Available at www.knowledge.scot.nhs.uk/media/CLT/ResourceUploads/tooest/
lHlLeadershipFramework-FEB2oo6versionFlNALpdf . Reprinted with permission.

Figure 8. Cascading Series of Goals and Drivers

Leader
Key Drivers to Achieve Goal Leaderts Goal Responsible

. Handwashing
o Lean processes: Flor
management, reduce wasted Reduce hospital-acquired
Chief Medical Officer,
time and effort of staff to glve infections by 50% in
Chief Nursing Officer
12 months

Fully deploy Ventilator

Bundle and Centrai Line
Bundle to all units within
six months

From Seven Leadership Leverage Points for Organization-Level lmprovement in Health Care (znd Edition, p. tl), by J. L. Reinertsen, M. Bisognano,
and M. D. Pugh, Cambridge, MA lnstitute for Healthcare lmprovement. Reprinted with permission.
 Q SoluEions
22

high-risk medications' or high-risk

high-risk processes, high-risk patients and populations,
on the potential consequences of injury or
actions or interventionl rhe level of risk is iased
risk is the frequency with which the pro-
harm to patients. Another aspect in assessing revel of
cess or procedure is performed. For
responding to a case of malignant hyperthermia
"*^*prJ, if the staff does not manage this scenario
would be consid"r.jiigt, risk for tt " prii"r,,, ,nd
team' Therefore' it may be a priority to per-
often, they may not respond as a highly effective
high-risk patients and processes will
form dri[s to ensure that staff is .o-i"r"rra. Managing
of high-risk processes include
significantly affect morbidity "rrd *ortrliry. Examples
. core processes: admission, transfer' discharge;
. surgery resuscitation;
high-risk processes: medication delivery or administration,
immunocompromised patients'
. high-risk patients: patients with reduced renal function,
patients' dementia patients at risk for
neonates, patients in critical care units, suicidal
wandering;
. high-risk medications: heparin (and oral anticoagulants), insulin, chemotherapy' opiates'
neuromuscular blocking agents; and
. high-risk actions and interventions: blood transfusions, use of restraints' extracorporeal
circulation, moderate sedation (White' 2OO 4)'
or a{]yili"t undertaken' Key steps
After priorities are established, specific initiatives l:
(Rosati, 2oo3; white, 2oo4)- These steps ensure
to implementing pr actMties are as ioilows
success of the PI Priorities:
for the PI initiative'
1. Ensure leadership support and commitment
on risk, resources' leadership support'
2. Assess priority and feasibility of initiative based
and organizational strategies'
3.Identifytheaimoftheinitiativeandincludethetopic,process,orproblemtobeim-
proved (have a good rationale)'
process experts with all key disciplines
4. convene an interdisciplinary ream of content and
asparticipants(involvealltherightstakeholdersandhaveachampionforthechange).
consensus-
best practices' research' and
5. Use tools and technique, to ,rdlre processes,
based evidence for the desired change'
timelines and accountability for the
6. Deverop the change to be implemenled and add
project.
the change has resulted in improvement; set
7. Identify the measures to demonstrate that
performance goals.
8. Educate staffon the desired change'
g.Implementandtestthechangeviatheredesignedprocesses.
redesigned process'
10. Collect, analyze, and evaluate data on the
and disseminate to all areas'
11. Make additional changes based on findings
12.Reportanddisplayresultstorewardstaffforimprovements'
ensure that the change is sustained'
13. Continue to *orriio, performance to
14. Compare performance internally and
externally'
15. Celebrate successes internally and externally.
use a prioritization matrix (Figure 9) to
when choosingbetween improvement activities,
assist in evaluating the items against
specific criteria. After leaders determine the improve-
ment priorities for process improve-"rrr,
they make decisions about the need to organize a
on
tasks, issues, or actions and prioritizes them based
team. A prioritization matrix organizes
agreed_upo, .rii"rir. The tool is helpful
in identifying criteria for specific priorities and ap-
prying a rating ;;;;" help make decisions
for the selection of specific activities. This matrix
Quality and Performance lmprovement 23

applies options under discussion to the priority considerations of the organization. The tool
combines the tree diagram and the L-shaped matrix diagram, displaying the best possible ef-
fect. The prioritization matrix is often used before more complex matrices are needed. This
matrix applies options under discussion to the priority considerations of the organization.
A project selection matrix ranks and compares potential project areas for implementa-
tion. Ranking criteria may include organizational and strategic goals, potential financial
impact to the organization, effect on patient and employee satisfaction, likelihood of success,
and completion within a specified time frame.
1.Reengineering or System Redesign
In the 1990s, reengineering was one of the major initiatives in hospitals. Most of these
efforts were focused on workforce redesign. There was fypically a focus on restructuring
or redesigning systems and departments into more efficient processes. For example, hos-
pitals experimented with creating new positions that combined work from several differ-
ent areas. A focus on cross-functional capabilities led to the dissolution of departmental
silos. A "patient service associate" or "technical associate" would deliver meals, clean pa-
tient rooms, stock supplies, and provide patient transportation. Many hospitals thought
that reengineering would increase profit margins and create financial stabiliry. The prob-
Iem was that reengineering often became associated with downsizing and layoffs. When
this happened, employee morale declined and productivity suffered. Because of these
negative connotations, reengineering has fallen out of vogue and been replaced by oth-
er improvement models and initiatives. The newer approach is to consider adopting the
Lean Enterprise method to increase financial stability by eliminating waste.
The key components and tools of a Lean Enterprise include identifyingvalue (value stream
mapping and voice of customer), eliminating waste (Table 5), establishing flow, enabling pull
(instead of push) systems, and pursuing perfection. The Six Sigma method includes a five-step
process: define, measure, analyze, improve, and control (DMAIC). Lean Enterprise and Six

Fiqure 9. Prioritization Matrix: Clinical lmprovement Priorities

High High Problem Customer
Risk Volume Prone Cost Satisfaction Regulatory Total

lnfectionRates 3 2 2 3 1 3 14

SurgicalComplicatlons 2 1 2 3 1, 12
'
EmergencyDepartment 1 3 1 1 3 0 9

Time to Treatment

FallsWithlnjuries 2 1 1 2 2 2 10

MedicationSafety 3 3 3 2 1 2 14

How to construct
1. Create an L-shaped matrix.
2. Prioritize and assign weights to the list of criteria that will be used in the prioritization.

3. Prioritize the list of options based on each criterion.

4. Prioritize and select the items across all the criteria.

When to use
When problem are identified and options must be narrowed down, when options have strong interrelationships,
and when options all need to be done but prioritization or sequencing is needed
Copyright zotz by NAHQ. All rights reserved.
24 Q SoluEions

Table 5. Types of Waste in Lean Production Systems

Type of Waste Waste Description Lean Strategy to Eliminate Waste

Tiansportation Moving material or information One-piece flow, avoid batching

lnventory (overproduction) Having more material than you need Standard work, 5-S tool

Motion Moving people to access or process Quick changeover, work cell, standard
material or information work

Waiting People waiting for material or Guick changeover, one-piece flow,

information, or material or information avoid batching
waiting to be processed

Overproduction Creating too much material or Standard work, one-piece flow, avoid
information batching

Overprocessing Processing more than necessary to Mistake-proofing, standard work

achieve the desired output

Defects (necessitating rework) Errors or mistakes necessitating rework Mistake-prooflng, standard work
to correct the problem

Sigma are often complementary tools. Lean Enterprise focuses on dramatically improving flow
in the value stream and eliminating waste to improve efficiency and speed. Six Sigma focuses
on eliminating defects and reducing variation in processes to improve effectiveness.
Berwick and Hackb arth QOL2) believe that the best healthcare reform and cost reduction
strategy is to eliminate waste. They have identified six categories where considerable costs are
represented by waste. Below is a list of categories and the estimated wasteful spending to the
U.S. healthcare system. Total waste detailed below cost the United States $558 billion-$1,263
billion in 2O11.
1. Failures of care delivery: waste from poor execution or lack of best practice adoption
resulting in injuries and poor outcomes ($tOZ billion-$lSa billion)
2. Failures of care coordination: waste related to fragmented care resulting in complica-
tions, readmissions, declines in functional status, and increased dependency of the
chronically ill ($25 billion-$aS billion)
3. Overtreatment waste from rendering care that is not useful ($tSS billion-$226 billion)
4. Administrative complexity: waste from state and federal government, accrediting agen-
cies, and payers creating inefficient or misguided rules ($toz billion_$3S9 billion)
5. Pricing failures: \Maste related to overpriced procedures and professional fees ($84
billion-$l78 billion)
6. Fraud and abuse: waste from fraudsters and fake healthcare bills ($gz billion-$272 billion;
pp. E1-E2)

H. Facilitate Development of QPI Action Plans and Projects

Once QPI priorities have been identified, an action plan puts them into motion. A standard
format includes
. who(accountability),
. what (specific actions or steps to be followed),
. when (time frame),
. status (progress made and ongoing monitoring), and
. completion (closure or closing the loop).
Quality and Performance lmprovement 25

Projects vary gleatly, ranging from improving a defined process to complete redesign or
even designing a new process or system. Although the scope varies, the key format remains
constant. The level of detail, number of steps, and length of time to complete will vary greatly.
Figure lO shows the framework for execution of plans for a QPI project (Nolan, 2OO7,p.5).
l. Facilitate Program Development Evaluation Planning, Prolecs, and Activities
Healthcare quality professionals often guide the planning and evaluation for projects and ac-
tivities. The first step is to understand data and tools to construct an overall plan and specifi-
cally the data collection plan- This will include the following steps:
. Determine who, what, when, where, how, and why.
. Structure the design.
. Choose and develop asamplingmethod.
. Determine and conduct training.
. Delegateresponsibilities.
. Facilitatecoordination
. Forecastbudget.
. Conduct pilots or tests of change.
A clear understandingof data and tools to assist in problem identification and solutions is
needed to facilitate planning and evaluating improvement projects. An overview of data and
data management is provided with some of the more common tools used in these processes.
1. Decision-Making Methods and Tools
Described next are epl methods and tools for decision making, measuring variation, and pro-
cessimprovement. Detailed descriptions and examples of these tools follow. More tools on data
analysis and statistical process control are described in Q Solutrons: lnformationManagement.

Achieve
Sffigi,eGo.!s

Provide Leaders
for Large System Projects

iilanage l-ocd Provide DaFtoDaY

Leaders ror Micro$Ystem s
BuiHCambilill
lmproucroed

ENVIROililET{T IHTRASTRUCTURE

(znd Edition, p 5), by J. L. Reinertsen, M' Bisognano, and

From Seven Leadership Leverage Points for Organization-Level lmprovement in Health Care
M. D. Pugh, Cambridge, MA: lnstitute Heahhcare lmprovement. Copyright zooa. Reprinted with permission.
for
 Q SoluEions
26

This ap-
Brainstorming (Figure l1). Brains torming is a free-flowing generation of ideas.
proach has the potential to generate excitement, equalize involvement, and
result in orig-
they are
inal solutions to the probl.*. th"te is no censoring or discussion of ideas as
generated, but the ,"r* can build upon the ideas of others. It is very important
that no
judgments are made concerning the idea's worth to the process, or whether the idea is
even feasible (money is no object in a brainstorming exercise).
Discussion of ideas comes
for tools in-
at a later point in the pro."rr. This technique works well to generate ideas
cluding the cause-and-effect diagram and the tree diagram.
the most popu-
iraultivoting (rigure t2). Mukivoring is an easy, quick method for determining
lar or important items fro* r list. The method uses a series of votes
to cut the list in half each
time, thus reducingthe number of items to be considered.
process for generat-
Nominal group t"In riq.r" (Figure I3). This is a group decision-making
ing a 1arge number of id.as in which each member works by himself
or herself. This tech-
,rif,rre is ised when group members are new to each other or
when they have different opin-
and multivoting'
ions and goals. rhis appioach is more structured than brainstorming
multivoting, and
Detphi Method. The'Delphi methodis a combination of the brainstorming,
are not in one lo---
nominal group techniques. This technique is used when group members
;;,*;;?;il;;;il;;,; by e-maiiwhen a meetins is not feasible. Ar.. ,".1:,"p i"

How to construct
t. Define the brainstorming topic.
"all ideas are good ideas" and (b) "all comments/evaluation
2. lnform participants of the ground rules that (a)
should be held in abeyance until the brainstorming is complete."
g. Give everyone a few minutes to think about the topic and write down
their ideas'

call out their ideas. This can be free-flowing, or a structure can

be used, such as going
4. Have the team members
around'
around the table with each person verbalizing one idea each time
a flip chart'
5. As the ideas are generated, one person should write the ideas on
When to use
' Use when a list of posslble ideas is needed'
. cause-and-effect diagram and the tree diagram'
This technique works well to generate ideas for such tools as the

How to construct
l. Generate a list of items and number them'

z. lf the grouP agrees, combine items that seem to be similar'

3. lf necessary, renumber all items.

4. Each member lists on a sheet of paper the items he or she

considers the most important (the number of items
chosen should be at least one-third of the total number of
items on the list).

5. Tally the votes beside each item on the list'

6. Eliminate items with the lowest scores'
number for the group to focus on or
7. Repeat the above process until the list is narrowed down to an apPropriate
the item with the top priority is identified'

When to use
Use after a brainstorming session to identify the key
items on which the group will focus'
Quality and Performance lmprovement 27

the process, the data are sent tp one person, who compiles the data and sends out the next
round for participants to complete.
Failure Mode and Effects Analysis (FMEA). FMEA is a preventive approach to identify fail-
ures and opportunities for error and can be used for processes as well as equipment. The tra-
ditional techniques for FMEA originated in manufacturing and other industries and have
been adapted to healthcare. The Veterans Affairs National Center for Patient Safery created
the Healthcare FMEATM (HFMEA) specifically for healthcare. There are six main steps to
HFMEA, as displayed in Figure 14.
Prioritization Matrix (Figure 15). This tool organizes tasks, issues, or actions and prioritizes
them based on agreed-upon criteria. The tool combines the tree diagram and the L-shaped
matrix diagram, displaying the best possible effect The prioritization matrix often is used
before more complex matrices are needed. fhis maffix applies options under discussion to
the priority considerations of the organization.

Fiqure 13. Nominal Group Gchnique

How to construct
t. Define the task as you would for brainstorming.

2. Describe the purpose of this technique and the process to the group.

3. Write the question to be answered for all to see. Be sure to clarifo the question as needed for the group.

4. Generate ideas to address the identified question by having the group write down their ideas in silence.

s. List all the items as you would in brainstorming, only be sure to use a structured approach so that all ideas are
listed (again, there is to be no discussion of the items at this time).

6. Clarify and discuss the ideas one at a time.

z. Give each member 4-8 cards or pieces of paper.

8. Members write one selection from the list on each card and assign a point value to each item. The highest
value should be assigned to the most important item (i.e., if there are four cards, the most important card is
numbered 4, next important 5, etc.)

9. The cards are collected and the votes are tallied; mark each item on the list with the value on the cards for that item.

10. The item with the largest number becomes the group's selection/priority.

When to use

' Use when team members are new to each other.

. Use when dealing with a controversial topic. l

Figure 14. Healthcare Failure Mode and Effects Analysis (HFMEA)

How to construct
There are six main steps to HFMEAS",

t. Define a topic and process to be studied.

2. Convene an interdisciplinary team with content and process experts.

J. Develop a flow diagram of the process with consecutive numbering of each step and lettering of all
subprocesses.

+. List all possible failure modes of each subprocess, including the severity and probability of the failure mode,
and then number these failure modes (brainstorming may be helpful to identiFy failure modes).

5. After analyzing the failure modes, determine the action for each failure mode to eliminate, control, or accePt.
6. ldentify the corresponding outcome measure to test the redesigned process (White, 2OOa, p. 61).
28 Q SoluEions

--
Fiqure 15. Prioritization Matrix: Decision Example
Meets
Low Accreditation MD
High Strategic Staff
Cost Priority Standards Concern Concern Totals

Repairroof 3 4 2 3 4 16

PurchasenewX-raymachine 5 2 0 1 5 13

Developskillednursing a 1 o 2 2 9

Developbettercommunications 2 3 1 4 3 13

with home health

Developstaffnewsletter 1 5 3 5 1 15

How to construct
1. Create a L-shaped matrix.
2. Prioritize and assign weights to the list of criteria that will be used in the prioritization.
5. Prioritize the list of options based on each criterion.
4. Prioritize and select the item(s) across all of the criteria.

When to use
' When issues are identifled and options must be narrowed down
' When options have strong interrelationships
. When options all need to be done, but prioritization or sequencing is needed.

Determining the cause of variation is critical in the QPI process.

Common-Cause Variation. Variation is inherent in any process. On a control chart, this type
of variation is exhibited as points between the control limits in no particular pattern. This is
variation that normally would be expected from a process. If this type of variation is treated
as being unpredictable, it could interfere with the process and make things worse. The root
cause of the variation must be identified before any attempt is made to fix the problem.
Special-Cause Variation. Variation that arises from sources that are not inherent in the pro-
cess is unpredictable. On a control chart, this type of variation is exhibited as points that fall
outside the control limits or, when inside the control limits, exhibit certain patterns. These
special-cause variations should be addressed whenever they occur, with interventions appro-
priate for the elimination of the special cause, if possible.
Root-Cause Analysis. When variation is inherent in the process and a reduction of the vari-
ation is desired, the root cause of the variation must be identified to eliminate tampering
with the effective components of the process. The Joint Commission requires this in re-
sponse to sentinel events. To start with, potential causes of the variation should be iden-
tified. An interdisciplinary team very familiar with the process should use brainstorming,
flowcharting, cause-and-effect diagrams, or some other process to determine these poten-
tial causes. The second step is to verify the potential causes by collecting data about the
process. After the data are collected and analyzed using the tools discussed in this module,
the actual causes of the variation (or at least the most probable causes) can be identified.
The following areas should be addressed in the analysis:
. human factors: communications and information management systems;
. human factors: training;
. human factors: fatigue and scheduling;
. environmentalfactors;
' equipment factors;
Quality and Performance lmprovement 29

. rules, policies, and procedures; and

. leadership systems and culture (White, 2OO4).
At this point, the team should develop and implement an action plan designed to elimi-
nate or minimize the root causes of the variation.
Spaghetti Diagram (frgure 16). A spaghetti diagram, also called a layout diagram, is a graphic
representation of the flow of traffic or movement.
Checklist (Frgure 17). A checklist is a standard way to ensure completion of critical tasks for a
process or activity.
5-S (Figure 18). 5-S is a lean tool that represents Sort, Straighten, Scrub/Shine, Systematizef
Sustain, Standardize.
Value Stream Mapping (Frgure Ir9). Value stream mapping is a map of the process in which
only value-added steps for the customer are retained and other waste removed.
Voice of the Customer (Figure 2o).Voice of the Customer is a list of needs, wants, and desires of
the customer of a process output. These are sometimes called specifications or requirements.
Supplier Input Process Output Customer (SIPOC; Figure 2l). A SIPOC is a tool in process
management to identify key drivers of a process.
When the healthcare quality professional has a clear understanding of data, types of
data, and tools, the process steps may be described with a variety of acronyms (e.9., Plan-Do-
Study-Act [PDSA]; Plan-Do-Check-Act [ppCe]; assess, plan, implement, evaluate [efm] but
include the similar components. For this module no specific improvement model is endorsed
so that the healthcare quality professional can use tools depending on the improvement ques-
tion and the organizational context. Regardless of the improvement model, the improvement
process seeks to accomplish the following:
. Ensure the project is a priority for the organi zation and is aligned with the strategic plan.
. Ensure leadership support and commitment.
. Assess the prioriry and feasibiliry of initiatives based on risks, resources,leadership sup-
port, and organizational strategies.
. Clarifi, the aim, stated in specific measurable terms.
. Present baseline data analysis that illustrates the problem. Use tools and techniques to
analyze.
. Demonstrate that the aim is based on own data and identifies the specific problem to be
solved, the program to be enhanced, or the process or system to be redesigned.
. Select an interdisciplinary team with content and process experts and all key disciplines
as members.
. Map the current process and collect data on key aspects of the process. Continue to use
data and tools to identify bottlenecks, constraints, delays, and other barriers.
. Define measures and collect data. Indicate how you will know a change is an
improvement.
. Describe the change to be made.
. Implement the change (small tests of change or pilot tests).
. Study the effects of the change and make a decision: adopt, adapt, or abandon the spe-
cific change.
. Map the new process.
. Spread the change throughout the organization in a defined implementation plan (in-
clude communication plan and education plan).
. Sustain the improvement by monitoring.
 Q SoluEions
30

Figure 16. Spaghetti Diagram (or Layout Diagram)

Eudlt|l rs* +r*t*

rxftJ
tuffireg

How to construct
1. Get a layout or blueprint of the area.
2. Pick the subject to follow for the flow.

3. Record every movement until completed'

When to use
. To demonstrate flow or movement in a process

' To identify excess or wasted travel or movement

Copyright 2otz by NAHQ. All righrs reserved-

How to construct
t. ldentify critical elements or tasks to be completed for a process'
2. Make a list of all elements with a space to indicate completion of the task before moving to the next item'

When to use
' When reliance on memory is not sufficient
. When tasks for a process or activity are critical and omission may cause
harm

Copyright zotz by NAHQ. All rights reserved.

Quality and Performance lmprovement 31

Figure 18. 5-S

How to construct
1. Use the five components to divide all items into categories (retain, return, rid).
2. Find a place for everything and put everything in place.

5. Clean the entire area.

+. Establish schedules and systems to maintain the area.

5. Form a new habit to sustain the performance.

When to use
' lb establish orderly flow eliminate waste, and organize the workplace
. To standardize the work setting
From "Lean Manufacturing and Environment", by the IJ.S. Environmental Protection Agenclt Novernber tO,2Ott. Available at hxp:/fwww.epa-govf lean/
e nvi ron men t/method s/five s.htm.

J.
Selection of Process and Outcome Measures
There are several rypes of performance measures. Before selecting a measure, one must un-
derstand what purpose each measure serves.
. Structural measures are measures of infrastructure, capacity, systems, and processes
(e.g., nurse staffing ratios).
. Process measures are measures of process performance. They tell whether the parts or
steps in the system are performing as planned. This can be "in process" or "end of pro-
cess" (e.g., timely administration of prophylactic suryical antibiotics).
. outcome measures are results of overall process or system performance (often risk ad-
justed; e.g., mortality).
. Balancing measures are measures that tell us \4ihat happened to the system as the pro-
cess or outcome measures improved. They may be the consequence of or affected by
another measure. The term unintended consequence is another way of thinking about bal-
ancing measures. For example, if the organization is workingto reduce cesarean section
(C-section) rates, a balancing measure to ensure that the change in C-section rates does
 Q SoluEions
32

mvl
19. Value Stream M

Funeral BeneflciarY
l- - - -
I
Home
I
I
I
I
I

I oxoxl
Print,
Receiving: Three Person Team:
Stuff and
Open and Doc Verifl cation, Clalm Verifi cation
and Check Authorlzation Mail Check
Array Docs

Valuable? valuable?
\aluable? \tlluable?
Valuable? capable? Capable?
capeble? capable?
capable? AVallable? Avallable?
Avallable? Avallable?
Avallable? Adpquete? Adequate?
EOgqrater Adequate?
Adequate?

4 nours 8.3 hours

I-'1 r'rn E6ffil

fl z'rn [j% re
'rn
How to construct
value to the customer or required by some regulatory
i. ldentify the current process (mark steps that are of no
body).

2. ldentify the ideal process state'

3. Close the gap between the two states'
When to use
lean functioning
To improve flow of the process, reduce waste, and imPlement
MA: lHl' Reprinted with petmission'
From Going Lean in Health c"rdp r), ay rne hstitute for Heakhcare lmprovement,2ooS, Cambridge'

2O. Voice of the Customer

' What do you like about the current process?

. What do you think needs improvement?
. what would you recommend to improve the current process?
. What could threaten the success of the project?
How to construct
1. ldentify customers of a process output'
and their needs'
2. Develop a list of questions to ask customers about the process
g, Refine the list to use with the process review and improvement'
When to use
To improve a Process
Quality and Performance lmprovement 33

Figure 21. Supplier lnput Proiess Output Customer (SIPOC)

o
Supplier name Process input Process step 1 Process output Customer name

Supplier name Process input Process step 2 Process output Customer name

Supplier name Process input Process step 3 Process output Customer name

How to construct
1. ldenti{y each element of the Sl POC and list across the top of a page.

2. Under each heading of SIPOC list the suppliers, their inputs, the process, the customers, and the outPuts.

When to use
To identifo internal and external customer needs in a process and to use with other lean tools for process improvement

Copyright zotz by NAHQ. All rights reserved.

not have a negative consequence is to monitor maternal and infant morbidity and mor-
tality. The balancing measures of maternal and infant morbidiry and mortality could be
affected if a needed C-section is delayed trying to increase vaginal deliveries and reduce
C-sections.
Numerous measures have been developed, vetted, and put into widespread use. Health-
care quality professionals should not develop their own measures because there are a multi-
tude of valid and reliable measures that have been evaluated and endorsed by various public-
private partnerships (i.e., NQF) and professional associations. The sources of these measures
generally include the following:
. administrative data (volumes, admissions, discharges, length of stay, billing data, codes,
Uniform Hospital Discharge Data Set [UHDDS]),
. patient medical records (clinical care, medication use, surgery and procedural data,
treatment data),
. standardized clinical data sets (core measures, ORYX', minimum data set [MDS],
Outcome and Assessment Information Set [OASIS], National Surgical Quality Im-
provement Program INSQIP], Healthcare Effectiveness Data and Information Set
[HEDIS], Agency for Healthcare Research and Quality IAHRQ] Quality Indicators
[Inpatient Quality Indicators, Patient Safety Indicators, Pediatric Quality Indica-
tors, Leapfrog Group's Measures, National Hospital Quality Measures]),
o patient surveys (ConsumerAssessment of Healthcare Providers and Systems [CAHPS]),
. employee patient safery culture surveys, and
. comments from individual patients and their families (complaint management).
The AHRQ has been instrumental in advancing the study of measures, especially out-
comes and the effectiveness of specific treatments. Criteria have been developed for the selec-
tion of measures based on attributes (AHRQ,2Ol2) that include the following:
. Standardization: Reporting the same kind of data in the same \ ray;
. Comparability: If appropriate, results are risk adjusted for factors (e.g., age, gender,
health status);
. Availabiliry: Data will be available;
. Timeliness: Results will be available when most needed;
34 Q SoluEions

. Relevance: Results measure concerns of stakeholders and users;

. Validity: Measures have been tested so they consistently and accurately reflect the measure;
. Experience: Organizations have experience with the measure so it reflects actual per-
formance;
. Stabiliry: The measure is not likely to be removed from use;
. Evaluability: The measure can be evaluated as better or worse;
. Distinguishabiliry: The measure denotes differences between organizations;
. Credibility: The measures can be audited-
Another important resource for measures and measure sets is the National Quality Forum
(NeF, 2ot1). faLle 6 identifies the NQF measure evaluation evidence criteria to support the
focus of measurement.
When measures have been developed or selected for use, there must be a context in
which to determine whether the performance of a specific measure is good. In order to
prees-
determine the goodness, there are several factors to consider. First, does the evidence
tablish the desired or expectbd performance level? If not, does any regulatory accreditation,
or payer agencies identify a desired or expected performance level? The use of comparative
data will assist the organization in setring desired targets or goals and provide a method
by
which to determine how well the organization is performing compared with similar organi-
zations, competitors, best in the industry, and best in class'
1. Comparative Data
Healthcare quality professionals facilitate analysis and interpretation of outcomes and de-
cision ,.rppoit data for the organization. The reference point for the outcome data must
goals
always be kept in mind whenever the results of such data are analyzed. The overall
for outcomes and decision support data are to improve quality, reduce costs and resource
consumption, increase profitability of the organization, and develop an information-based
strategic plan. Compariions of length of stay, costs, complications, and mortality cannot be
*"d"1"gitimately without adjusting severity at the patient level. Severity adjustment and
"their
clinical case mix permit effective analysis and eliminate practitioners'concerns that
patients are sicker."
Decision suppoft data facilitate cross-functional analyses to improve patient care pro-
cesses and outcomes. Decision support data integrate financial and clinical data and
provide
the opportunity to perform highly sophisticated data analysis, involving predictive outcome
and executive staff evaluate cur-
-*rg;-ent. These data help healthcare quality managers
rent operations and the feasibility of the development of new product lines and services.
Healthcare quality managers coordinate the outcome and decision support data by posing
pertinent questions:
. What kinds of comparative analyses will be most important?
. With whom should we compare ourselves?
. How can we be sure the data are really comparable?
. What do we do when the data reveal significant differences in our outcomes and the
outcomes of the peer or benchmark?
2. Benchmarking
The healthcare organization's leaders can begin to ask questions internally to determine the
cause of variancecrevealed by comparisons. The challenge for healthcare quality staff is to
display the outcome data in a meaningful way that will be used by the involved departments
o1. i.r-r. Graphic display of the data improves understanding and usefulness of
the results.
euality and Performance lmprovement 35

Tabte 6. Evidence to Support ihe Focus of Measurement

Example of Measure Type and Evidence to Be
Type of Measures Evidence Addressed
Health Outcome A rationale supports the #O23O: Acute myocardial infarction (AMl).
An outcome of care is the relationship of the health
3O-day mortality.
health status of a patient outcome to at least one
healthcare structure, process, Survival is a goal of seeking and providing
(or change in health sta-
intervention, or service. treatment for A.Ml.
tus) resulting from health-
care, desirable or adverse. Rationale hnking healthcare processes or
interventions (aspirin, reperfusion) to mortality or
ln some situations,
surviva[.
resource use may be
considered a proxy # 1 : Acute ca re hospitalization (risk-adjusted)
O17

for a health state (e.g., [of home care patients].

hospitalization may lmprovement or stabilization of condition to
represent deterioration in remain at home is a goal of seeking and providing
health status). home care services.
Rationale linking healthcare processes (e.g., med-
ication reconciliation, care coordination) to hospi-
talization of patients receiving home care services.
#0140: Ventilator-associated pneumonia for
intensive care unit (lCU) and high-risk nursery
patients.
Avoiding harm from treatment is a goal when
seeking and providing healthcare.
Rationale linking healthcare processes (e.g., ventila-
tor bundle) to ventilator-acquired pneumonia.
lntermediate Clinical Quantity, quality, and #O059: Hemoglobin Alc management (A1c > 9).
Outcome consistency of a body of
Evidence that hemoglobin Atc level leads to
An intermediate outcome evidence that the measured
health outcomes (e.g., prevention of renal disease,
is a change in physiologic
intermediate clinical outcome
heart disease, amputation, mortality).
leads to a desired health
state that leads to a lon-
ger-term health outcome. outcome.

Process Quantity, quality, and #0551: Angiotensin-converting enzyme (ACE)

A process of care is a consistency of a body of inhibitor and angiotensin receptor blocker (ARB)
healthcare-related activi- evidence that the measured use and persistence among members with
ty performed for, on be- healthcare process leads to coronary artery disease at high risk for coronary
half o[ or by a patient. desired health outcomes in the events.
target population with benefits Evidence that use of ACE inhibitor and ARB
that outweigh harms to patients. results in lower mortality or cardiac events.
Specific drugs and devices
#0058: lnappropriate antibiotic treatment for
should have Food and Drug
adults with acute bronchitis.
Administration approval for the
target condition. Evidence that antibiotics are not effective for
acute bronchitis.
lf the measure focus is on
inappropriate use, then quantity,
qualiry and consistency of
a body of evidence that the
measured healthcare process
does not lead to desired
health outcomes in the target
population.

(continued)
 Q Soluuions
36

Table 6. Evidence to SuPPort the Focus of Measurement (continued)

Example of Measure Type and Evidence to Be

Type of Measures Evidence Addressed

Structure Quantity, quality, and #O'l9O: Nurse staffing hours'

consistenry of a body of , Evidence that increasing nursing hours results in
Structure of care is a
evidence that the measured lower mortality or morbidlty or leads to provision
feature of a healthcare
o,s";i,"ron or crinician
related to its capacity :::i:::i:i,l[i:'JJ.:5::'J;,
benefits that outwergh narms
::;siil: ffi iJ?:t:::[::Jl"J:'medication
to provide high-quality evidence
-of
th" lrnk
healthcare' A"lrrJu.,g
L ..r" fro."r,es and
the"ff".tir"
link from the care Processes
to desired health outcomes).
Specia! Considerations bY ToPic

Patient Experience with Evidence that the measured #0166: HCAHPS.

Care aspects of care are those valued Evidence that patients or consumers value
by patients and for which the the aspects of care being measured (e'g',
patient is the best or onlY source communication with doctors and nurses,
of information (often acquired responsiveness of hospital staff, pain control,
through gualitative studies) or communication about medicines, cleanliness and
Evidence that patient exPerience quiet of the hospital environment, and discharge
with care is correlated with information).
desired outcomes.

Efficiency measured with Currently, there are no NQF-endorsed efficiency

Efficiency
combination of qualitY measures measures that combine quality and resource use'
Measures of efficiency and resource-use measures. Potential measure: Diabetes quality measures or
combine the concepts of
Quality measure comPonent: composite used in conjunction with a measure of
resource use and quality.
Evidence for the selected qualltY resource use Per ePisode.
measures as described in this Evidence for diabetes quallty measures as
table. described in this table.
Resource-use measure
component: Does not require
clinical evidence as described in
this table.

ocusofQualityMeasurementandlmportancetoMeasureandReport(p.ts-te),by
linkit.aspx?Linkldentifier=idaltem
the Natrona/ eu ality Forum,January 2o11, Washington,DC NQE Ava,/a ble at www.qualityforum.org/WorkAreaf
I D=7O94. Re printed with permi ssion.

practitioner's
Benchmarking is the comparison of an organization's or an individual
results against a rlference poini. Idealry, the reference
point should be a demonstrated best
practitioners in
practice. Healthcare qualiry professionals assist the organization and its
aspects of
interpreting benchmaikingresurts. Ir is important to clarify two very important
b.rr.irm^rking. rhe organization,s or practitioner's actual performance or outcomes
always

stay the same. uowevJr, depending on to whom the organization

or physician is compared,
rate may only be
the expected value can change. For instance, an organization's complication
6zo hilher than expected when compared with a selected
market. However, the same orga-
with the
nization may have'artL1o/ohigher-than-expected complication rate when compared
U.S. average. rn other words, the comparison value and
the magnitude of difference change.
ho\M their
Healthcare qualiry professionals need to ask the right questions to find out
performers. The
organization wo;ks and ihen ask more questions to compare it with the best
go;l is to identify how to improve the organization's outcomes, not to identify the differences
between it and the benchmarking partner. It is important to be able to take the benchmarking
Quality and Performance lmprovement 37

data and provide the pertinent results to the right audience. When variance is identified, the
department or service involved must ask the following questions:
. What are we doing?
. How are we doing it?
. What is the measure of howwell we do it?
. why are we looking for improvement?
Directed and focused questions help managers identifl, performance gaps. Benchmarking
must be an essential element of clinical pathway development to ensure that the highest-cost,
highest-opportunity diagnosis-related groups (DRG, are prioritized. Data-driven internal
and external comparisons not only help to set best practices but also appeal to healthcare
professionals by providing objective data for clinical pathway development. In general, three
steps must be followed in benchmarking clinical pathways:
1. Identify high-resource-use DRGs.
2. Assess internal variabiliry.
3. Benchmark against external sources.
Table 7 provides examples of benchmarkingprojects.
Benchmarking enables an organization to set a target or goal for its performance im-
provement activities. It is up to the QPI team to determine whether it wants to be average
(the industry standarO or to raise the bar to a much higher level of performance. The goal
is to improve performance, so the goal depends on the level of current performance and the
commitment of the performance team and healthcare providers. One of the most critical
decisions an organization makes when launching a benchmarking initiative is selecting the
source of. its benchmarking comparative data. Healthcare quality professionals often coor-
dinate an organization's benchmarking efforts. Most healthcare regulatory agencies require
benchmarking as part of a comprehensive QPI program.
Potential data sources for benchmarking include the following:
. Government data available from Centers for Medicare & Medicaid Services (CMS) and
state government agencies.
. Alliances such as large healthcare systems (partnership organizations often provide data
extrapolation for their members, often providing databases for internal and external
benchmarking).

Table 7. Examples of Benchmarking Projects

Type of Benchmarking Example Topic Measures

lnternal Cesarean section rate Physician A vs. B vs. C, etc.; physician group
practice A vs. B, etc.; physicians vs. midwives.

lnternal Time to antibiotic forXYZ Emergency department vs. unit A vs. unit B, etc.;
lnfection emergency department vs. urgent care setting.

External Use of angiotensin-converting Health system or proprietary database

enzyme inhibitors with acute performance of all hospitals vs. region vs. similar-
myocardial infarction size hospital vs. own hospital.

External Central line-associated blood- Own unit vs. National Healthcare Safety
stream infection rates Network data for similar units. Can compare by
quartile or median rates (industry standard).

Zero-incidence Wrong site, wrong procedure, or Own hospital's incidence vs. zero incidence.
wrong Person surgery
38 Q SoluEions

Proprietary databases such as the National Database of Nursing Quality Indicators'

(NDNQT').
State peer review organizations and state hospital associations that offer free bench-
marking opportunities for hospitals in their state.
For-profit database companies that offer software that helps hospitals or organiza-
tions extrapolate and compile their own benchmark data or provide benchmarking data
through a centralized database compiled by the company. These data also are report-
ed to regulatory agencies upon request, such as the Joint Commission's ORYX and Core
Measures, CMS3 OASIS, and the National Committee for Quality Assurance's HEDIS
requirement.

V. Decision Support, Risk Adlustment, Data Interpretation, and Benchmarking

A. Decision Support
Performance outcome measurement or decision support systems can provide a primary focus
to determine the quality of healthcare services provided to consumers. By analyzing data and
information generated by an effective performance outcome measurement system, health-
care quality professionals will be able to help identifii areas for improving qualiry and resourc-
es in their organizations. Other uses for outcome systems include helping identify how an or-
ganization measures up in relation to its competitors, identifiiing individual providers and
practitioners who meet acceptable levels of qualiry allowing providers to respond more rapid-
ly to market changes, and paying for exceptional performance.
Organizations should use available decision support systems to develop an outcome in-
formation management plan, which includes evaluating performance outcome measurement
systems. Outcomes are viewed in terms of various clinical topics, including mortaliry compli-
cation rates, infection rates, cesarean section rates, and other clinical outcome measurement
categories. Categories might or might not reflect the resources (e.g., cost, charges, length of
stay) associated with a grven outcome.
To analyze and interpret such outcome data, healthcare quality professionals would
start with the rype of system. There are two types: electronic health record (EHR)-based and
code-based. With EHR-based systems, nursing or medical record analysts review the medical
records of all discharged inpatients to capture and input diagnostic, procedural, and detailed
clinical findings, such as laboratory results. This is done to identify severity- and risk-adjusted
information at the time of the patient's admission and at different points throughout the
hospitalization.
Code-based systems are based on retrospective administrative data, such as data in the
Uniform Bill documentLgg2 (UB-92) or claim data. These systems include clinical infor-
mation spanning the patient's entire stay but not identifying the specific timing of certain
conditions. This additional type of information can be available in an EHR-based system.
There also are some very significant benefits to using a code-based system, including much
lower costs. Another benefit of a code-based system is that is it more likely to contain a
sample size sufficient to develop more reliable models and output and to provide sufficient
and meaningful groups for comparing data. Most states require hospitals to submit all payer
data that are deemed public information. These data can be purchased by an interested
organization and then analyzed and interpreted using statistical tools in search of key vari-
ables that might predict the likelihood of a desired outcome.
Quality and Performance lmprovement 39

1. Evaluation and Selection of Evidence-Based Practice Guidelines

Evidence-based medicine is the 'tonscientious, explicit, and judicious use of current best
evidence in making decisions about the care of individual patients" (Sackett, Rosenberg,
Muir-Gray, Haynes, & Richardson, 1996, p. 7l).Because multiple disciplines are involved in
healthcare delivery however, the term eyidence-based practice (EBP) is more appropriate than
evidence-based medicine from a healthcare quality perspective. Clinicians not only should
base their care on the experimental evidence but also should consider experiential evidence,
physiologic principles, patient and professional values, and system features in their decision
making (Tonelli,2OOl). This allows individualized application and dissemination of aggregate
research evidence (Greenhal gh, \9 9 9 ; Tonelli, 20 0l).
EBP promotes patient safety through the provision of effective and efficient healthcare,
resultingin less variation in care and fewer unnecessary or nontherapeutic interventions (IOM,
2OO1). EBP and outcomes measurement are iterative; one facilitates the other (Deaton,2OOl).
EBP complements the principles of continuous quality improvement (CQI). Outcome evalua-
tion at the individual and aggregate level is an essential step in evaluating the impact of EBP.
Evidence-based quality management is based on two types of research: clinical research
and health services research. Clinical research evaluates the impact of interventions on
patient outcomes. Outcome measures may include clinical outcomes, functional outcomes,
and patient satisfaction. This type of research assists healthcare quality professionals in
determining clinical evidence-based best practices. Health services research evaluates
the health system at the micro and macro levels. Results from this type of research guide
healthcare qualiry professionals in improvingwork processes and systems of care.
To facilitate research-based practice-that is, to promote research use-healthcare
quality professionals must collaborate with organizational leaders to promote a culture of
excellence. Healthcare providers must be motivated to provide the best possible care and
to use the best system processes based on the evidence in the research literature or on
data obtained in their own organizations. A key strategJ is to keep all discussions based on
improving the patient's experience and outcomes and keep personaliry conflicts out of the
conversation, based on previously established ground rules. Research use is a key aspect of
the CQI process and critical to obtaining healthcare qualiry as defined by the IOM.
The rating of evidence for EBP is often based on the U.S. Preventive Services Task
Force (USPSTF') levels of evidence and grading system. Evidence for practice can be clas-
sified according to certain levels or strength of the evidence. The USPSTF has also defined
levels of certainty about net benefit. The USPSTF levels of evidence (Table 8; Sawaya,
Guirguis-Blake, LeFevre, et al.,2OO7) are often used to rate the evidence so that practitio-
ners can make wise decisions about care and treatment options with some degree of cer-
tainty about outcomes. Strong evidence is transformed into practice and then measured in
standardized formats. For example, there is strong evidence that timely administration of
aspirin in AMI decreases mortality. This practice is then implemented widely, as in the Core
Measure for AMI. Organizations operationalize this practice by using clinical pathways,
standard order sets, plans of care, and ongoing measurement processes.
Common sources for EBP guidelines and national measures are
. AHRQ (e.g., National Clinical Guideline),
. Cochrane (e.g., clinical evidence comparisons),
. Specialtyprofessional associations and societies (e.g.,American CardiologyAssociation),
. Leapfrog Group (e.g., hospital-based measures), and
 Q SoluEions
40

Table 8. Levels of About Net Benefit

Level of Description
Certainty
Htglr The available evidence usually includes consistent results from well-designed, well-corducted
studies in representative primary care populations. These studies assess the effects of the
preventive service on health ort.orn"r. This conclusion is therefore unlikely to be strongly affected
by the results of future studies.
Moderate The available evidence is sufficient to determine the effects of the preventive service on heaith
outcomes, but confidence in the estimate is constrained by factors such as
. the number, size, or quality of individual studies;
' inconsistency of flndings across individual studies;
. limited generalizability of findings to routine primary care practice; and
' lack of coherence in the chain of evidence.
could
As more information becomes available, the magnitude or direction of the observed effect
change, and this change may be large enough to change the conclusion.

Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient
because of
. the limited number or size of studies,
' important flaws in study design or methods,
' inconsistency of findings across individual studies,
' gaps in the chain of evidence,
. findings not generalizable to routine primary care practice, and
. lack of information on important health outcomes'
More information may allow estimation of effects on health outcomes.
preventive service is correct-" Ihe net benefit ls
N"". Il" uspSIF d"r ainty as "/rkelihoo d that the USPSIF assessm ent of the net benefit of a
the preventive service as implemented in a general, primary care population. From "lJpdate on the Methods of the u's'
defined as benefit minusharm o,f
i",*,'err,^ating Certainty and Masnitude of Netbenefit." by G. E sawaya. J. Guirguis-Blake, M. LeFevre, and u'S Preventative
;;:;;il;.;'l*t Reprinted with permission'
po. a7t-g7s. Copyright zool by American College of Physicians.
Servrtes rask Force 2ooZ Annals of lnternal Medicine, 147,

. NeF (e.g.,29 Never Events, Nurse Sensitive Measures, Ambulatory Sensitive Mea-
sures, Long-Term Care Measures, Hospital Measures)'
The USpSTF (200g) updated its definitions of the grades it assigns to recommenda-
(Table 9). These
tions and now includes suggestions for practice associated with each grade
definitions apply to USPSTF recommendations voted on after May 2OO7'
2. QPI Research Continuum
1O. Both are based
epl activities and research exist on a continuum of rigor, as seen in Table
on the scientific method and are used to better understand phenomena. The scientific ap-
proach is the most sophisticated method of acquiring knowledge. This approach involves in-
ductive and deductive reasoning to define a process that self-evaluates in an attempt to reach
conclusions superior to those arrived at through reliance on tradition, authoriry, and
experi-
ence. Integrating the right pieces of data and information into a research-based
framework for
quality.
the study of p.opt" *r* contribution of the earliest pioneers in the field of healthcare
1.he underlying assumptions of design, measurement, and interpretation are the same.
Healthcare qualiry professirgnals should use the level of research rigor that best ans\Mers the
specific performance improvement question. There needs to be a balance between rigor and
practicality (Byers 8c geaudin ,2oo2).Research studies and systematic reviews can be evaluated
for usefulness to a practice setting using critical appraisal tools. These tools guide healthcare
quatity professionis through the research critique process, allowing effective evaluation and
synthesi of research findings for use in QPI activities (Byers & Beaudin, 2001).
Quality and Performance lmprovement 41

Table 9. USPSTF Updated D"finitiont

Grade Definition Suggestions for Practice
A The USPSTF recommends the service. There is high Offer or provide this service.
certainty that the net benefit is substantial.
B The USPSTF recommends the service. There is high Offer or provide this service.
certainty that the net benefit is moderate or there is
moderate certainty that the net beneflt is moderate to
substantial.
C Note: The following statement is undergoing revision Offer or provide this service only if
Clinicians may provide this service to selected patients other considerations support offering
depending on individual circumstances. However, for
or providing the service in an individual
most individuals without signs or symptoms, there patient. is
likely to be only a small benefit from this service.
D The USPSTF recommends against the service. There Discourage the use of this service.
is moderate or high certainty that the service has no net
benefit or that the harms outweigh the benefits.
I Statement The USPSTF concludes that the current evidence is Read the clinical considerations section of
insufficient to assess the balance of beneflts and harms USPSTF Recommendation Statement.
of the service. Evidence is lacking, of poor quality, or lf the service is offered, patients should
conflicting, and the balance of benefits and harms understand the uncertainty about the
cannot be determined. balance of benefits and harms.
From "What the Grades Mean and Suggestions for Practice," by l-).5. Preventatlve Servrtes Task Force, May 2OO8. Copyright ZOOa by USPSIE
Available at www.uspreventiveservicestaskforce.orgfuspstffEades.htm. Reprinted with permission.

Table 1o. Research Process Versus Quality lmprovement Process

Scientific Process or Research Process Quality lmprovement Process

ldentify the information needs or ask the question to be ldentify the process improvement, survey the literature,
investigated. and flowchart the process.

Define the variables or the elements for which data are Define the customers and problem.
needed.

Formulate a plan of study orhypotheses. Formulate a plan'

Choose or design the research design and collection Choose one or a combination of basic or quality
tools or instruments. management and planning tools'

Collect the data. Collect the data.

Analyze the data. Analyze the data. Look for root causes.

Dlsplay the data. Display the data.

Report the data and findings. Report the data and findings.

Draw conclusions. Draw conclusions.

Act on recommendations deduced from the Act on recommendations deduced from the
conclusions. conclusions.

Continue to monitor the process. Continue to monitor the process.

Evaluate and communicate conclusions. Evaluate and communicate conclusions.

Hold the improvement.

42 Q SoluEions

3. Development of Clinical and Critical Pathways or Guidelines

Clinical guidelines are consensus statements developed to assist in clinical management de-
cisions, and clinical pathways are tools to manage quality outcomes and cost of care based on
clinical guidelines and current evidence. Clinical path\Mays are document-based tools that pro-
vide a link between the best available evidence and clinical practice. Clinical pathways, also
known as care pathways, critical pathways, integrated care pathways, or care maps, are one
tool used to manage the qualiry in healthcare concerning the standardization of care process-
es. A variety of terms have been used for this tool, and for simplicity the term clinical pathway
will be used in this module. Clinical pathways support EBP and clinical guidelines in a time-
oriented plan. The use of pathways or gpidelines reduces variation of clinical practice to op-
timize patient outcomes. The concept was introduced in 1985 by Karen Zander and Kathleen
Bower at the New England Medical Center in Boston. They were early nursing pioneers in
applyrng process management thinking and techniques to improve patient care (Zarrder &
Bower, 1987). Clinical pathways operationalize evidence into daily practice for patient care.
Clinical pathways are intended to create an integrated comprehensive approach or plan to the
patient's care rather than individual professions functioning independently. Interdisciplinary
communication, collaboration, and teamwork are enhanced by working from one pathway,
and continuity and care coordination are achieved for the patient.
The pathway shapes expectations or outcomes of care as the patient progresses, based on
what is the best practice for most patients most of the time. The pathway is written in a manner
to ensure that actions or interventions are completed at designated points with the expected
outcome. They are designed to support clinical management, clinical and nonclinical resource
management, audit management, and also financial management. Often, the improved clinical
outcomes are intended to support cost-effective use of resources such as length of stay, diag-
nostic tests, and pharmaceutical management. Because there will be differences in patients'
responses for the same condition or treatment, individual variances must be captured,
documented, and addressed. This continuous monitoring and data evaluation component is
essential to pathway improvement through continual revision of pathways. It is expected that
over time variation will decrease, costs will decrease, and the value of care will improve.
Although standardization is important to the pathways, they are not intended to be
overly prescriptive and should still allow personalized care. However, one critique of path-
ways is that not all variation in patient care is negative, and standardized care or "cookbook
medicine" would be a detriment to patient care and clinician autonomy. Individual patient
factors may contribute to variation that cannot or should not be controlled by the system.
Pathways tend to address processes in the ideal or uncomplicated patient and may not ad-
dress problems in the majoriry of patients. It is important to identify which patients are
appropriate for the pathway. In general, pathways are more applicable to patients with
uncomplicated illnesses undergoing procedures or surgery. Medical patients may be more
difficult to fit into a standard pathway.
The standardized approach is designed to empower patients such that each patient
knows the plan and his or her expected outcome at each phase of recovery (e.g., on postop-
erative day two, the hip replacement patient is expected to ambulate a defined number of
steps or feet and void without a urinary catheter). Standardization also helps reduce clinical
risk by ensuring that for specific conditions there are no lapses in care to be provided, and if
outcomes are not met there is an immediate assessment of the reason. When differences or
unwanted variances do occur, they should be noted and accommodations made in the plan of
care to ensure safety and effectiveness. Some common areas addressed by clinical pathways
include orthopedic surgery such as hips, knees, and shoulders. It should be noted that surgical
-
Quality and Performance lmprovement 43

care is more often conducive-to clinical pathways than medical conditions, where more differ-
ences in the patient's condition occur.
Clinical pathways facilitate the development of standardized physician order sets, inter-
ventions for the patient, and documentation of the patient's condition, and they are often
used in the following situations:
. prevalent pathology in the care setting (e.g., pain),
. pathology with a significant risk for patients (e.g., venous thromboembolism),
. pathology with a high cost for the hospital (e.g., total hip joint replacement),
. predictable clinical course (e.g., total knee replacement),
. patholory that is well defined and permits homogeneous care (e.g., laminectomy, trans-
urethral prostate resection),
. existence of recommendations of good practices or experts opinions (e.g.,diabetes),
. possibility of obtaining professional agreement (e.g., coronary angioplasry),
. multidisciplinary implementation (e.g., joint replacement), and
. relatively mature guidelines (e.g., stroke; Every, Hochman, Becker, Kopecky, & Cannon,
2OoO).
Nthough based on current evidence or clinical guidelines, the clinical pathway details
processes of care for the specific condition and, in noting any variances, highlights inefficien-
cies. TWenty-seven studies involving 11,398 participants were included in a meta-analysis of
clinical pathway effectiveness (Rotter, Kinsman, James et al., 2O1O). Twenty srudies compared
stand-alone clinical pathways to usual care. These studies indicated a reduction in in-hospital
complications and improved documentation. There was no evidence of differences in read-
mission to hospital or in-hospital mortality. Length of stay was the most commonly employed
outcome measure with most stLldies reporting significant reductions. A decrease in hospital
costs or charges was also observed. Seven studies compared clinical pathways as part of a mul-
tifaceted intervention with usual care. No evidence of differences were found between inter-
vention and control groups. There are both strengths and limitations of the pathway process
that an organization must consider in its development and use of the tool.
The development of a clinical pathway includes the following steps:
1. Select the topic. The topic should concentrate on high-volume, high-cost diagnoses
and procedures; higher mortality; longer length of stay; or greater number of outcome
variations. Surgical procedures are more suitable for pathways because of the predictable
course of events that occur during the hospitalization.
2. Select a multidisciplinary team, including representatives from all groups that would be
affected by the pathway. Without physician support of the pathway, it is unlikely to be
successful and achieve any of the stated goals.
3. Evaluate and map the current process of care for the condition or procedure to identifi'
current variation and create an idealized process.
4. Evaluate the current evidence in the literature. In the absence of best practices, compari-
son with other organizations, or benchmarking, is the best method to use.
5. Determine the clinical pathway form. This may be a hardcopy checklist placed in the
patient's medical record or at bedside or an electronic tool capable of tracking variances'
6. Educate all users on how to use the tool and implement it. It is critical to define roles
within the pathway for it to be successful.
pathway-
7. Document and analyzevariances that do not meet the expectation of the Jden-
tification of factors that contribute to variance and interventions to improve those factors
are the key features of process improvement. Often, a case manager or other
utilization
44 Q SoluEions

management staffmember collects data on use of the pathway and variances. These data
must then be analyzed and processes improved to achieve cost savings and QPI.
4. External Quality Awards
Viewing organizations as complex systems is consistent with the principles of quality pioneers
such as Deming (2OOO) and Juran (1989) because QPI practices influence all processes, func-
tions, and departments in an organization. Making changes in one process or department will
entail changes in other processes, functions, and departments. Thus, effectiveness depends on
alignment of the parts of the system.
Healthcare organizations are among the most complex entities, with ever-changing tech-
nolory, new environmental pressures, and complicated relationships between professionals,
disciplines, departments, and organizations. Therefore, research suggests that healthcare
leaders must consider the science of complex adaptive systems to effectively manage and
improve their organizations. Complex implies diversiry a wide variety of elements. Adaptive
suggests the capacity to change, the abiliry to learn from experience. A system is a set of con-
nected or interdependent things (Begun, Zimmerman, & Dooley, 2OO3).
One framework used to understand QPI in complex systems is the Baldrige National
Health Care Criteria for Performance Excellence Framework, depicted in Figure 22. The
Baldrige Award \Mas created in 1982 named for former U.S. Secretary of Commerce Malcolm
Baldrige in tribute to his managerial ability. The award is given to organizations demonstrat-
ing a commitment to quality excellence. This model displays the principles of QPI and shows
the relationships bemreen the structural, process, and outcome factors. Other common quality
awards or designations are shown in Table 11.
There are other external awards that are not necessarily called quality awards but ac-
knowledge high-performing organizations that demonstrate evidence of that performance
according to defined criteria. Usually through a rigorous evaluation process, the organization
is selected for the award, prize,or designation.

Figure 22. Baldrige National Health Care Criteria for Performance Excellence
Framework zott-zotz

7 5
Strategic Workforce
Planning rocus

lrl
I Leadership I

3 6
i Customer Operations
\
\ Focus Focus

4
, and Knowledge Management

From "Baldrige Criteria for Performance Excellence Framework A Systems Pespective," in 2O11-2O12 Criteria for Performance Excellence (p. U), ZOtt,
Gaithersburg, MD: Baldrige Performance Excellence Program at the Natlona/ /nstitute of Standards and Technology. Available at www.nist.gov/
baldrige/publicationdarchive/upload/zoo8-Business-Nonprofit-Criteria.pdf. Adapted with permission.
Quality and Performance lmprovement 45

Table 11. Common Quatity Awards or Designations

Owner

..

Baldrige Performance National lnstitute of National organizations

Excellence Program Standards and Technology (dlfferent sectors eligible,
e.g., healthcare, education,
business, government)

Robert W. Carey Department olr Veterans Veterans Affairs Based on Baldrige criteria
Performance Affairs., :. ' ,, oqganizatlonr,
.....
,
,, ,,.;;;,;,;,.,
Excellence Award

State quality awards States (publ ic-private lndividual states Most similar to Baldrige
partnerships) criteria or criteria set by states

Magnet Recognition Healthcare organizations Nursing services and

Program , : ,' and systems :. qmpirical outcomes for
patients and nursing
Beacon Award for American Association of Critical care hospital units Hospital nursing units
Excellence Critical-Care Nurses (high acuity and critically ill
patients)

Shingo Prize Utah State University Customer focus and

for Operational Any part of world business results
Excellence

John M. Eisenberg National Qualiry Forum Organizations whose

Patient Safety and and the Joint Commission accomplishments are clearly
Quality Awards linked to the principles
Dr. Eisenberg promoted
throughout lris career
Healthcare Quality NationalAssociationfor lndividualprofessional
AI
r\warOs Healthcare Quality recognition, state
recognition

Steps in evaluating readiness to apply for external qualiry awards include the following:
1. Demonstrate ownership and commitment to the cultural transformation for performance
excellence.
2. Make the pursuit of quality an organizational commitment for the sake of improve-
ment, not just to win an award.
3. Create the organizationcultural transformation by upholdingthe standards in daily practice.
4. Identify the specific qualify reward or recognition program and requirements.
5. Review the standards and criteria.
6. Determine eligibility.
7. Develop a team approach to self-assessment (facilitator or coordinator and subject
matter experts).
8. Perform a self-assessment or gap analysis (Table 12) of current performance compared
with the standards or criteria.
46 Q SoluEions

Strength or Evidence
1

2.

Opportunity for lmprovement

1.

2.

Strength or Evidence

2.

Opportunity for mprovement

I

2.

From Healthcare Criteria for Performance Excellence: Optional self-analysis workheet NAHQ thanks the Baldrige Performance Excellence Program
at the Nationa/ /nstitute of Sranda rds and kchnology for use of text/graphics from the Criteria for Performance Excellence (Gaithersburg, MD: 2ol1).
Avai Ia b I e at www.n i st.g ovf bal d rige / public a ti ons/ h c-cri te r ia.cfm

9. Identify strengths or evidence of compliance for each criterion.

1O. Identify opportunities for improvement based on the criteria.
11. Prioritize findings from the self-assessment or gap analysis.
12. PIan a course of action to meet the standards.
13. Develop an action plan based on the priority for each criterion.
14. Perform ongoing feedback and update evidence of compliance.
15. Determine who will coordinate the application.
16. Complete an application.
17. Submit the application.
18. PIan for a site visit and documentation of evidence.
19. Sustain the process.
20. Integrate into daily operations.
21. Celebrate successes.
B. QPI Teams
An important structural element for QPI is creating a team-based organization. Because pa-
tient care involves multiple disciplines, the linchpin for improvement is an employee base
that has regular communication and contact that allows them to coordinate and problem
solve to continuously improve quality of care. The organization must develop an infrastruc-
ture within which the cycle of improvement can operate. One feature of this infrastructure
is teams.
Quality and Performance lmprovement 47

What is a team? A team is la group of people who are interdependent with respect to in-
formation, resources, and skills and who seek to combine their efforts to achieve a common
goal" (Thompson, 2000, p. 2).
1. Types of QPI Gams
There are many types of teams. Figure 23 provides a mechanism for classifuing teams along
five major dimensions: purpose or mission, time, degree of autonomy, authority structure,
and physical presence (Greenberg & Baron, 2OO3).In QPI, two teams are of great importance:
steering committees (also called quality councils) and QPI teams. However, there are many
other types of formal and informal teams.
Within QPI, there may be temporary project teams with a special focus on im-
provement, problem solving or product development and often have both core and
resource members. Core members participate throughout the project and often have
complementary skills needed for the desired work outpuL Resource members may be
critical only for specific phases of the project and may move in and out of the team.
Other ongoing or functional work teams are usually pernanent or may be long-standing.
Natural work teams involve the people in a glven work setting who share responsibil-
ity for a process, workflow or type of work. A self-directed work team is a rype of natural
work team that shares many management responsibilities, such as scheduling work,
managing budgets, evaluating performance, and hiring new team members. A process
management team focuses on sharing responsibility for monitoring and controlling a
work process, such as new product development. Members may rotate on and off the

Figure 23. Classification of Teams

Work Teams lmprovement Teams

(concerned with products (concerned with improving
and services) the effectiveness of process)

Temporary Teams Permanent Teams

(exist for finite period) (remain intact as long as the
organization is in existence)

Work Groups Self-Managed Work Teams

(leaders make decisions (team members are free to
for group members) make their own key
decisions)

Cross-functional Teams
Intact Teams (teams consisting of members
(work within own
from several different
specialty area)
specialties)

Physical Teams Virhral Teams

(members are physically (members meet via elechonic
present) means)

From Behavior in Organizations (ath ed), by J. Greenberg & R. A. Baron, 2oO3, Upper Saddle Ri,nr, NJ: Prentice Hall. Copyright 2oo3 by Prentice
Hall. Reprinted with permission.
48 Q SoluEions

team based on their contributions (expertise). Virtual teams typically use technology-
supported communications rather than face-to-face interactions to accomplish their tasks.
They may cross boundaries, such as time zones, geography, and organizational units. Virtual
teams can be either project teams or ongoing teams.
Steering Committees. Steering committees (often known as a quality councils) are
permanent QPI teams consisting of cross-functional members. These committees are self-
managed teams that provide direction and focus by identifying and prioritizing improve-
ment opportunities in the organization. The role of the steering committee or qualiry
council is to sustain, facilitate, and expand the QPI initiative based on the strategic plan. It
should comprise top leaders in the organization, including medical staff. The main respon-
sibilities of the qualiry council include
. lending legitimacy to the QPI efforts;
. maintaining organization focus on the identified goals and priorities;
. fostering teamwork for improvement;
.
providing necessary resources (e.g., human, financial); and
.
formulating QPI policies regarding quality and safety priorities, participation, annual
self-assessments, and reward and recognition systems.
QPI Teams. QPI teams can be natural work teams, which are teams with members who
work together each day in order to complete the task. These teams can be cross-functional,
as with an operating room team, or intact, such as a team of nurses in a particular unit. Au-
tonomy varies, but there rypically is a leader. These teams can be temporary (e.g., brought
together to solve a single problem) or permanent (e.g., continuous improvement teams).
2. When Should Teams Be Used?
Managers need to examine three aspects of the required task before deciding whether to use a
team: task complexity, task interdependence, and task objectives (Luecke, 2OO4).
Tasks are considered to be complex when they involve large amounts of information,
they are performed under conditions of high uncertainty, they contain many subtasks that
require people with specialized skills and knowledge, and there are no standardized proce-
dures for completing the tasks. Teams are important because they bring larger numbers of
specialized individuals (i.e., subject matter experts) to carry the burden and offer greater
diverse inputs that are more likely to result in more alternatives generated and more creative
solutions. Creativiry is particularly important when there are no standardized procedures and
the environment is uncertain.
Task interdependence means that the work of one person is highly dependent on the
work of others. Patient care typically involves a multitude of disciplines that must coordinate
their work, and this requires intense communication. Teams therefore are appropriate, be-
cause this type of structure can foster communication between the various disciplines.
Finally, teams are appropriate to use when the task objectives are clear and time-bound.
One approach for making task objectives clear is to develop a tearn charter. The charter
should contain the following information (Schwarz, Landis, & Rowe, L999):
. description of the process, why it needs improvement, and who is affected;
. development of criteria to demonstrate that the process has improved;
. timeline for meetings;
. resources available;
. structure of leadership (e.g., self-managed, leader-directed); and
. expected communication of progress, and results.
Quality and Performance lmprovement 49

3. How Do Teams Develop or Grow?

Teams develop, mature, and change over time. Tuckman (1965) described four stages of devel-
opment in one popular model with somewhat predictable stages. This classic framework con-
tinues to be used to this day.
Stage 1. Forming. During the first stage, the members try to get to know each other, agree on
the goal or vision, and delegate tasks. They cautiously explore boundaries in an attempt to de-
termine acceptable group behavior. Discussions focus on how to accomplish the tasks and the
information and resources needed, and the team accomplishes little at this stage. This is a pe-
riod of testing to find out what kind of behavior is appropriate. Members tend to defer to the
leader or dominant member for guidance. In this stage, team leaders need to be directive and
provide role clarification. Members get to know each other, agree on goals, and delegate tasks;
members may feel anxiety, excitement, and uncertainry and they may test boundaries of be-
havior. The team leader needs to be directive, with high-task relationships, and provide role
clarification. The team depends on the leader during this learning stage. This stage is short if
the tasks are clearly defined and easily achievable.
Stage 2. Storming. This second stage is where conflict typically arises. Members try to ex-
press their individualify and resist group pressures and influence. There often are emotion-
al responses to group demands, especially if the group is under pressure to achieve results.
To prevent the group from becoming stuck at this stage, leaders need to manage the conflict,
not by suppressing it but by using it to energize the team. Conflict and tension often arise, and
members assert their individual roles and compete for control. The leader moves to a coach-
ing style of leadership. At this stage, reality sets in. There is the realization that the task may
be difficult, they notice their lack of progress, and there is resistance to the task. Resources
are applied to the task rather than education about the problem. People are willing to suggest
tasks, and the leader then delegates the tasks. People do not take responsibility for problems,
yet the team is building cohesion. This is probably the most difficult stage. Arguing defensive-
ness, disuniry and tension are often evident.
Stage 3. Norming. In this stage, members develop close ties and a strong identiry with the team.
There is a shift from "I" to "'we" and a willingness to accept the views of others. Team members
develop feelings of mutual respect, harmony, and trust. Group standards and members' roles
emerge. Leaders need to challenge the team members to continue to grow and guard against
too much conformity to group norms. The team develops close ties and a strong identiry; mem-
bers develop harmonyby avoidingconflict. Tentative constructive criticism is allowed.
A supporting leadership sryle evolves. Concern moves from silos to the interdisciplin-
ary group. Members volunteer instead of just providing suggestions. There is an emerglng
leadership or ownership of functional roles by the members. There is acceptance of team
rules, norms, and roles and finally optimism that things will work out. More harmony, cohe-
sion, and discussion of team dynamics occur.
Stage 4. Performing. In the fourth stage, the team works harmoniously toward a common
goal and is very productive. The team develops a functional but flexible structure, and roles
are interrelated. Interpersonal conflicts are resolved, and the group is highly task oriented.
In this stage, the leader needs to develop mechanisms for sharing leadership responsibilities.
The team works harmoniously and gains insight into the team's process. Improvement of the
team's process and team identification begins to predominate. The team is task oriented and
accomplishes its work. GoaI orientation is now optimized, and task competency is high. High
morale, support, and appreciation come from team members. Roles diminish, and partici-
pation by all is encouraged. The team may begin to take on additional responsibilities and is
functioning at an optimal level.
50 Q SoluEions

Not all teams progress through these four stages, and if they do, they probably move
back and forth through the stages as new issues are identified. Nevertheless, the stages point
to important developmental issues that have implications for team leaders, facilitators, and
coaches. Lack of effectiveness often results from leadership and facilitation problems and a
lack of clear goals and expectations. Teamwork components of cohesiveness, communication,
role clariry and goal clarity from The Team Handbook (Scholtes, Joiner, & Streibel, 2oo3) are
integrated into these stages in Table 13.
4. Characteristics of Effective Teams
It is widely known that teams often fail to produce the results for which they were
brought together. What makes a team successful? Abundant research and practice have
demonstrated that the following are important predictors of team success (Campion,
Medsker, & Higgs, L993;George, L995; Hackman,L987; Katzenbach & Smith,1994; Saunier
& Hawk, 1994; Wageman,1997):
. competenr members with technical, problem-solving, interpersonal, and organiza-
tional skills;
. commitment to clear, common goals;
. standards of excellence;
. contributions from every member;
. collaborative environment (culture to support teamwork);
. leadership support;
. nonhierarchical structure; and
. external support and recognition.
Characteristics of effective and ineffective teams are further described in Thble f4.
Four key traits can predict a team's success (Scholtes et al., 2003):
. cohesiveness,
. communication,
. clear roles, and
. clear goals.
Cohesiveness is the social glue that binds the team members together as a unit. Cohe-
siveness can be increased by the establishment of ground rules, or norms, addressing
how
meetings will be run, how team members will interact, and what kind of behavior is accept-
able. Each member is expected to respect these rules, which usually prevents misunder-
standings and disagr."-.ntr. Balanced participation is encouraged to strengthen the team's
cohesion. Because every team member has a stake in the achievements, everyone should
participate in discussions and decisions, share commitment to the project's success, and con-
iribute his or her talents. The use of brainstorming or a nominal group technique to obtain
input from all team members during discussions is one method to encourage members to
bond. When a team is cohesive, members are attracted to the team; find membership in
the
team to be a personally meaningful experience; enjoy the company of the other team mem-
bers; support, nurture, and care for each other; feel free to share ideas and suggest ways
to
improve i."- function; feel they are using their unique skills for the benefit of the team;
have a strong "we" feeling; and routinely develop creative solutions to problems.
Communication is the next key component to successful teams. Communication
involves a full range of topics, including decision making and problem solving. Effective
communication becomes easier once the team has developed a certain level of cohesive-
ness. Communication is key because further team development and effective functioning
Quality and Performance lmprovement 51

cannot occur without team communication. When a team is communicating effectively,

team members always
. freely saywhat they feel and think;
. are always direct, truthful, respectful, and positive;
. openly discuss all decisions before they are made;
. handle conflict in a calm, caring, and healing manner;

Table 13. Team Roles

Sponsor Sponsors are the formal leaders and prime movers of the project. They ahgn resources and
monitor progress. Sponsors hold others accountable to get on with change. The sponsor inspires
the team members to say, "l believe in this project." Some project tasks require sponsors at
multiple levels to obtain adequate resources and buy-in from the entire project team.
Champion Champions are the respected opinion leaders who provide credibility to the project and are
integral to the social structure. The champions are respected clinicians or staff with influence
through clinical reputation or leadership qualities. Their experience provides credibility for the
project team and task. They support the change and work for its implementation by speaking
favorably about it and sharing their first-hand knowledge or experience.
Leader Leaders guide the team to achieve successful outcomes and attain the established goals. They
are responsible for guiding the team through the process to achieve the aim or goals. They
provide direction and support. The team leader knows meeting procedures and has strong
communication and interpersonal skills.

Timekeeper Monitors meeting agendas, ensures the team is aware of the time allotted for each agenda item,
and reminds the team when they go over the allotted time-
Process The process owner is the leader among frontline staff directly involved in the process. This ls the
owner team member who is responsible and accountable for sustaining improvements during and after
implementation. ldeally, the process owner should be someone with authority over frontline staff
directly involved in the process evaluation.
Facilitator Although facilitators (change agents or coaches) have no formal authority over other team
members, they are instrumental in implementing the change through planning, helping, and
facilitating. The facilitator is not vested in the project but is skilled in problem solving and adult
learning and has good communication and interpersonal skills. As change agents, they are
the technical experts on the team; they influence progress by gathering measurable data and
information. They listen to the concerns of other team members and help remove barriers. They
support the sponsors by advancing the team's work to goal achievement.
They promote effective group dynamics and are concerned with how decisions are made.
They may also serve as coaches or consultants. They keep the team on track. They provide
expertise on using tools. Coaches focus on helping the team to learn rather than teaching them.
The facilitator needs to have a clear perception of the facts and information and the ability
to determine what is relevant. That ability includes an understanding of systems, dynamics,
relationships between system components, and psychology. The facilitator, change agent, or
coach needs to understand when and how emotions or desires distort onei perception.
Member Actual representative on the team. Although project team comPosition varies, in most cases
the project team includes the frontline staff (e.g., nurses, physicians, clerks, ancillary services
staff) and area supervisors directly affected by the project task. To identify these personnel,
consider all relevant stakeholders to the process. The idealteam size is 8-12 people. Unless
necessary, team size should not exceed 15 people. They are able to collect data and information
related to the process of focus. For the stakeholders not represented, develop a communication
mechanism (team minutes, session report) and designate one or more people to disseminate
this information regularty. Chosen team members must be able to commit to attend team
meetings and meet their responsibilities.
Scribe This role may be assigned to one person or rotated between members. The role includes
documenting minutes of meetings and other recordkeeping activities.
52 Q SoluEions

Table 14. Team Characteristics

Effective Teams lneffective Teams

Mutual agreement and identification with respect to Does not distinguish between facts, opinions, and feelings
the team goal Does not separate idea generation from idea evaluation
Open communication between members Prematurely closes discussion before all alternatives are
Mutual trust and support identified
Management of human differences Dominated by aggressive members
Selective use of the team Fails to assign specific responsibilities

Appropriate member skills Does not review minutes, tasks, or due dates

Leadership Works on problems that are outside the scope of the team

Values and goals of the members interpreted as Exhiblts uncertainty about the team! direction
needs and values of theteam Launches many improvement projects without clear
Team believes it can accomplish the impossible objectives

Understands the value of constructive team Fails to apply discussion skills

coheslveness and how to use it Hides a secret agenda
Mutual influence between members and the leader Relies on one person to manage discussion without sharing
Exhibits clear goals, purposes, discussions, and responsibility
decisions Discusses the project outside the meeting rather than
Agrees on the goal bringing issues to the team

Has formally defined roles Repeats points of discussion

Revises plan as needed Concedes to opinions rather than fact-based data

Uses tool to map the process and project steps Uses majority rule rather than consensus in disagreements

Effectively uses talents of members Uses decision by default, with silence assumed as consent

Balances participation of all members Avoids certain topics

Discusses issues openly Does not acknowledge ground rules

Clarifies ideas or issues Has recurring differences on acceptable behavior

Uses consensus-based decision making Has conflicting expectations

Uses data for problem solving Does not attend to clues or shifts in the team mood

Applies resources and training throughout the Makes remarks that discount someonei behavior or
project contribution

. openly explore options to solve problems when they arise;

. do not gossip about each other; and
. do nothave ahidden agenda.
Good, clear communication depends on how well information is passed between team
members. Ideally, team members should speak clearly, directly, and succinctly. They should
ask questions in an inviting way. Members should listen actively and avoid interrupting when
otheis are speaking. Teams should encourage all members to use the skills and practices that
make discussions and meetings more effective. Team members should initiate discussions,
seek information and opinions, suggest procedures, elaborate on ideas, complete assign-
ments on time, and summarize. Team leaders and facilitators act as gatekeepers during com-
munication by managlng member participation, keeping discussion focused, and resolving
differences creatively. Considering the stage of team development, such as storming, leaders
and facilitators may need to ease tension and work through difficulties. Communication also
includes well-defined decision-making procedures. A team should always be aware of the
Quality and Performance lmprovement 53

different ways it reaches decisions. The team should discuss how decisions will be made, ex-
plore important issues by polling, test for agreement, and use data as the basis for decisions.
Occasionally, the team may want to designate a member to observe team interactions and
give feedback on how decisions are made so the group can talk about any changes it needs
to make. Team members should also be sensitive to nonverbal communication. This includes
seeing, hearing, and feelingthe team dynamics.
Role clariry is the next area to facilitate team success. The role of team member super-
sedes individual professional roles. Although professional roles brought to the team give the
team its potential strength, it is also important for team development that individuals feel
equally valued. In addition, team members should know who is doing what and what other
team members expect of them. When a team achieves role clariry members feel that ac-
complishments of the team are placed above those of individuals, understand the roles and
responsibilities of all other team members, and have a clear understanding of what other
team members expect of them. Teams should also have an identified facilitator. Facilitation
requires skills that are both art and science. A skilled facilitator guides group process in an un-
biased manner ensuring that the meeting agenda is carried out and decisions are responsibly
reached with independent contributions from all team members.
The final component of team development to become a fully functioning and high-
performing team is clearly defining team goals and the means used to reach these goals.
When a team achieves goal clariry team members agree on what the real work of the team
is, clearly understand the goals, agree on how to reach the goals, and agree on clear criteria
for evaluating the outcomes of the team. Teams operate most efficiently when they tap ev-
eryone's talents and when all members understand their duties and know who is responsible
for what issues and tasks. Goal clarity begins with a charter.
Successful teams are one of the most important aspects of effective organizational
functioning and QPI. Two special team types have patient safety as their main focus but
include essential elements of teams that increase their ability to address patient safety and
error reduction. The first is Team Strategies and Tools to Enhance Performance and Patient
Safety (TeamSTEPPS@; Figure 24), ateamwork system designed for healthcare professionals.
This is an evidence-based teamwork system designed to improve communication and team-
work skills. Team members learn four primary teamwork skills: leadership, communication,
situation monitoring, and mutual support. Three types of team outcomes are desired: perfor-
mance, knowledge, and attitudes.
The TeamSTEPPS model is based on lessons learned, change models, the literature of
quality and patient safery and culture change. Phase 1 assesses an organization's readiness
for undertaking the initiative. Phase 2 includes planning training and implementation; op-
tions in this phase include tools and strategies. Phase 3 sustains and spreads improvements
in teamwork performance, clinical processes, and outcomes (AHRQ, n.d).
The second special type of team is Crew Resource Management (CRM). A specific CRM
training program based on airline safety was developed for healthcare. Although the team is
focused on patient safety, the effectiveness of team functioning is a first critical component
(American Combatives, 2009). Additional elements include a focus on the patient safety mind-
set and high-reliability functioning. The team learns skills in decision making under stressful
situations through continued practice, simulation, and use of checklists to embed teamwork be-
haviors into daily work and provide numerous opportunities to practice the desired behaviors.
For those organizations employing Six Sigma or lean QPI methods, a Workout is a fast
track change acceleration process developed originally at General Electric. The Workout is
conducted by a group of team members in a short period of time (hours or days; Zrruelo,2010).
54 Q SoluEions

Fisure 24. The TeamSTEPPS'Model

From'TeanSTEPPS@: National lmplementation," by the Agency for Heakkare Research and Quality, U.S. Depanment of Health a Human Services,
zotz, Rockville, MD: AHRQ. Available at http://teamstepps.ahrq.gou/teamsteppslogo.htm.

C. Evaluating
Team Performance
Because teams are so important to organizational operations, how should teams be evaluated?
Three key actions determine the success of any team:
. developingshared goals and methods to accomplish outcomes,
. developing methods and skills to communicate and make decisions across systems and
organizations, and
. engaging leadership that balances getting input and making decisions, so work moves
ahead.
Team performance also requires formal evaluation. In general, evaluation of a team in-
cludes three criteria:
. Productivity or results: The extent to which the goals were met. Did the team accom-
plish what it set out to do and within the defined time frame?
. Satisfaction of team members: It is important that team members be able to work to-
gether in the future. To the extent that members are satisfied with the team, theywill be
more likely to work well together in the future.
. Individual growth: The extent to which individual members developed professionally by
serving as team members.
A more formalized manner of evaluating team performance includes the following pro-
cess criteria:
. Organizationalalignment:
Does the team have statements of mission, vision, values, structures, roles, and goals?
Does the team have a charter? Is the god important to the organization's strategic
priorities?
. Goal clariry: Are there clearly stated goals, and do actions exist to achieve the goals?
. Leadership: Is there clear leadership support of the team?
Quality and Performance lmprovement 55

a Roles: Have team roles beep defined?

a Norms: Does the team have defined ground rules and abide by them?
a Team participation: Do all members of the team participate and share tasks?
a TEam meetings: Are team meetings organized with agendas, time frames, action plans,
and decisions?
a Competency to perform tasks: Are members trained to work on tasks?
a Communication: Is communication open, honest, and constructive?
a Atmosphere: Is the atmosphere warm, accepting, and supportive for all team members?
a Decision making: Does the team achieve consensus on decisions and look at multiple al-
ternatives before reaching a decision?
Problem solving: Is the team able to validate problem identification before movingto a
solution by using sound data and tools?
a Conflicts: Does the team have a process for constructively managingconflict?
a Performance management: Does the team manage its performance, or must manage-
ment intervene?
Work tools and training: Has the team been trained on tools and data management to
function effectively?
Boundary management: Has the team developed relationships with other teams, stake-
holders, and customers?

D. Coordinating and Participating in QPI Pro;ects

Healthcare quality professionals play an important role in leading or facilitating QPI
projects.,Many different types of improvement projects may be chartered. They vary in
breadth, scope, and duration. There are also different names that may be assigned to proj-
ects, but they all can be categorized under the umbrella of QPI. For example, there may be
rapid process improvement teams, gfeen belt project teams, black belt project teams, lean
projects, Six Sigma projects, and redesign projects. All are similar in their basic approach.
The types of tools and level of statistical analysis may also vary by type of team. Depend-
ing on the complexity of the project, a simple action plan may be sufficient, or the use of a
Gantt or PERT chart for project management may be needed.
Abasic approach and actual steps in a QPI project include the following:
t. Alignment with priorities and strategic goals and objectives.
. This first step ensures the leaders support this project because it aligns with the strategic
goals and performance improvement priorities and are willing to devote resources to it.
. A team charter is usually written at this point and describes the scope, boundaries, ex-
pected results, and resources used by a process improvement team. The individual or
group who formed the team usually provides the charter. Sometimes the process owner
or the team members develop a charter. A charter is always needed for a team working
on a process that crosses departmental lines. A charter may not be necessary for a team
that is improving a process found solely within a work center or office space.
. Basic team functions are identified, including
members of the team,
roles within the team,
meeting schedule,
project timeline,
56 Q SoluEions

resources available and needed to complete the improvement project, and

expected communication of progress and results.
. A clear defined aim must be identified for the team to work toward a common goal.
. Analysis of baseline performance and problem identification is needed to determine the
level of improvement.
o A rrap of the process (current and ideal) should be developed.
2. Description of the process: why it needs improvement and who is affected.
3. Development of criteria to demonstrate that the process is improved.
4. Measurement of success; this includes the numerator and denominator for a percentage,
rate, or otherweighted measure.
5. Changes to be tested and implemented.
6. Tests of change supported by data collection, analysis, and reporting.
7. Control or methods to sustain the change.
8. Results or outcomes of the project.
9. Reporting of the project and results to leaders, the organization, or others.
1O. Evaluation tools for the team process.

E. Organizational Reviews and Audits

Performance monitoring is an important role of QPI staff. A number of areas have been iden-
tified in accreditation standards, regulatory requirements, and organizational demands. Gen-
erally, these areas have been identified as high risk to patient safety and quality of care. The
areas that are most common will be presented. General criteria to be considered for a review
or audit include the following:
. 'Was the intervention used?
. 'Was it performed properly according to specific criteria?
. Was it performed safely?
. Was there any adverse effect or outcome to the patient?
o ![/x5 staffcompetent to perform the intervention?
. Was it effective (this may include cost effectiveness)?
. Was there a better alternative to the intervention?
These general criteria will be applied to several areas to demonstrate what should be con-
sidered for monitoring or auditing the specific process.
Medication Use. Safe medication practices, including medication use evaluation, pharmacy
and therapeutics, adverse drug reactions, and adverse drug events, are reviewed in healthcare
organizations. The qpes of medications and the setting in which they are used will indicate
which medications are high risk, high alert, frequently used, and most vulnerable to underuse,
overuse, and misuse. Thousands of drugs are currently on the market. Many are hazardous to
use but have beneficial effects for patients. Organizations should identifi, the drugs they pro-
vide in a standard formulary and identifu methods to obtain nonformulary items. The use of
nonformulary medications should be monitored, usually by the pharmacy, to determine cost-
effective, safe medications for administration and ways to integrate new medications into use.
High-risk medications include antibiotics, opioids, insulin, anticoagulants, and chemo-
therapy. High-risk populations may include infants and children, frail older adults, immtino-
compromised patients, critically ill patients, and transplant recipients.
The purpose of medication use monitoring is to improve the efficiency and effective-
ness of medication use and the appropriate use of medication. Because of the frequent use
Quality and Performance lmprovement 57

of medications in healthcare, o-ngoing monitoring is needed. Priorities for monitoring are

based on the numbers of patients affected (volume), the degree of risk associated with the
drug's use (risk), the degree to which the medication is known to be problem prone, and
other criteria developed by the medical staff. The usual steps in measuring improvement
include
1. prescribingappropriate medication,
2. preparing and dispensing medications,
3. administeringmedications, and
4. monitoringthe effects of mediations on patients.
Trends and patterns of usage can be presented in several different ways, which may in-
clude a description of use in the four steps just listed. Trends can be described in terms of spe-
cific medication types, such as antibiotic usage, and compared with antibiograms for specific
organisms. Patterns a]so can be presented relative to overuse, underuse, and misuse. Thble 15
uses the basic monitoring criteria to illustrate medication monitoring of a specific case that
can be used to aggregate the data into trends.
Blood Use. The administration of blood and blood products is a high-risk aspect of care.
Staff must consider the risk and the therapeutic benefit, including the risk of bloodborne
pathogens, transfusion reactions, and transfusion errors. It is also a high-cost item. The key
elements to be monitored include ordering, distribution (availability and timeliness of ad-
ministration), handling and dispensing, administration, and monitoring of the effects on
patients. Individual cases are reviewed (Table 16), and then an evaluation of blood usage
practices for providers and the organization can be performed. An evaluation might include
blood that is administered when not indicated, not administered when indicated, or admin-
istered incorrectly. Specific standards from the College of American Pathologists and the
American Association of Blood Banks may be useful for evaluating transfusion services.
Restraints. Restraint use is another high-risk procedure that may be used in certain popula-
tions. It is no longer allowed in the long-term care setting but may be used in acute hospitals
for medical-surgical populations, for inpatient behavioral health populations, and in the emer-
gency department for highly unpredictable patients and situations. Some national and state
organizations are calling for the eradication of restraint use in behavioral health settings aI-
together because of high-profile adverse events related to their use. Recently developed core
measures in inpatient behavioral health include metrics for restraint and seclusion use.
The CMS has established specific rules related to restraint usage, and these have been
adopted by the Joint Commission, which has deemed status with CMS. The monitoring of
this process includes each episode of restraint application (Table U). Often a checklist is
used to ensure that all required components are met. If a checklist or template is used, each
episode can be monitored easily according to criteria. Ari aggregate summary allows the or-
ganization to determine any trends in usage. Such trends may reveal patterns associated with
. time of day or day of week in which restraint usage may be higher, such as nights or
weekends;
. units in which restraint usage may be higher, such as geropsychiatric units or units
with higher numbers of patients with tubes and other devices; and
o providers whose ordering practices reveal higher restraint use.
Operative and InvasiveProcedure Review. Operative, invasive, and noninvasive procedures
are important diagnostic and therapeutic interventions. They often pose risk to patients and
must be monitored systematically (Table f8). Aspects to be considered for monitoring in-
clude the following:
58 Q SoluEions

Table 15. Medication Monitoring

General Criteria Specific Criteria

Was the intervention used? ... .,,lll
What class or type of medication is being monitored (e.g., antibiotic, ,

,1, , ,,:.'.,,. opioid,insulin,anticoagutant)? .,.,, : : :,, ::

Was it performed properly according to Was the medication administered in accordance with policy, criteria,
specific criteria? or current evidence (e.g., was the proper antibiotic preoperatively
administered and within t hour)?
Was the medication administered safefy (eg., should the medication ,

be administered by an infusion device to control rate, ihou[d it be ,,i ,.

administered in a central versus peripheral site, was it diluted properly)?

Was there any adverse effect or outcome Were there any adverse effects to patients (e.g., medication reactions
to the patient? or complications, allergies, errors, interactions with other medications
or foods)?
.:
Was staff competent to perform the Was the staff who administered the medication competent in the '

intervention? procedure (e.g., does the route of administration require special

knowledge and skill, does the type of medication require a certain
setting,for.observation, is there a spedific competency)? , ,

Was it effective? Did the medication achieve the desired result or an untoward result?

Was there a better alternative to the Were there clearly documented indications for use of the medication?
intervention? lf the medication is high risk, high alert, or nonformulary was there
documentation on usage?

Table 16. Blood Usage Monitoring

General Criteria Specific Criteria

.Wit,L" interveniion used?

t
' '.t" Was blood or blood components administered?

Was it performed properly according to Was the order for the blood products clear and documented in the
specific criteria? medical record?
Was blood administration performed according to defined policy
including vital signs before, during, and after administration?
Were proper tubing, filters, and administration devices used?

Was it performed safely? Was the patient monitored during the administration?
Was the rate of administration in accordance with policy, orders, and
',,,1i:t,::'..r ,', .'.,',1 . :r.::. the patient's condition?
.
Was there any adverse effect or outcome Were there any adverse reactions to the administration (immediate or
to the patient? delayed)? lf there was a reaction, was the response in accordance with
policy?

,,Was staff competent to perform the Were the staff who administered the blood products competent in the
intervention? procedure (is there a specific competency)?

Was it effective? Was the most appropriate blood product administered for the patient's
condition?

Was there a better alternative to the Was there a review of lab results, vital signs, and other results before
,:.intgrvention? the order to determine rvhether the particular blood product was
indicated (e.g., iron, watchfut waiting)?
Was there a review of any special considerations before administration,
such as religious betiefs?
Quality and Performance lmprovement 59

Table 17. Restraint Use Monit6ring

General Criteria Specific Criteria

Was the intervention used? Were. restraints applied to the patient (what type of restraint and what
limb or body part was restrained)?
Was the restraint considered medical-surgical or behavioral health?

Was it performed properly according to Were restraints applied properly in accordance with policy, CMS
specific criteria? regulations, and Joint Commission standards?
Was there compliance with requirements for orders, timeliness, trial
releases, alternatives, initial face-to-face assessment, and ongoing
monitoring?

Was it performed safely? Were restraints applied safely so that the patient was not at risk for
or harm?
. l1jurX
Was there any adverse effect or outcome Were there any adverse effects (e.g., physical, emotional) to the
to the patient? patient related to the application of restraints?

Was staff competent to perform the Were the staff who applied the restraints competent in the procedure
intervention? , (is there a specific competency)?

Was it effective? Did the use of the restraints achieve the desired result?

Was there a better alternative to the Were other alternatives tried before restraints applied (and
intervention? documented)?
lWas seclusion used with restraints?

Table 18. Operative and lnvasive Procedure Monitoring

General Criteria Specific Criteria

Was the intervention .^))
u'.-. What was the surgical or invasive procedure performed?
Was it performed properly according to Were there documented indications for the procedure?
specific criteria? Was the patient properly informed of risks, benefits, and alternatives?

Was it performed safely? Was the procedure performed according to policy, guidelines, or other
criteria?

Was there any adverse effect or Was there any adverse effect on the patient before, during, or after the
outcome to the patient? procedure?
Was any action taken to Prevent, mitigat':, or respond to an adverse
event (e.g., preprocedure positioning to prevent injury, postprocedure
X ray if a retained object was suspected)?
Was staff competent to perform the Were staff performing the procedure competent?
intervention? Were providers privileged to perform the procedure?

Was it effective? What was the final result for the patient?
. ,Was there a better alternative to the Was the procedure elective, urgent, or emergent?
intervention? Were all possible options considered and discussed with the patient?
Were specialists consulted if needed?
Was the procedure performed in the right setting (e,9', inpatient or
outpatient, or in a specialry hospital, or a hospital that performs a
hiqh volume of procedures .rs. a hospital that infrequently performs a

pr-o.edrr", especially one of high risk and complexity)?

60 Q SoluEions

. selection of the appropriate procedures,

o patient preparation for procedures,
. performance of the procedure and patient monitoring,
. postprocedure care,
. preprocedure and postprocedure patient education,
. preprocedure andpostprocedure diagnostic discrepancies,
. moderate sedation monitoring, and
. complications or adverse events related to the procedure.
Procedures always carry the risk of complications even when performed properly. Risk
is greater with procedures performed when not indicated, not performed when indicated,
and performed poorly or incorrectly. Outcomes are influenced by clinical performance of
all preprocedure processes; clinical performance of the procedure; and patient monitoring
before, during, and after the procedure.
Other factors may also be monitored as indicators of possible quality-of-care problems
(Griffin & Resal 2OO9):
. return to surgery;
. change in procedure;
. admission to ICU postoperatively (unplanned);
. intubation, reintubation, or use of bilevel positive airway pressure in postanesthesia
care unit;
o )( ray intraoperatively or in postanesthesia care unit;
. intraoperative or postoperative death;
. mechanical ventilation more than24 hours after surgery;
. intraoperative administration of epinephrine, norepinephrine, naloxone, or flumazepil;
. postoperative increase in troponin levels greater than 1.5 ng/ml;
. injury repair or removal of organ during operative procedure (unplanned); and
. occurrence of any operative complication.
Several national databases allow comparisons of organizational data with risk-adjusted
surgical cases for observed-to-expected ratios of morbidiry and mortaliry. This allows the
organization to use an external comparison or benchmark to assess its rate of complications
as a trigger or threshold for action (e.g., National Surgical Qualiry Improvement Program;
Chevron Supplier Quality Improvement Process, Society of Thoracic Surgeons National
Database).
Cardiopulmonary Resuscitation (CPR) Monitoring. CPR monitoring and the outcomes are
important to include in any QPI program (Table r9). Cardiopulmonary resuscitation is de-
fined as the application of chest compressions, defibrillation, and artificial respirations or
rescue breathing. One consideration in CPR monitoring is whether the patient exhibited
any signs or symptoms that should have been identified for early intervention before a full
arrest occurred. In the event that CPR must be performed, there are specific guidelines on
chest compressions, airway maintenance and breathing defibrillation, and medications. Ad-
vanced care and ffeatment depend on the setting and patient's underlying condition. A na-
tional registry for data on CPR events collects detailed information on exact interventions,
times, and results (including electrocardiograms). The use of a registry allows comparison
of data on process and outcome measures.
Quality and Performance lmprovement 61

Table 19. Cardi Rdsuscitation (CPR) Monitori

General Criteria Specific Criteria

support or advanced cardiac life support guidelines?

Mortality and Morbidity Review. Review of mortaliry and morbidity is often based on
specific criteria. For mortality a revie\M of expected or unexpected mortality (observed
vs. expected) is performed by condition, within specific time frames (e.g., immediate-
ly in the operating room, in the hospital setting, or within 3O days after discharge), and
based on inclusion and exclusion criteria. For example, patients who are expected to die
based on a terminal condition with a Do Not Resuscitate order, who are in hospice, or
who have an end-stage condition are usually excluded from review. Other mortalities are
then reviewed as outcomes that can provide information about the quality of care provid-
ed. Similarly, complications are also reviewed, and the criteria for cases and conditions to
be reviewed are established by the medical staff. Individual cases are then identified and
reviewed, and aggregated reports are trended to identify opportunities for improvement.
Comparisons of trends can be made internally over time or externally compared with na-
tional databases.
Morbidity and mortality data are often risk adjusted to compare similar patients (usu-
ally with similar conditions, procedures, or DRGs). National databases allow comparison of
morbidiry and'mortality using a risk-adjusted model (e.g., all Patient Refined DRGs). Typical
occurrence screening examples for mortaliry include
. death within 24 hours of admission to a hospital;
. death within 72 hours of transfer out of special care unit;
. lack of documentation of deterioration during 48 hours preceding death;
. failure of physician to respond to notification of change in patient's condition during
48 hours preceding death;
. lack of documentation indicating death was expected;
. lack of concordance between premortem and postmortem diagnosis;
. clinically significant incident or occurrence within T2hours of death;
. clinically significant complication of surgical procedure within 72 hours of death;
. clinically significant complication of invasive procedure within T2hours of death;
. death during surgery;
. unplanned organ removal during operative procedure within 2 months preceding death;
62 Q SoluEions

. surglcal procedure to repair a perforation, laceration, or other injury of an organ dur-

ing an invasive procedure within 2 months preceding death;
. repeat of any surgical procedure within 2 months preceding death;
. myocardial infarction within 24 hours of a surgical or invasive procedure;
. death within 48 hours of elective surgical procedure; and
. lack of concordance between preoperative and postoperative diagnosis.

F. lnfection Prevention and Control Processes

The goal of the infection prevention and control (IPC) program is to identify and reduce
the risks of acquiring and transmitting endemic and epidemic infections among patients,
employees, physicians, other IPCs, contractors, volunteers, students, and visitors. This in-
cludes both direct patient care and support staff. The three major aspects of the IPC pro-
gram are surveillance, prevention, and control.
The usual responsibilities of the IPC program include
. definitions of healthcare-associated infections (HAIs),
. definitions of data elements,
. rationale for surveillance method selected,
. description of patient population studied,
. data collection methods,
. quality control procedures for data validation,
. responsibiliry
. systems for reporting and follow-up,
. reporting to public health authorities, and
. documentation of employee infections of epidemiologic significance.
The prevention and control methods used in IPC include
. policies and procedures to protect and prevent infections;
. defined barrier precautions;
. orientation and ongoing education of staff;
. reporting to public health officials;
. methods for screening and documentation of epidemiologically significant infections;
. systems for required waste identification;
. use of personal protective equipment and supplies:
patient care supplies and equipment (e.g., sterile and nonsterile supplies, hand
hygiene facilities),
protective apparel, and
engineering controls;
. precautions used to reduce the risk of infection:
surveillance, and
assessment and analysis of infection rates;
. decontamination, high-level disinfection, and sterilization:
reusable medical equipment,
policies and procedures, and
processes identified:
Quality and Performance lmprovement 63

> principles of asepsis;

> disinfection,sterilization;
> sanitation of rooms, equipment;
> selection, use, and cleaning of personal protective equipment; and
> traffic control.
The IPC program is based on a risk assessment of the organization. This assessment
includes factors such as
. geographic location of the organization,
. populations within the region or organization and level of risk (e.g., neonates, infants
and children, and patients in various ICUs),
. volume of patients served and volume of conditions (e.g., number of patients with
positive human immunodeficiency virus, tuberculosis, and colonized with methicillin-
resistant Staphylococcus dureus [MRSA]),
. clinical focus of programs (e.g.,types of surgeries and invasive procedures, immuno-
compromised patients such as patients on chemotherapy, transplant patients),
. number of employees (often encompasses employee health services), and
. scope of services provided (e.g., acute, ambulatory,long-term, and home care).
After the risk assessment is completed, priorities are identified and strategies to pre-
vent or mitigate problems are determined. In many healthcare settings the prevention of
HAIs in high-risk units (ICU, neonatal and pediatric ICU, transplant units, dialysis units,
and surgical units) is a key responsibiliry. These HAIs must be monitored and analyzed to
determine trends and ways to reduce their occurrence. The rypes of surveillance for IPC
proglams include total house, priority directed, targeted, problem oriented, and outbreak
response.
The most important factor in monitoring prevention of HRIs is proper hand hygiene.
The monitoring of hand hygiene using either Centers for Disease Control or World Health
Organization criteria is a requirement of the Joint Commission and one of the National
Patient Safety Goals.
Specific monitoring is performed for surgical-site infections and for device-related
infections including ventilator-associated pneumonia, central line-associated bloodstream
infection, and catheter-associated urinary tract infection.
Another key role is to identify communicable diseases, control outbreaks when identi-
fied in patients, and report specific results to the public health department. One preventive
measure for controlling certain outbreaks is immunization programs conducted in col-
laboration with occupational health staff. These might include vaccination for hepatitis B,
influenza, pneumonia, and other viral diseases. The infection preventionist is also respon-
sible for monitoring epidemiologically important and multidrug-resistant organisms such
as M RSA, Clo stri dium dffi cile, and vancomycin - res i stant E nte r o c o c cus.
G. Departmental Reviews
The organization should have an organization-wide plan for performance improvement.
Examples of key activities and quality control methods should be defined for each service.
There are numerous regulations at the federal, state, and local level that govern qualify con-
trol monitoring and reporting. This is especially true for diagnostic services such as pathol-
ory and laboratory services, radiolory, nuclear medicine, and pharmacy. Content experts in
these services should lead the identification of regulations or other requirements and the
specific quality control processes and measures that must be maintained. The requirements
64 Q Soluuions

may include provisions for employee exposure monitoring, including issuance of individual
radiology badges or devices. euality management personnel are often involved in the direct
of data or reports from these services. The
-o.ritorirrg within services or the aggregation
unit or service level is considered a microsystem, and it is at this level that change happens
and improvements generally occur.
A format that can be used for a service-level QPI plan includes the following tasks:
. identifuing customers served;
. describing services provided;
. developing performance improvement priorities at the service level, aligned with the
organization's goals and strategic plan;
. identifying any requirr:ments related to performance improvement, qualify control,
and quality monitoring (e.g., accreditation standards, regulations, device monitoring,
qualiry control);
. selecting valid and reliable metrics for the service;
. developing a monitoring plan (e.g., sample, frequency, reporting);
. analyzing the results;
. evaluating the performance; and
. improving the performance.
A standard format can make the development of service plans or qualify monitoring
across multiple services and sites more efficient and effective for tracking, trending, and
reporting.
H. Health Records
Healthcare facilities and clinical staff who treat patients are required to maintain adequate
medical records to serve as a basis for planning care and for communicating about patients'
conditions and treatments with other healthcare providers. The medical or health record
serves other purposes as well. For example, medical records are reviewed by administra-
tive staff performing quality, utilization, and risk management (RM) functions and by phy-
sicians engaged in peer review. outside organizations also use the medical record for mat-
ters relating to payment and accreditation. In malpractice cases, the medical record serves
as the major source of evidence about the care the patient received. Information contained
in medical records also is used in retrospective clinical research. If protected health infor-
mation (PHI) is collected for research, institutional review board approval is needed.
Healthcare organizations should have a clear policy about who may have access to
medical records, whether those records are written, computerized, or otherwise main-
tained. policy statements also should make clear what, other than actual medical records,
constitutes a portion of the record. For example, with the advent of and frequent use of
videotaping oi pro."dures or fetal heart monitoring strips, it is important to address (based
on statelaw and legal advice) whether such media are part of the medical record.
The legal basisfor confidentialiry derives from the physician-patient privilege, set forth
by statute in almost all states. This is one of several relationships recognized as special by
law. The preservation of confidentiality is viewed as essential to the maintenance of the
relationship. The need for confidentiality in the physician-patient relationship gives rise to
a legal privilege. This means that, absent a patient authorization or waiver or an overrid-
ing law or public policy, medical information about a patient is protected from the process
known as discoyery, through which parties to a lawsuit normally can compel disclosure of
relevant evidence. In certain states, the physician-patient privilege is extended beyond
Quality and Performance lmprovement 65

physicians to protect the patient's relationship with other healthcare practitioners (e.g.,
psychologists, clinical social workers, clinical nurse specialists, nurse practitioners).
1. lnformation Covered by Privilege
This information extends beyond oral communication between practitioner and patient to
cover written entries in the patient's medical record, as well as X rays, cardiograph or fetal
monitoring strips, laboratory results, and other information about a patient's condition that
is kept bylfre individual provider or healthcare institution. Information that is privileged
must satisfy the following conditions:
. It must have been communicated in the context of the physician-patient relationship.
. It must have been glven with the expectation that it remain confidential.
. It must be necessary for the diagnosis and treatment of the patient'
In understanding the function of the medical record to provide information about the
patient's care, treatment, and services and to serve as the method of sharing this informa-
tion between caregivers, there are monitoring processes to ensure the integriry, accuracy,
and completeness of the record and reflect the pertinent clinical documentation. The medi-
cal record may be a hard copy document or electronic (or a combination). With current
legislation demanding that healthcare organizations implement electronic health records,
there has been an increase in electronic records.
The monitoringof the medical record usually includes elements in several categories:
. Required documentation content: The requirements vary by setting, procedure, and
even profession. For example, the requirements for a treatment plan will be different
for an acute care hospital and a long-term-care facility. The requirements for surgery
with general anesthesia will be different from those for an outpatient procedure with
moderate sedation. Each facility must first identify the required content for the record
and then develop a process to monitor important elements. Checklists, databases, or
other tools make this process more efficient. This step often reflects the presence or
absence of the required content.
. Timeliness of documentation: The next requirement is the time requirement of spe-
cific documentation. Most common elements monitored for timeliness include histo-
ry and physical, preoperative and postoperative notes, and discharge summaries. This
step reflects whether the documentation met or did not meet the required timeline.
. Appropriateness of documentation (clinical pertinence): The monitoringof clinical
pertinence requires an assessment of the documentation in terms of the patient's con-
dition, diagnostic results, intervention procedures, vital signs, and other information.
This review may determine that documentation was appropriate or not appropriate
to the standard of care, key elements of the assessment, treatment plan, interventions,
and medication management.

I. Medical Peer Review

The data contained in a medical record are private and highly confidential. Policies and proce-
dures clearly define who may have access to a medical record and under what circumstances,
in accordance with medical staffbylaws, hospital policy, and applicable laws and regulations.
Because of the complexity of those issues, consultation from general counsel regarding nation-
al and state statutes is critical. Practitioner profiles can be maintained as a paft of the creden-
tials file or in a separate locked file. Most states have laws governing medical peer review and
its activities. When applicable, files, their contents, and meeting minutes should be marked as
"Confidential: Peer ReviewAccordingto Statute X' or with a simple "Confidential" stamp.
66 Q SoluEions

A rnechanism also should be developed to track actMty on each individual practitioner

profile. A 1og or sign-out sheet attached to each file should contain the date of request, reason
for request or review, name of person reviewing and any pertinent notes such as requests for
copies of the contents. Policies and procedures define the circumstances under which copies
of contents are made, such as individual physician requests. In accordance with medical staff
bylaws and rules and regulations, a mechanism for release of information with specification of
contents to be disclosed should be developed. This mechanism is in response to evaluation of a
practitioner's competence for appointment and reappointment to other healthcare institutions.
Minutes of Qnf activities usually are protected under the medical peer review statutes.
Therefore, maintenance of confidentiality of records extends beyond credentialing to the
entire QPI program in the organization.
Peer review is the review of an episode of care conducted for the purpose of improv-
ing the qualiry of patient care or the use of healthcare resources. It is a process protected
by statute in most states, although this varies, and by federal statute for federal healthcare
facilities. A peer is generally defined as a healthcare professional who has comparable edu-
cation, training, experience, licensure, or similar clinical privileges or scope of practice. The
peer review process includes a case review according to criteria established by the medical
staff. These reviews may include an assessment of the degree to which a standard was met
or if providers in the same situation would have acted in the same manner. These ratings
may be noted as a score or level number for tracking purposes or as a trigger for FPPE
when continued quality concerns are identified. Results may be trended by individual pro-
vider performance or by organization system. Usually, a peer review committee manages
the review and reporting function as a subcommittee of the medical executive committee.
Participation in peer review is one way medical staff members are involved in measuring,
assessing, and improving performance of licensed practitioners.
Medical staff identify criteria or circumstances that initiate a peer review, set time
frames for the review to occur, identify reviewers, and provide mechanisms for participation
by the person whose performance is being reviewed. goth outcomes and processes should
be measured.
An effective peer review process will include the following elements:
. Consistency: Peer review is conducted according to defined procedures.
. Defensibility: Conclusions reached through the process are supported by a rationale.
. Balance: Minoriry opinions and views of the person being reviewed are considered
and recorded.
. Peer review activities are considered in the reappointment process.
. Conclusions from peer review are tracked over time.
. Actions based on conclusions are monitored for effectiveness.
. Findings, conclusions, recommendations, and actions are communicated to appropri-
ate entities.
. Recommendations to improve performance are implemented.
. Physician leaders have a role in improving clinical processes used for clinical privileging.
As discussed in the section on credentialing and privilegrng, practitioner profiles are
extremely important to maintain and are used to evaluate performance and maintain privi-
Ieges. Some key aspects of these files include the following:
. Profiles are based on performance.
. Profiles are provided to each physician or provider on a regular basis.
Quality and Performance lmprovement 67

. Organizations may use risl5-adjusted software.

. Evidence-based medicine determines metrics used.
. Data are timely and accurate.
. Profiles are process focused.
. Physician data are grouped by specialty type or specific diagnoses.
. Data are reported regularly.
. Physician champions talk directly with medical staff about their data.
The physician data must be meaningful to physicians. They should represent major
service lines and patient safery issues and include inpatient as well as outpatient data. When
available, national targets and benchmarks are used to compare performance. For example,
national rates of complications of certain procedures when compared with a specific physi-
cian or service can help the organization identify performance concerns about what is ex-
pected for the same procedure. The data are easily accessed and shared with the physician
to improve performance, and the profiles vary according to the physician's specialty or area
of practice. Some examples of elements that might be found in a physician profile can be
found in the section on OPPE, such as
o patient volume,
. Iength of stay,
. average lengh of stay,
. DRGs,
. average cost per case,
. conformity with systemwide initiatives (e.g., use of deep vein thrombosis or pulmo-
nary embolism prophylaxis),
. legibility of records,
. use of unapproved abbreviations,
. severiry-adjusted mortalityrate,
. severity-adjusted morbidity rate,
. death or loss of function related to HAI,
. unexpected transfers to ICU,
. unexpected death,
. unplanned return to surgery,
r procedurecomplications,
. charges for the patients treated by the physician compared with those for physicians
in the same specialty,
. discharges,
. medication errors, and
o patient satisfaction (complaints or compliments).
Finally, these profiles are confidential, and there must be a mechanism to track activ-
ity when they are viewed. This might include a log or sign-out sheet (e.g., date of request,
reason for request, name of person reviewing, and pertinent notes). Policies and procedures
are needed to establish the system for document management. As for medical records, there
must be defined mechanisms for how this information is shared or viewed.
68 Q Soluuions

J. Patient Advocacy
1.
Recognition of lnternal Customers
An important structural element in QPI is recognizing internal customers. Every process
has both internal and external customers. Most people readily understand the concept of
being a supplier of goods to an external customer. However, the idea of internal customers
is equally important to QPI.
An employee can be a customer when she or he receives material, information, or
services from others in the organization. Conversely, an employee also can be a supplier
when she or he provides material, information, or services to others in the organization or
to external customers. For example, when a nurse sends a specimen to the laboratory the
nurse is the supplier and the laboratory is the customer. When the laboratory sends a report
back to the nurse, the laboratory is the supplier and the nurse is the customer. Just as there
are suppliers to internal customers, those internal customers can, in turn, be suppliers to
external customers. This approach can help to
. remind departments that do not have direct contact with external customers that they
are still a critical link to customer satisfaction,
. improverelationships,
. make the work process flow smoothly, and
.
avert potential bottlenecks.
Table 2o provides an example of an approach one organization followed to ensure the
recognition of internal customers. Notice that the customer service standard pledge reflects
the values necessary to make QPI a reality (e.g., teamwork, information sharing).

Table 2o. Customer Service Standards and Pledge

Respect Me and My Job We Are All Professionals Work and Communicate Smile-lti Contagious
Our need: Respect. O r u need: Professionalism. With Me Our need, Positive
Our response: I understand Our response: I understand Our need: Teamwork. attitude.
the need to be respectful, the need to represent the Our response: I understand Our response, I

and lwill hospital in a professional the need for teamwork, and understand the need
. acknowledge you, manner, and I will lwill for a positive work
' take responsibility for my . pitch in and offer to help environment, and lwill
' be sensitive to your point
. be sensitive to the
of view, actions, you whenever possible,
. thank you for a job well . protect confidential 'ask for your input before effects my actions have
information about making a decision that on others,
done,
. value your time and patients and fellow may affect you, ' replace criticism with
employees, . talk to you directly positive ideas,
priorities,
. look professional in dress, instead of talking to . try to see things through
' discuss my concerns with
grooming, and manner, others secretly if I have a the other person's eyes,
you in private,
' coach others when concern, . attempt to leave any
'value your job and its . listen to you, offer positive
necessary and personal problems at
contribution to the
. follow through on my advice, and not interrupt home,
organization,
promise to you. untilyou are finished, ' coach my coworkers in
' treat you as I rvould like
to be treated, and ' recognize that everyone portraying a positive
has a valid opinion, and attitude, and
' speak to you in a
pleasant tone in person ' seek out information and ' project a caring and
share what I have learned. concerned attitude.
or on the phone.
Frorn Customer Service in Health Care, A Grassroots Approach to Creating a Culture of Service Excellence, by K. Band. Copyright zooo by Jossey-
Bass. Reprinted with permission of John Wiley & Sons, lnc.
Quality and Performance Improvement 69

In most healthcare organizations and as above, senrice excellence is as important as

clinical excellence. For example, Sharp HealthCare QOl2), a Malcolm Baldrige award re-
cipient, has several initiatives that form the foundation of service excellence. These include
1. AIDET Acknowledge, Introduce, Duration, Explanation, Thank you
2. Behavior standards:
. Attitude is everything, create a lasting impression.
. Thank somebody, reward and recognition.
. Make words work, talk, listen and learn.
. All for one, and one for all, teamwork.
. Make it better, service recovery.
. Think safe, be safe, safety at work.
. Look Sharp-Be sharp, appearance speaks.
. Keep in touch, ease waiting times.
. It's a private matter, confidentiality.
. To "E" or not to "E," e-mail manngrs.
. Vive la difference! Diversity.
. Get smart, increasing skills and competence.
3. Must haves:
. Greet people with a smile and "Hello," using their name when possible.
. Take people where they are going rather than pointing or giving directions.
. Use key words at key times: "Is there anything else I can do for you? I have the time."
. Foster an attitude of gratitude. Send thank-you notes to deserving employees.
. Round with reason to better connect with staff patients, family, and other customers.
4. On Stage/OffStage:
This framework allows employees to stage patient and guest experiences, based on the
premise that every action, object, and detail can either add to an experience or detract
from it. Even small acts can be of great importance to patients and their families.
5. Storytelling:
The development and sharingof stories can be a potent means or promotingvalues and
beliefs in an organization. StoryCorps, a nonprofit organization, helps organizations
"remind one another of our shared humanity, strengthen and build the connections
between people, teach the value of listening, and weave into the fabric of our culture
the understanding that every life matters" (StoryCorps, 2012, para.2).
The measurement of customer perception, satisfaction, and loyalty is important for
healthcare organizations to determine how their customers like the services provided.
There are many vendors who survey these customers and provide data back to the organi-
zation for tracking, trending, and benchmarking performance.
The CMS has identified customer perception as a key component of measuring hospital
performance and developed the Hospital Consumer Assessment of Healthcare Providers
and Systems (HCAHPS; CMS, 2OL2) survey as a standardized method to compare perfor-
mance and link payment to performance. The HCAHPS is the first national, standardized,
publicly reported survey of patients' perspectives of hospital care. Before the advent of
HCAHPS, there was no national standard for collecting and publicly reporting information
about patient experience of care that allowed comparisons across hospitals locally, region-
ally, and nationally.
70 Q SoluEions

The survey is designed to produce data about patients' perceptions of care that al-
low objective comparisons of hospitals on topics that are important to consumers. Public
reporting of the survey results increases accountability by increasing transparency in the
quality of care. The CMS and the HCAHPS Project Team have taken steps to ensure the
survey is credible, useful, and practical.
In 2OO2 CMS partnered with the AHRQ to develop and test the HCAHPS survey. In
May 2OO5 the HCAHPS survey was endorsed by the NQF, and approval for the national
implementation for public reporting occurred in March 2008. The survey, methods, and
results are in the public domain.
The Deficit Reduction Act of ZOOS created an additional incentive for acute care hospi-
tals to participate in HCAHPS. As of July 2OO7, hospitals must collect and submit HCAHPS
data to receive their full Inpatient Prospective Payment System annual payment update.
Inpatient Prospective Payment System hospitals that fail to publicly report the HCAHPS
survey may receive an annual payment update that is reduced by 2 percentage points. The
Patient Protection and Affordable Care Act of ZO1O (P.L. 111-148) includes HCAHPS among
the measures to be used to calculate value-based incentive payments in the Hospital Value-
Based Purchasing program, beginning with discharges in October 2Ot2. HCAHPS results
are published on the Hospital Compare website (www.hospitalcompare.hhs.gov) four times
a year (www.hcahpsonline.org; CMS, n.d). The survey consists of ZZ questions with both
inpatient and outpatient items depending on the population assessed.
Patient advocacy includes addressing the rights and responsibilities of patients and
involving them in shared decision making obtaining informed consent for treatment,
and disclosing unanticipated outcomes. An advocate or ombudsman is often available to
manage inquiries, requests, complaints, and grievances, with a process to document and
track reported issues to resolution. An ethical framework is often applied with ethics con-
sultation to respond to issues that may create conflict with the rights of the patient and
the organization or others. The protection of the patients' rights may include a variety of
concerns, such as
. abuse, neglect, and exploitation;
. financialresponsibility;
. caregiving;
. decision-making ability and use of surrogates or durable power of attorney;
. advance directives or livingwills;
. choices about healthcare and treatment;
. treatment without fear of retaliation; and
. visitation and support.
A recent change in patient rights is the inclusion of patients' responsibilities to actively
engage in promoting health, decision making, and care as noted in Figure 25.
A patient's bill of rights was first adopted by the American Hospital Association in1973.
A revised version was approved in 1992 andis available on their website. More recently they
have published the Potient Care Psrtnership.'[Jnderstanding Expectations, Rights ond Responsr-
bilities, replacing the rights with a plain-language brochure.
Healthcare reform stresses an imperative to engage families in their own care. Enhanc-
ing patient-centered care that results in empowerment, engagement, and activation will
become everyone's job. Patients and their families need to understand their role and re-
sponsibilities related to quality and safety. Patient-centered communication has been shown
to improve clinical outcomes (Epstein & Street, 2OO7).
 Performance lmprovement
6gslity and

Patients' Bill of Rights and Responsibilities

F.gure 25.
Disclosure
L lnformation
receive and easily information about your,hu"l,h
t, h.u" the right,to :.::::* lnder;,tool . ll",n1.h::|il*l:
ll*"..,r""1t, and healthcare facilities. lf you speak another language, have a physical or mental disability, or just
will be provided so you can make informed healthcare decisions.
5o"n,.,na"rr,and something, assistance
Providers and Plans
ll. Choice of
right to a choice of healthcare providers that is sufficient to prov;de you with access to appropriate,
. you h.u" the
healthcare'
: high-qualitY
Services
tti l.."tt to EmergencY
jeopardy,
.iiro, t.'.* severe pain, an injury, or sudden illness that convinces you that your health is in serious
l;":,;;""" the right to receive screening and stabilization emergency services whenever and wherever needed,
or financial penalty'
,";1i;;, prior authorization
in Tieatment Decisions
V. Participation
your care. Parents, guardians,
1ou have the right to know all your treatment options and to participate in decisions about
or other individuals that you designate can represent you if you cannot make your own decisions.
.""l,iu ."n,,,U"rs,

I Respect and
Nondiscrimination
ru have the right
to considerate, respectful, and nondiscriminatory care from your doctors, health plan
and other healthcare providers'
^,o.entatives,
. Confidentiality of Health lnformation
ru have the right
to talk in confidence with healthcare providers and to have your healthcare information
;ro.t.d. You also have the rlght to review and copy your own medical record and request that your
lsician amend your record if it is not accurate, relevant, or complete.
l. Complaints and
APPeals

ha,re the right to a fair, fast, and objective

review of any complaint you have against your health plan,
tors, hospitals, or other healthcare
personnel. This includes complaints about waiting times, operating hours,
rnduct of healthcare personnel, and the adequacy of healthcare facilities.

Consumer ResPonsibilities
ter individual involvement by consumers in their care increases the likelihood of achieving the best
s and helps support a quality improvement, cost-conscious environment. Such responsibilities include

rresponsibility for maximizing healthy habits, such as exercising, not smoking, and eating a healthy diet.
:ome involved in specific healthcare decisions.
collaboratively with healthcare providers in developing and carrying out agreed-upon treatment plans.
close releuant information and clearly communicate your wants and needs'
health plan's internal complaint and appeal processes to address concerns that may arise.
knowingly spreading disease.
ize the reality of risks and limits of the science of medical care and the human fallibility of the
professional.
aware of a healthcare provider's obligation to be reasonably efficient and equitable in providing care to
s and the community.
re knowledgeable about your health plan coverage and health plan options (when available) including
benefits, limitations, and exclusions, rules regarding use of network providers, coverage and referral
iate processes to secure additional information, and the process to appeal coverage decisions.
for other patients and health workers
good-faith effort to meet financial obligations.
administrative and operational procedures of health plans, health care providers, and Government
Programs.
and fraud to appropriate resources or legal authorities'
'Bill of Rights," in President! Advisory Commission on Consumer Protection and Quality in the Health Care lndustry, by the
Research and Qu ality, t998. Available at www:hcqualitycommission.govfcborr.
72 Q SoluEions

Engagement is defined as "actions an individual must make to obtain the greatest benefit
from the healthcare services available to them" (Center for Advancing Health, 2010, p.2).
Engaged patients produces better health outcomes (Von Korff, Gruman, Schaeffer, Curry, &
Wagner, 1997; Kaplan, Greenfield, & Ware, L989; Glascow, 2OO2).In this context, patient en-
gagement involves an active process of synthesizing health information, recommendations
of health care professionals, and personal beliefs and preferences to manage one's illness.
Various public and private entities have launched several initiatives to support con-
sumer engagement. They are described below.
AHRQ: TalkingQuality. TalkingQuality is a comprehensive resource and guide for organiza-
tions that produce and disseminate reports to consumers on the quality of care healthcare
organizations (e.g., hospitals, health plans, medical groups, nursing homes) and individual
physicians provide. Consumer report sponsors share a common mission to improve the
quality of care consumers receive. They also share a common challenge on how to con-
vey comparative information about healthcare quality in a way that achieves the follow-
ing objectives.
. Consumers are motivated to use it.
. Consumers can understand it.
. Consumers can apply the information to their own health care choices.
TalkingQuality was created to help you ans\Mer this question. It offers
. innovative ideas for communicating complex information on healthcare quality to
consumers,
. information on the latest research findings, and
. real-world examples to illustrate various approaches and concepts.
While TalkingQuality focuses on the challenges and process of consumer reporting,
much of the guidance applies equally well to organizations producing reports on healthcare
qualiry to drive quality improvement and to inform other audiences, such as providers of
care, payers, employers, and other stakeholders (AHRQ, n.d).
AHRQ: Communication and Patient-Centered Care Toolkits. These toolkits contain re-
sources to enhance communication between caregivers and patients.
. Improving Hospital Discharge Through Medication Reconciliation and Education,
. Improving Medication Adherence,
. Improving Medication Safety in Clinics for Patients 55 and Older,
. Improving Patient Safety Through Enhanced Provider Communication,
. MultidisciplinaryTrainingfor Medication Reconciliation,
. Reducing Discrepancies in Medication Orders and Histories at Handoffs,
. A Simulation-Based Safety Curriculum in a Childrenb Hospital ED,
. Testing the Re-engineered Hospital Discharge, and
. Using Military Simulation to Improve Rural Obstetric Safeti',
AHRQ: Consumers and Patients. AHRQ has developed exceptional tools geared toward
consumers and patients, providing "the latest evidence-based information for improving
your health." "Getting Safer Care" includes resources in various forms, including written lit-
erature, podcasts, and videos.
Americans for Qualrty Health Care Qualrty Tool Box: Consumer Engagement, The Na-
tional Partnership for Women and Families (NPWF) believe that "no single person, group
or profession can improve health and healthcare throughout a community without the sup-
port of others" (NPWF,2oL2).
Quality and Performance lmprovement 73

The partnership has also "developed a Consumer Partnership for e-Health. Tools have
been developed for engaging consumers.
patient-Centered Outcomes Research Institute (PCORI). According to it's website, PCORI
an independent organization created to help people make informed healthcare decisions
.,is

and improve healthcare delivery. PCORI will commission research that is guided by
patients,
caregivers, and the broader healthcare community and will produce high integriry evidence-
based information. pCORI is committed to transparency and a rigorous stakeholder-driven
process that emphasizes patient engagement. PCORI witl use a variety of forums and public
.o.rr*"rr. periods to obtain public input throughout its work (PCORI, zol2,para- 1-2).
In March 2oL2, the pCORI Board refined its definition of patient-centered outcomes
research. "patient-centered outcomes research (PCOR) helps people and their caregivers com-
municate and make informed healthcare decisions, allowing their voices to be heard in assess-
ingthe value of healthcare options." This research answers patient-centered questions such as
1. Given my personal characteristics, conditions and preferences, what should I expect
will happen to me?
2. What are my options and what are the potential benefits and harms of those options?
3. What can I do to improve the outcomes that are most important to me?
4. How can clinicians and the care delivery systems they work in help me make the best
decisions about my health and healthcare? (PCORI, 2OL2)
pCORI has established national priorities for patient-centered comparative clinical ef-
fectiveness, which are
. Assessment of Prevention, Diagnosis, and Treatment Options: the research goal is
to determine which option(s) work best for distinct populations with specific health
problems;
. Improving Healthcare Systems: focuses on ways to improve healthcare services, such
as the coordination of care for patients with multiple chronic conditions;
. Communication and Dissemination: looks at ways to provide information to patients
so that they, in turn, can make informed healthcare decisions with clinicians;
. Addressing Disparities: assures that research addresses the healthcare needs of all pa-
tient populations. This is needed as treatments may notwork equally well for every-
one; and
. Accelefating patient-Centered and Methodological Research: includes patients and
caregivers in the design of research that is quick, safe, and efficient (PCORI, 2OL2).
partnership for patients. partnership for Patients: Better Care, Lower Costs is a new public-
private parinership that will help improve the quality, safety, and affordability of healthcare
for all Americans. Using as much-as $i billion in new funding provided by the Affordable Care
Act and leveraging a nimber of ongoing programs, the U.S. Department of Health and Hu-
man Services (urrS) will work with a wide variety of public and private partners to achieve
sicker in the
the rwo core goals oithis partnership-keeping patients from getting injured or
healthcare system and helping patients heal without complication by improving
transiiions
facility' Itt
from acute-care hospitals io oit .r care settings, such as home or a skilled nursing
mission is to help patients "take care into their own hands."
is an important
Beyond .ed.rcing harm caused in hospitals, the Partnership for Patients
health problem'
test of what can occur when the nation acts as one to address a major national
Medicaid Servic-
The recently formed Innovation Center at the Center for Medicare &
es intends to dedicate over $500 million to test models of safer
care delivery and.promote
million for a
implementation of best practices in patient safety. cMS will also provide $5oo

I
74 Q SoluEions

Community-Based Care Transition Program created by the Affordable Care Act to support
hospitals and community-based organizations in helping Medicare beneficiaries at high risk
for readmission to the hospital safely transition from the hospital to other care settings.
More than Z3O0 partners, including more than 3,200 hospitals as well as physicians and
nurses groups, consumer groups, and employers, have pledged their commitment to the
Partnership for Patients (U.S. Department of Health and Human Services,2OlL, para.1-4).
K. Risk Management
"Risk management (RM) for healthcare entities can be defined as an organized effort to
identify, assess, and reduce, where appropriate, risk to patients, visitors, staff and organiza-
tional assets" (Kavaler & Spiegel, 1997, p. 3). The goal of RM in any organization is to pro-
tect the organization from financial losses, which may arise because of the risks to which it
is exposed. A healthcare risk manager must consider such things as regulatory compliance,
safety management, credentialing, client-provider relations, publiciry and media coverage,
and, most importantly, patient care. In this way, RM and QPI are closely related. Both are
keenly interested in maintaining or exceeding the applicable standard of care.
In the 1970s, RM was the initial reaction to continually increasing litigation. Howevet
as litigation continued to rise, RM assumed a more proactive role in attempting to reduce
the incidents of unsafe care. Table 2I outlines the evolution of RM.
Risk management is the process of making and carrying out decisions that will mini-
mize the adverse effects of accidental losses. The goal of RVt is to protect the organization
from financial loss, which may arise as a result of risks to which it is exposed. Whereas the
traditional evolution demonstrates a strong focus on clinical RM, the concept of enterprise
risk management is becoming more popular in expanding the focus of risks that affect the
entire organization, not just the clinical operations. "Enterprise risk management (ERM)
is a comprehensive business decision-making process instituted and supported by the
healthcare organization's board, executive management, and medical staff leadership. ERM
recognizes the synergistic effect of risks across the continuum of care, and has as its goals to
reduce uncertainty and process variabiliry promote patient safety and maximize the return
on investment (ROI) through asset preservation, and the recognition of actionable risk op-
portunities" (Carroll,2010, p. 585). The major categories of risk in ERM include
. operational: risks related to the business operation that may result from failed pro-
cesses, people, or systems (medical professional liabiliry);
. financial: risks that affect the profitabiliry, cash flow access to capital, or financial ratings;
. human capital: risks associated with a tight labor market, including selection, reten-
tion, and compensation;
. strategtc: brand and reputational risks associated with business stratery, changing pri-
orities, and competition;
. legal and regulatory: risks associated with licensure, accreditation, product liabiliry
and intellectual properry issues;
. technology: risks associated with machines, equipment, devices, hardware, and soft-
ware; and
. hazard: risks related to physical loss of assets, often associated with natural hazards.
1. Risk Identification
Risk identification is the first step to determine what risks can affect the achievement of
organizational goals. Both formal and informal methods are used, and the risks may be in-
ternal or external to the organization. Approaches used include retrospective, concurrent,
Quality and Performance lmprovement 75

Table 21. Evolution of Healthiare Risk

Number one goal: protect financial Number one goal' improve patient safety and minimize risk of harm
resources and reputation. to patient through better understanding of systemic factors that limit
caregiver's ability to provide safe care.

Paper occurrence form required. Variety of methods to report: paper form, electronic form, telephone
call, anonymous reporting, person-to-person reporting.

lnvestigate only the serious Encourage reporting of "near misses," and investigate and discuss the
occurrences. potential root causes.

lnterview staff one on one when there Have root cause analysis meetings with the entire team of caregivers.
is an adverse incident. ldentify system factors that contributed to the event.

lnformation from investigation kept Develop corrective action, share with patient safety committee and
confidential. others in the organization.

Blame and train. Perform a criticality analysis chart and determine the root cause of the
"near miss" or the adverse occurrence.

Talk to the patient or patient! family Advise physician to speak directly with the patient or family and talk
only if necessary and be vague about with them about any unexpected outcomes and errors; keep them
findings. apprised of steps taken to make environment safe for next patient.

Work with department involved to Work with team to develop a patient safety improvement plan.
develop corrective action.

Assume that action is taken to correct Monitor the patient safety improvement plan to determine that changes
the problem that occurred, notice only have been initiated and that the changes have made a difference.
when it happens again that no action
was taken.

Keep patients in the dark about Establtsh ongoing patient safety education; publish patient safety bulletins
risk management and occurrence that address specific patient safety issues and the organization's approach
reporting. to managing them; provide opportunity for patients to identify methods
of improving patient safety and to share them with administration.
in Health Care,
From "The need for risk management to evolve to assure a culture of safety," by A. M. Kuhn, & B. J. Youngberg,2Oo2, Quality and Safety
11,pp. tSB-162. Copyright zooz by Quality and Safety in Health Care, BMJ Publishing Group. Reprinted
with permission.

pre-interventional, and prospective. Once the risks have been identified, the next step is to
conduct a risk assessment to quantify the magnitude or severiry of the risks, the exposure
through possible results, frequency of occurrence, probability of the occurrence, and time to
act. Through this analysis, the organization can determine RM techniques that can be ap-
plied to the exposures to mitigate loss, select the best RM technique for the situation, pri-
|ritize actions, identify resources needed, identifi, risk control and risk financing methods,
implement the techniques, monitor the effectiveness of the technique, and trend and an-
alyze results. Table 22 shows domains and measures to be considered for possible clinical
risk areas based on the NQF'5 Consensus Stondords for Quality of Hospital Care.
2.
Risk Evaluation and Prevention
The enterprise risk manager is an important asset to the organization, as that person is
charged with risk identification, risk assessment and evaluation, and application of tech-
niques to reduce risks. Duties vary widely by organization, but the basic enterprise RM
functions are
. risk identification, assessment, planning, mitigation, and evaluation;
. maintenance and monitoring of effective incident reporting and occurrence screen
programs;
76 Q Soluuions

. claim management;
. clinical and administrative responsibilities such as policy review, credentialing, con-
tract review, internal and external reporting, and education;
. collaboration and communication with safety officer, patient safeqv officer, and quality
management;
. collaboration with the financial officer on insurance and other risk financing methods;
. collaboration and communication with legal representatives for claim management; and
. regulatorycompliance.

Table 22. National Quality Forum Consensus Standards for Quality of Hospital Care
Domain Measure
Length of stay Risk-adjusted average length of inpatient hospital stay
and readmission Overall inpatient hospital average length of stay (ALOS) and ALOS by diagnosis-related
group (DRG) service category
All-cause readmission index
50-day all-cause risk standardized readmission rate following heart failure hospitalization
Severity: standardized ALOS-routine care
Severity: standardized ALOS-special care
Severity: standardized ALOS-deliveries
Patient safety, Accidental puncture or laceration
adult Death in low-mortality DRGs
latrogenic pneumothorax
Death among surgical inpatients with serious, treatable complications
Bilateral cardiac catheterization rate
Blood cultures performed within 24 hours before or 24 hours after hospital arrival for patients
who were transferred or admitted to intensive care unit (lCU) within 24hours of hospital arrival
Congestive heart failure mortality
Hip fracture mortality rate
Tiansfusion reaction, age 18 years and older

Domain Measure
Patient safety, Accidental puncture or laceration
Pediatrics Decubitus ulcer
latrogenic pneumothorax in nonneonates
Tiansfusion reaction, age under'18 years

Pediatrics Pediatric ICU (PICU) severity-adjusted length of stay

PICU unplanned readmission rate
Review of unplanned PICU readmissions
Home management plan-of-care document given to patient or caregiver
Pediatric heart surgery mortality
Pediatric heart surgery volume
PICU pain assessment on admission
PICU periodic pain assessment
PICU standardized mortality ratio (continued)
Quality and Performance lmprovement 77

Table 22. National Quality Fo?um: Consensus Standards for Qualily ol Hospital Care
(continued)

and
Surgery Abdominal aortic aneurysm volume
anesthesia Abdominal aortic aneurysm repair mortality rate
Esophageal resection mortality rate
Esophageal resection volume
lncidental appendectomy in the elderly rate
Pancreatic resection mortality rate
Pancreatic resection volume
Postoperative wound dehiscence, age under 18 years
Postoperative wound dehiscence, age 18 years and older

Foreign body left after procedure, age under 18 years

Foreign body left in during procedure, 18 years and older

Failure to rescue-in-hospital mortality

Failure to rescue-50-day mortality

Venous thrombo- VTE prophylaxis

embolism (VTE)
ICU VTE prophylaxis
VTE patients with anticoagulation overlap therapy
VTE patients-unfractionated heparin dosages/platelet count monitoring by protocol (or no-
mogram)
VTE discharge instructions
lncidence of potentially preventable VTE
From "Nationa/ O uality Forum Endorses Consensus Sranda a
for Quality of Hospital Care: Patient Safel in Hospitals Focus of
rds NQF-Endorsed
Measures.'Retle ved from www.gualityforum.org/Projecu/h/Hospital-Care-Performance-(zooZ)/Hospital-Care-Performance-Evaluation-
Framework.aspx. Copyright 2otz by National Quality Forum. Reprinted with permission.

Risk Management Plan. A healthcare organizationtypically has a plan explaining its enter-
prise RM philosophy. Often the enterprise RM plan is integrated with the qualiry manage-
ment plan because the two processes are interdependent. Important plan elements include
. purpose and board statement of support of enterprise RM;
. scope of the proglam, authoriry, and confidentiality assertions;
. data collection and reporting mechanisms Goth internal and external); and
r integration with qualify management and proglam effectiveness reviews.
Within the plan, prevention of risk is often managed with
. contract review,
. internal and external reporting processes,
. education of staffand providers,
. policy review to protect the organization, and
. informed consent.
Usually risk control is managed through incident (or variance) reporting, occurrence
screening, and claim management. The data that may be useful when trended or analyzed
include
. liability claims,
. workers'compensationclaims,
. physical malpractice coverage,
78 Q SoluEions

. incident reports,
. occurrence screens,
- review of records using criteria to note variations,
- details of the occurrence,
- records that need more in-depth review;
- confirmation of the variation or absence of an untovrard event, and
- summary of data with trends
. patient complaints, and
. tort claims.
Possible causes of losses for organizations include
. criminal acts by employees;
. breach ofcontract;
. patient harm related to inabilify of contractors to perform services;
. clinical treatment by qualified or unqualified staff;
. improper use of equipment by staff, patients, or families;
. inappropriate discharge;
. falls with injury;
. medication errors with harm;
. lack of informed consent;
. privacy violations;
. problems with employer-employee relations;
. failure to meet licensing laws or regulations;
. antitrust issues; and
. Medicare or Medicaid fraud.
An important aspect of enterprise RM is management of claims. Figure 26 lists the
types of professional liability sources often considered in determining the validity of a
claim, and Figure 27 shows the key elements for a tort.

26. Professional Liabil Sources

Corporate liability Based on recognition that the organization owes a duty to the patients it serves

Mcarious liability lndirect responsibility for the acts of another person; respondeat superior, which holds the
employer responsible for the wrongful acts of its employees
Ostensible agenry Generally an organization is not liable for injuries sustained by patients because of the actions
of an independent contractor. However, the extension of respondeat superior to the doctrine of
the ostensible agency may extend liability exposure to the organization for acts of nonemploy-
ed, independent contractor physicians where no employer-employee relationship exists.

Res ipsa loquitur Allows a patient to prove his or her case without needing to establish the standard of care in
which there is clear and obvious negligence.

Figure 27. Elements for a Tort

Duty Harm or injury as a result of the breach

Breach of duty Causation

Quality and Performance lmprovement 79

Education and Skills for Risk Managers. It is helpful for risk managers to have some clini-
cal knowledge, because they must review care and provide guidance to clinical providers of
care. Because risk managers must review defense counsel work and legal documents, they
should have some knowledge of healthcare law and have a thorough understanding of the
legal system. Finally, understanding the insurance industry is important because risk man-
agers help make decisions about various insurance coverages such as hospital professional
liability, general liability, and workers' compensation.
L. Organizational QPI Tiaining
Everyone in the organization is responsible for quality and safety. Therefore, educating all
employees at all levels of the organization is critical to the success of QPI. Because the most
common cause of failure in any QPI effort is uninvolved or indifferent top and middle man-
agement, it is essential that all leaders be educated from the start. Training should begin
at the top and cascade down through the organization. Ultirnately, senior and middle man-
agement should be part of the teaching team; this will demonstrate to employees that they
are committed to QPI. The method of education or training must be tailored to the audi-
ence and use tools and methods to match the audience needs and learning styles. Governing
body or board members must also be included in understanding QPI and their accountabil-
ity for quality of care in the organization. Some form of board training is often included for
new members. A comprehensive program for all levels of employees, management, board,
and physicians should be designed to meet the needs of these different gloups. For exam-
ple, governing-board training should include a review of oversight responsibility for the or-
ganization's quality and safety performance, some form of quality and safety committee or
review function, use of quality performance as a criterion in rating executive performance,
and trends and public reporting of the organization's data and its image in the community.
1. Determining Education and Training Needs
There are many ways to determine the educational needs of Qft participants (Gaucher
& Coffey, L993; Kirkpatrick,tggS Phillips & Stone, 2OO2). Methods to obtain information
should include
. evaluating knowledge and skills contained in the job description,
. asking participants,
. askingparticipants'supervisors,
. asking others rryho are knowledgeable about the job (e.g., customer, peers, experts in QPI),
. testing participants on their skills and knowledge, and
. analyzing participants' past performance appraisals.
2.Fundamentals of QPI Curriculum
The curriculum should include the following elements:
. explanation of the need for organizational improvement, including individual and col-
lective benefits of QPI;
. development and use of common quality language or taxonomy;
. discussion of the organization's QPI goals;
. definition of the QPI structure;
. articulation of Qff philosophy and a model for improvement;
. description of the QPI process;
. description and clarification of responsibilities;
. tools and techniques to participate in teams and to manage work processes;
80 Q SoluEions

. description of how change may affect the individual's job and work relationships;
. metrics for the organization; and
. reporting structure for leaders and staff.
Training should be tailored to the specific needs of each group (i.e., top management,
middle management, front-line staff). Thble 23 offers a comparison of topics addressed
across major groups in a QPI curriculum. Another approach to considering training is the
Institute for Healthcare Improvement (IHD Improvement Advisor Professional Develop-
ment Program (IHI, n.d.), which includes the following agenda for training:
. science of improvement (includes high reliability organizations),
. model for improvement,
. scoping improvement efforts,
. understanding systems and processes,
. using data for improvement,
. understandingrelationships,
. gatheringinformation,
. organizinginformation,
. developing powerful ideas for change,
. testing changes,
. implementingchanges,
. decision making,

Table 23. Suggested Substantive lssues for QPI Education and Training
Quality as a strategic Key concepts of quality and performance Quality awareness, definition of
advantage management (e.g., customer satisfaction, quality
process management, teamwork,
continuous improvement methods)

Role of leadership in Principles of customer service Quality participation: fundamental

creating and sustaining training in QPl, including process
quality vision improvement tools and techniques

lntegrating quality values Managing process performance Organization's mission, vision, and
into day-to-day leadership (measurement, QPI tools, variation, problem QPlplan
solving, data collection and analysis)

lndicators for measuring Measurement of quality outcomes Concepts of quality management:

and evaluating quality and customer satisfaction, process
organizational performance improvement, teamwork, continuous
improvement

Components of Management practices for building Promoting cooperation between

quality management teamwork, employee involvement and coworkers within and between
implementation process recognition for customer service, team departments
contributions for quality, team leadership
skills, conflict resolution, communication
skills, listening and giving feedback,
accreditation standards

Basic GPltools Communication skills

Role as team leaders Customer service

Awareness of accreditation Relevant standards

standards
Quality and Performance lmprovement 81

. workingwith people, and -

. plannedexperimentation.
3. What Skills Do Healthcare Quality Professionals Need?
The key operating assumption of building capacity is that different groups of people will
have different levels of need for QPI knowledge and skills. A teaching plan should ensure
that each group receives the knowledge and skill sets they need, when they need them, and
in the appropriate amounts. Figure 28 shows a pyramid model in which experts need a high
level of specific knowledge on performance improvement, quality management, and tools,
whereas most staff need a much lower level of knowledge in this area.
The potential audience for QPI training includes experts, executives or top management,
middle management, and staff. Training topics for these groups can be classified as follows:
Top management education topics:
. quality and safety as strategic advantages;
. role of leadership in sustaining quality vision;
. integration of quality and safety culture and values;
. indicators for measuring and evaluating;
. components of Qft implementation process;
. basic QPI tools;
. role as team leaders, champions, and sponsors; and
. awareness of accreditation and regulatory standards.
Middle management education topics:
. QPI key concepts;
. customer service principles;
. management of process performance;
. measurement of quality and safety outcomes; and
. management practices regarding teams, conflict resolution, communication skills,
regulations, and accreditation standards.
Staff(what everyone should know) education topics:
. QPI awareness: definition of quality;
. fundamerital QPI training;

Figure 28. Levels of Knowledge

High Levelof Knowledge

Middle Managers

Low Level of Knowledge

82 Q SoluEions

. organization's mission, vision, and QPI plan;

o concepts of QPI: customer satisfaction, process improvement, teamwork, and continu-
ous imProvement;
o prorrrotion of cooperation between coworkers for cross-functional or interdisciplinary
teams;
. communicationskills;
. customer service;
. just-in-time team training; and
. relevant standards.
There are some common reasons why managers are often reluctant to support training
in this area. These barriers must be overcome for the organization to develop the infra-
structure necessary to support healthcare quality and safety. They include
. no results from the training;
. too costly;
. no input on the content, process, or timing;
. no relevance of the content to actual work;
. no involvement in the process;
. no time for staffto participate;
. lack of preparation of programs;
. lack of knowledge about learning and development; and
. no requirements for the training (e.g., no regulations; Phillips & Phillips, 2oO3,pp.2-4).

M. Training on QPl, Program Development, and Evaluation

Providing the training on QPI is often a collaborative effort between healthcare qualiry pro-
fessionals as the subject matter experts and educators as the experts on teaching and learn-
ing modalities. There are multiple approaches to education using adult learning principles
and accelerated learning methods, including the following:
. Engage multiple senses to enhance learning (auditory visual, kinesthetic).
. Use concepts and principles, then add application into practice.
. Allow "toys'to activate the brain to facilitate learning.
. Allow students to teach each other key concepts; acting as a teacher promotes a stron-
ger focus on learning.
. Chunk learning material into key categories and teach in segments, building on easier
concepts and then adding more difficult ones.
The use of simulation and case studies to apply concepts or tools is another effective
way to enhance training. Most fypes of hands-on experience and practice will make the
learning fun and more relevant and increase muscle memory for the task.
Training on QPI must address the current employee base, new employees, and ongo-
ing processes. Although core concepts and tools can be taught and reemphasized to embed
the improvement philosophy into the culture, there will be degradation in memory unless
the information is clearly integrated into daily work and used often. For this reason, just-in-
time training is often used for teams or projects.
New tools and techniques are continuously added to the toolbox for employees so that
advanced data management and analysis can be performed. This accumulation supports the
concepts of a learning organization, as described by both Senge and Garvin. Senge (1990)
Quality and Performance lmprovement 83

first described the key compongnts of a learning organization: systems thinking, personal
mastery, mental models, shared vision, and team learning.
Senge also described the benefits of a learning organization:
. maintaining levels of innovation and remaining competitive,
. learning to respond to external pressures,
. learning to link resources to customer needs,
. improving quality at all levels,
. improving organizational image, and
. increasing the pace of change in the organization.
According to Garvin, three issues must be addressed before an organization can become
a learning organization (Garvin, 1993). He defined learning organization in this way: 'A learn-
ing organization is an organization skilled at creating, acquiring and transferring knowledge
and at modifying its behavior to reflect new knowledge and insights" (Garvin, 1993, p. 80).
The three areas that must be addressed by leadership are meaning, management, and mea-
surement. Although he describes five components of the learning organization, they differ
slightly from Senge's description. He states that an organization must be skilled at five key
activities:
. systematic problem solving,
. experimentation with new approaches,
. learning from past experience,
. learning from best practices, and
. transferring knowledge quickly and efficiently throughout the organization.
By building a learning organization,leaders foster an environment conducive to learn-
ing. This opens up boundaries across departments, disciplines, and professions and stimu-
lates the exchange of ideas. The way to foster this development is to create learning forums,
which may take many forms to achieve innovation and learning. The learning organization
will excel in a culture of performance excellence and improvement because the cultural
foundation will support ongoing learning change, and improvement.
N. Effectiveness Evaluation of QPI Tiaining
Kirkpatrick's fo,undational principles for evaluating effectiveness of training were first pub-
lished in 1959. The focus was a return on expectations as the ultimate indicator of value, and
value must be created before it can be measured. The framework for evaluation can be en-
visioned as a compelling chain of evidence that demonstrates the bottom-line value to the
organization (Figur e 29).
1. Framework for Evaluating the Results of Tiaining
As an expert in the field of training, Donald Kirkpatrick (1993) perceived three reasons for
evaluating training programs:
. to determine how to improve future training
o to determine whether the current training should be continued, and
. to justifu the existence of the trainingdepartment.
To the extent trainers can demonstrate important outcomes from training, they will
be seen as important to the QPI movement and the organization itself. Kirkpatrick (1998)
suggests there are four important levels of training evaluation: reaction, learning, behav-
ior, and results. This model is often used to describe various levels of measuring training
effectiveness.
84 Q SoluEions

Figure 29. Framework Linkage

T
]. ,,

Level t Level z Level 3 Level 4

Reaction Learning Behavior Results
From The Kirkpatrick Model. Retrieved from www.kirkpatrickpanners.com/OurPhilosophy/tabid/ce/Default.aspx. Copyright 2ott by Kirkpatrick Partners.
Reprinted with permission.

Reaction. This is the extent to which the participants are satisfied with training. Because
negative attitudes toward the program can interfere with learning, this is an important
measurement. Reactions are often measured at the end of the training program or soon af-
ter the program has ended through use of a questionnaire about what participants thought
and felt about the training. For example, here are two ways of measuring reactions:
. Customer (trainee) satisfaction, or their opinion (What did they like? What did they
learn? Was anything missing?), using a Likert rating scale for feedback.
. Good facilitator, interesting or useful subject, adequate facilities, opinion of atmo-
sphere, scheduling, additional comments.
Learning. When participants change attitudes, improve knowledge, or increase skill as a re-
sult of the program, learning has occurred. Unless one of these parameters has changed, it
is unlikely that behavior will change. Learning is best measured both before and after train-
ing and, where possible, should include some rype of control group as a basis of comparison.
The type of measure used will depend on what is being evaluated. For example, increased
skill may need to be evaluated by a specialist in that particular area, whereas a change in at-
titude can be measured using a before-and-after questionnaire. For example, learning can
be measured by a change in attitude, skills, or knowledge and using pre- and posttests, test
performance, demonstrations, or role play.
Behavior. This level refers to behavioral change as a result of training. It focuses on the
transfer of knowledge, skills, or attitudes from the classroom to the job. Although positive
reactions may produce a desire to change behavior, and learning may give participants the
skills to know how and what to change, it does not necessarily follow that behavior will ac-
tually change. In addition to positive reactions and learning, employees must work in a cli-
mate supportive of change, and they must see some reward associated with changing their
behaviors. This does not have to be tangible rewards; intangible rewards such as a feeling
of achievement also are important motivators for change. The climate depends heavily on
the support of the supervisor, further supporting the importance of all levels of manage-
ment being involved in QPI education and training. Ideally, behaviors are measured both
before and after training, allowing ample time for behavioral change to occur. Pretraining
and posttraining information can be collected in the form of questionnaires and interviews
and should be elicited from participants and from those who are in a position to observe
participants'behaviors (e.g., immediate supervisor, customers, peers). Some relevant exam-
ples of behavioral changes relating to QPI may include the extent to which
Quality and Performance lmprovement 85

. department heads deploy QPI concepts, methods, and tools;

. senior leaders communicate the organization's values (measured by employee ques-
tionnaires and focus groups); and
. leadership practices reflect employee involvement and participation.
Results. This is the last-and probably the most important-level of program evaluation
described by Kirkpatrick. Indicators used to measure results should be tied to the driving
force behind conducting training in the first place. For example, did quality of care actual-
ly improve, and was this a function of Qff training? Were overall errors reduced through
organization-wide QPI training? As with evaluation of behavioral changes, result evalua-
tion should be conducted before and after training use a control group, allow ample time
for results to be achieved, monitor results over time, and compare the cost of the training
program with the benefit. In some cases, a direct link between training and results will be
difficult to prove because many other factors might influence a particular outcome. How-
ever, evidence that supports the link should be gathered. Examples of results may include
. final overall change for the business as a result of the training program;
. improved quality, improved production, or decreased costs; and
. increased job satisfaction, reduced problems or accidents, or increased sales.
Return on Investment. J. J. Phillips has suggested a fifth level of evaluation: ROI evalua-
tion, in which the fourth level of the standard model is compared with the overall costs of
training (Phillips, 1996; Phillips & Phillips, 2005). The ROI evaluation addresses how the
bottom line changed as a result of training. The ROI asks the question "Were the benefits
greater than the cost?" (Phillips, 1996). Phillips describes methods for isolating the effects
of the program or process, methods of converting data to monetary values, cost categories,
intangible benefits, and communication targets.
2. Aligning Rewards to Support Quality
Reward systems are critical to the success of QPI. In fact, "The most damaging alignment
problem to which many total quality failures have been attributed is the lack of alignment
between expectations that arise from total quality change processes and reward systems"
(Evans & Dean, 2OO3, p. 362). Rewards are important because they can motivate people.
Motivating people to provide excellent customer service is a top priority for most orga-
nizations. Therefore, before discussing rewards, it is important to understand motivation.
a. Basics of Motivation
Work motivation is "the psychological forces that determine the direction of a person's be-
havior in an organization, a person's level of effort, and a person's level of persistence"
(George & Jones, 2OO2, p. 181). There are many theories of motivation, and each has some-
what different but complementary implications for actions managers can take to motivate
employees. Therefore, a basic understanding of all the major theories is important. One way
to view all theories is through the "motivation equation" (George & Jones, 2OO2). Each the-
ory stresses different parts of the equation (Figure 3o).
1.) Need Theories
Need theories center on what employees are motivated to obtain from work (outcomes).
These theories include Maslow's hierarchy of needs, McClelland's need theory, and Hertz-
berg's two -factor theory.
Abraham H. Maslow's (1954) need theory was first published in L943. Maslow, a psy-
chologist, believed that human needs could be arranged in a hierarchy from the most basic
to higher order needs, as follows:
86 Q SoluEions

Fiqure 50. Motivation Equation

INPUTS PERFORMANCE OUTCOMES

Need Theory Equity Theory

Wlaat outcomcs are individuals motirated to obtain Are outcomes perceived as being at an
in the workplace? appropriate level in comparison wrth inpux?

Expectancy Theory ProceduralJustice

Do individuals believe that their inputswill Are the proceduruused to assess inputs
result in a given level of performancd and performance and to distribute
Do individuals believe that performazce at this level outcomes perceived as fair?
will lead to obtaining outcomcs they desire?

From Organizational Behavioc by J.M. George & G.R. Jones,2Oo2, Upper Saddle Rivec NJ, Prentice Hall. Copyright zoo2 by Prentice Hall. Reprinted
with permission.

.
physiological or survival needs (basic survival needs such as food and water),
.
safety or security needs (protection from harm or physical deprivation),
.
belongrngness or social needs (the need for interaction with others, companionship,
belonging, and friendship),
. esteem or status needs (needs for recognition and appreciation), and
. self-actualization needs (the need for self-fulfillment or to reach one's highest potential).
Maslow believed that basic needs had to be met before higher order needs. For ex-
ample, employees would have to meet basic survival needs (e.g., working in a safe environ-
ment) before they would focus on esteem needs. In addition, Maslow maintained that only
unsatisfied needs served to motivate people; people want what they do not have.
David C. McClelland proposed a concept similar to Maslow's, narrowing the number of
needs to three types: achievement, power, and affiliation (McClelland, Atkinson, Clark, &
Lowell, t976).
Finally, Frederick Herzberg's two-factor theory classified the elements of motivation
into two categories: motivators and hygiene factors (Herzberg, Maysner, & Snyderman,
L966). Motivators are the elements of a job that increase job satisfaction, including chal-
lenging work, achievement, recognition, growth, and advancement. Hygiene factors, on
the other hand, do not contribute to motivation, but their absence leads to dissatisfaction.
Hygiene factors include company policy and administrative issues such as supervision,
working conditions, interpersonal relations, safery salaries, morale, and productivity. Herz-
berg expanded on Maslow's theory, making a distinction between factors that motivate and
factors that maintain motivation.
At least two managerial implications for motivation are clear from need theories:
. There are many different needs, and these differ between employees.
. If employees are not motivated, managers should seek to determine what needs em-
ployees have and which are satisfied or unsatisfied.
2.) Expectancy Theory
Expectancy theory is concerned with how people decide which behaviors to engage in
and how much effort they should give to that behavior. This theory focuses on the person's
Quality and Performance lmprovement 87

perception of effort-to-performance and performance-to-outcome links. Essentially, a person

asks himself or herself, "If I work hard (effort), will I be able to perform?" Motivation is im-
proved by strengthening that link. Managers want to be certain that employees believe that if
ih"y *ork hard, they will achieve high performance. Thus, providing training and education
so that they have the appropriate skills to perform the work would improve motivation.
Individuals also ask themselves, "If I perform at a high level, will there be an outcome,
and is it something I care about?" To strengthen this performance-outcome link, managers
want employees to believe that if they perform at a high level, there will be an outcome that
they desire. Managers can strengthen this link by having valid performance appraisal sys-
tems that capture quality performance and also by having systems in place to reward such
performance. For example, when an employee reports an adverse event, there should be an
immediate outcome that is positive in the eyes of that employee.
In accordance with this theory managers should do the following:
. Be certain employees have the necessary skills to perform well.
. Coach employees to believe that if they work hard they will be successful.
. Knowwhat outcomes employees perceive as important (as detailed by needs theory).
. Flave clear policies about what levels of performance are rewarded (result in out-
comes) and which levels are not.
3.) Equity Theory
Equity theory centers on the input and outcomes part of the motivation equation. The
overall idea is that employees are motivated when there is fairness in the workplace. This
theory contends that employees determine fairness by looking at the ratio of their inputs
(work eff,ort) to their outcomes (e.g., rewards, benefits). For example, Employee A may be
motivated if she receives a financial bonus that she perceives to be equitable given her ef-
fort on the QPI project. According to this theory, however, employees also compare the
ratio of their inputs to outcomes with those of others' inputs and outcomes. Therefore,
if Employee B in the same department is awarded a larger financial bonus for the same
amount of effort, Employee As motivation would probably drop. Some ways for managers
to motivate employees include the following:
. Acknowledge different performance levels with different levels of rewards.
. Periodically check employees'perceptions about their own input and outcomes as
well as those of others.
. Knowwhat outcomes are desirable and tie those to performance in a timely manner.
4.) Procedural Justice
procedural justice is a theory of motivation that focuses on fairness with respect to processes
or procedures used to allocate outcomes. Research has demonstrated that people are more
likely to see outcome allocations as fair when the following conditions exist:
. Employees have input into how decisions are made.
. There is an opportunity for performance errors to be corrected.
. Rules and policies for allocation of outcomes are applied consistently.
. Decisions are made in an unbiased manner.
b. What Do Employees Say?
There is research support for these various motivation theories. In the past 25 years, the
Gallup Organization undertook rwo extremely large studies. The first asked, "What do the
most talented employees need from their workplace?" For this part of the research, Gallup
88 Q SoluEions

interviewed more than 1 million people who were employed across a broad range of compa-
nies, industries, and countries. This study's "most powerful" conclusion is that the retention
and performance of an employee is determined "by his relationship with his immediate su-
pervisor" (Buckingham & Coffman, lggg). So what makes a good supervisor? Gallup's data
indicate that there are 12 factors critical to the retention and performance of employees:
. Do I knowwhat is expected of me at work?
. Do I have the materials and equipment I need to do my work correctly?
. Do I have the opportunity at work to do what I do best every day?
. In the last 7 days, have I received recognition or praise for doing good work?
. Does my supervisor, or someone at work, seem to care about me as a person?
. Is there someone at work who encourages my development?
. Do my opinions seem to count at work?
. Does the mission or purpose of mywork organization make me feel my job is important?
. Are my coworkers committed to doing high-qualiry work?
. Do I have a best friend at work?
. In the last 6 months, has someone at work talked to me about my progress?
. This past year, have I had opportunities at work to learn and grow?
These factors clearly are consistent with the theories of motivation discussed
previously.
3. Setting Up Reward System
"
Given the role rewards play in employee motivation, setting up an effective reward system
is important. Seven steps are fundamental to a reward system (Gaucher & Coffey, 1993):
. Determine priorities and values; behaviors that will be rewarded are prioritized.
. Identify the criteria or milestones.
. Establish a budget for recognition.
. Determine who will be accountable for managing the recognition.
. Develop specific procedures and features of the rewards and recognition.
. Obtain feedback from employees on desired rewards and recognition.
. Modify program based on feedback.
The most important step is to reward the desired behavior.
O. Communicating Successes
Sharing organization success stories internally and externally is important for several rea-
sons. As described earlier, it motivates employees and serves as both reward and recogni-
tion to them. The value is demonstrated to the employees in increasing knowledge transfer,
learning from experience, sharing best practices, and stimulating innovation within the or-
ganization. Value is next demonstrated to the customer in showcasing successful processes
and outcomes to the people served. Communicating successes also demonstrates account-
ability and transparency to the community and public served. There may be other stake-
holders for whom communicating success is also important. Externally, sharing of lessons
learned with other organizations, professional groups, online communities, and the public
might be performed in different ways. Some of the more common groups for sharing are
professional conferences, committees, and professional organizations. The report format
often includes
Quality and Performance lmprovement 89

. abstract,
. title,
. objectives,
. outline,
. content,
. results, and
. references.
The form in which communication takes place can also include face-to-face presenta-
tions, webinars, posters and storyboards, publications, and social nenvorking tools. Publica-
tions may be local newsletters, peer-reviewed journals, or online forums including blogs. It
is necessary to follow specific submission guidelines for a poster, abstract, or article. The
publishing organization will define poster measurements, labeling design, and key ele-
ments for text and gfaphics. Abstract criteria will focus on topics of interest, maximum and
minimum word limits, and categories to include. Journal articles must conform to author
guidelines and use a specific writing style. In preparing to use any of these external com-
munication methods, it is essential to have samples of work product reviewed to increase
the chances of acceptance.

Vl. Summary
A formal QPI program and infrastructure is required to ensure quality and safety. The tenets
of quality and safety must first be developed through strategic planning. In this book, a dis-
cussion of strategic planning is followed by the establishment of priorities for QPI activities,
translating strategic goals into qualiry outcomes, and aligning culture and structure to sup-
port QPI. QPI teams are described, as are patient advocacy, risk management, and training.
Through the understanding of QPI principles reviewed herein and in other Q Solutions
products, the healthcare quality professional can apply evidence-based techniques to en-
sure quality and safety in their healthcare organizations.