of Impact Quality on Healthcare
Trends Impacting Healthcare
Increasing costs at a rate greater than general inflation therefore increasing the % of the GDP dedicated to healthcare. Growing international and national competition (e.g., Specialty Hospitals)
Threatens profitability Decreases profit margins
Consumerism
Elderly Population
Aging of the population is a contributor to increased healthcare expenditures[i]
The number of Americans 85 years or older increased at a steady 4.3% growth rate per year. The population growth rate of Americans between 90 and 99 years old averages 6.1% per year. While the centurion population growth rate averaged 8.4% over the last 10 years and it grew at a projected phenomenal rate of 15.3% from 1999 to 2000. The end result is that the population is living longer and more productive lives.
[i] Accessed from the U.S. Census Bureau Web-Site on February 2, 2001 (http://www.census.gov /population/estimates/nation/intfile2-1.txt)
Trends Impacting Healthcare
Societal concerns about the quality of the US healthcare system vs. Other Developed Countries
Better outcomes Smaller per capita expenditures
Health insurance shields consumers from the true costs of medical care Reimbursement for New Technologies (I.e. PET Scanners) Nursing Shortages
Trends Impacting Healthcare
HMO Failures Medicare and Non-Medicare Federal and State Regulations and Insurance Programs
Medical Errors False Claims "Rockiness" of some state Medicaid programs HIPPA regulations
Other Trends
What has been the providers response to these trends?
Aggressive service development and expanding physical facilities by hospital to attract more patients. Adoption of business practices designed to improve efficiency and effectiveness by physicians. Provider movement towards IDS to improve negotiation positions and market power Application of technology by providers towards improving diagnostic and therapeutic efficacy as well as the facilitation of information transfers Health system consolidation of services, divestiture of unprofitable facilities, HMO's
Importance of Quality Improvement in Healthcare
Add value to services in terms of increased quality and reduced costs. Improve market share and profitability through greater consumer demand for services.
Barriers
What QI adoption barriers must be overcome for QI initiatives to work in
Hospital Clinic Home Health Company Nursing Home Other Health Care Settings
Relationship between QI and Access to Care
Quality Health Care = Access to appropriate services in appropriate settings at the appropriate time. Quality Improvements Process Evaluation
Process Evaluation = Best Practice Determination + Appropriate Care Sites Process Evaluation Focus Health Care System demonstration to Payers of the delivery high value or quality care within the limits of the healthcare expenditure.
Unfettered access does not ensure quality and so QI efforts may need to be directed at redirecting consumer demand to proper settings and types of care
Impact of Accreditation Organizations
Increase acceptance of QI initiatives Provide incentives for short as well as long term initiatives to improve quality of care and efficiency in healthcare. QI requirements can be counterproductive if
Organization attempts to meet the standards rather than improve care Standards are used punitively rather than as a means of QI Standards add administrative overhead to an organization rather than improve the quality or value of services render
How has QI reshaped Healthcare Management? It has reshaped the healthcare manager into a "true leader"
Clear sense of mission and values Responsibility to envision a different future.
Develop true collaborative, working teams that embraces continuous quality improvement
Total Quality Improvement
Three Quality Philosophies
Crosby Deming Juran
Quality without Tears
Quality is conformance to requirements Quality improvement should emphasize prevention rather than appraisal.
Appraisal is checking and inspecting Prevention involved process examination and identify areas where errors may occur and take the steps to remove them permanently.
Quality without Tears
Ultimate goals is "zero defects" Errors Caused by lack of knowledge or attention "Zero defects" Any error, no matter how small is not acceptable. Cost is the best measurement of quality
Price of Non-Conformance Price of Conformance
Crosby : How does it work?
Transformation occurs only if all employees absorb the common language of total quality and begin to understand their roles. Top management support is key. Importance of QI should be stressed and employees encouraged to form QI teams. 14 step process
Deming
Quality must be built into the process Organizational excellence Commitment
Consistent Purpose
Innovations Long Term Planning Resources
Improvement of a Competitive position
Commitment to producing "zero" defect products
Deming
Create a secure environment Employ statistical methods rather than 100% inspection Provide education and training Top management should push for continued improvement within the organization Benefits from QI initiatives
Reduction in waste Higher productivity
Increased market share Cost Reductions
Juran
Quality is fitness for use. Ultimate goal is to supply products and services meeting the needs of customers
Identify needs Communicate need effectively in an easy to understand message or language
Quality comprises a) Quality Planning, b) Quality Control and c) Quality Improvement
Quality Planning
Quality Planning is the creation of a process designed to meet specific goals under operating conditions.
Identify internal and external customers Identify needs and features associated with the products or services. Determine process to produce the specific features Determine process capability Meet quality goals under operating conditions
Quality Control
Quality Control begins to define the control subjects. The end result is that the operation performs according to quality plans.
What aspects are critical to overall product quality Define items, units of measure and measurement frequency. Establish requirements and costs based on process capabilities Study the process and take corrective steps to eliminate variances.
Quality Improvement
Quality Improvement involves
Proof of need Identification of Major Projects for Improvement Organization for Quality Improvement: Quality Improvement Control Organization for Quality Improvement: Project Teams Diagnosis to Find the Causes
Quality Improvement
Quality Improvement involves
Reduction of Worker Controllable Errors Remedy Communication of Results Give Recognition Institutionalizing Quality Improvement
Differences
Crosby Quality Definition Cost of Quality Conformance to Requirements Standard Definition Measure & Monitor Trends Project Improvement Teams (Employee based) Cultural change and motivational tools Juran Fitness for use Standard Definition Measure & Monitor Trends Top down driven Deming Customer defined requirements Monitor and understand process variations Project Improvement Teams (Employee based) No slogans due to lack of follow-up Use of basic statistics to understand the process
QI Approach
Background Impact on QI
Use of basic statistics to understand the process
Common Concepts
Top Management Leadership
Involved in quality improvement Provide leadership role Active and driven participation
Corporate Framework for Quality
Incorporation of commitment to quality in the organizational mission and values statements Quality Improvement must be a routine organizational activity.
Common Concepts
Cultural Transformation
Emphasize quality Seek improvement not blame
Quality Education and Training
Training at all levels mgmt and employees Develop a common understanding of quality Provide basic foundational skills in problem solving, cause-effect diagrams, data plotting and simple statistical principles.
Common Concepts
Continuous Quality Improvement
Do not rest on laurels Achieve new levels of quality Develop new products and services At the same time, reduce costs
Customer Role
Identify needs Measure and monitor satisfaction Develop management complaint systems
Common Concepts
Focus on System Improvement
Constant evaluation of process variations and their sources Remove variations through trans-cultural QI teams
Measurement and Experimentation
Measure characteristics associated with quality improvement Organization wide training in basic measurement tools and data analysis
Common Concepts
Recognition and Communication
Communicate constantly Recognize employee contributions to the total quality Share employee QI experiences
Quality Management Process
Integral part of daily management is critical to success and daily management activities should incorporate:
Quality Monitoring Quality Control Quality Planning and Quality Improvement
Gustafson Organizational Change Model
Model of Organizational and Individual Change
Feedback Tension for Change Monitoring Superior Attitude Commitment and Planning Change
Social Support
Skills and Self-Efficacy
Tension for Change
Identification of two sets of leaders
Innovators Have a history of trying new ideas Opinion Leaders Open to change, approach cautiously and respected by most in the organization.
Both groups must believe that organizational change needs to occur QI process must alleviate tension not add to it and see the future benefits of CQI.
CQI is a Superior Alternative
Innovators and Opinion leaders are more likely to seek implementation of CQI when they can
Understand and communicate its uniqueness See how the new alternative is superior to existing ways
Belief that CQI will correct important organizational weaknesses and open new opportunities well as as meet their own professional needs.
Why does CQI work?
Determine the customer needs Discovery
What does the customer expect? What does the customer want? How can the customer be helped?
Building Social Support
Social support systems provide a mechanism for individuals to discuss change with other through a) study groups, b) organizational meeting or c) professional organizations. Social support systems allow individuals to see themselves as one of many not facing the challenges of change alone. Successful change through social support is more likely to occur
Persons attempting change believe that those they respect
Are also changing Want them to change Will help them succeed
Believe that failure will not only impact them but their social support group
Skills and Self-Efficacy
CQI Transformation requires
Organizational developed training in concepts, tools and skills associated with CQI. Providing opportunities for practice and feedback.
Commitment and Plan to Change
When the first four steps are in place, the organization can began to consider change implementation which requires:
A commitment to change A plan for change
Pilot test the organizational changes to allow for problems to be address before an organizational wide deployment
Management Strategy and Schedule for Change should: Examine the corporate mission Is it consistent with CQI Select customers, discover needs and implement programs to meet the needs Develop a vision for the new organization
How is it different from the old organization
Develop a training plan CQI Initiatives Decide on resources and benchmarks
What is Next?
Beginning to Change
Change takes time Start small Once successful, roll out organizational wide
Monitoring and Feedback
What worked
Strengths Weaknesses
Mechanism for Feedback without fear of retribution
Group Process
Teamwork Cornerstone of QI Efforts Quality Improvement seeks to capitalize on the group process to solve complex problems collaboratively Healthcare systems have successfully implemented QI initiatives
Keys to Team Organization
Teams Mediums for Change but
Person(s) impacted by change must be on the team Motivation is highest when member is invested in the results All Team Members must work together for change
Recommended changes should support the teams purpose.
Keys to Team Organization
Change occurs when a shared perception of change is created Information must be available to everyone Change must be uniform throughout the group to avoid loss of group effectiveness.
Team Organizational Benefits
Capitalize on diversity
Brings different viewpoints and skills to focus on the problem
Promote greater buy-in for a project
Everyone is a champion for the project
Enhance organizational collaboration
Foster team work and new organizational relationships
How can a team be successful?
Meaningful and clearly defined task
Formed around specific tasks Task accomplishment is primary goal
Objectives should be clear and well articulated Members should have unique and meaningful tasks
How can a team be successful?
Individual performance should be assessed and appropriate feedback provided
Responsibilities Abilities and Interest Project interest determined during selection process Undergo conditioning to improve commitment
Discussion with team leader (Simple Objective) Formal Training (Complex Objective)
Regular Feedback concerning team success in meeting objectives
I. Project Selection
Viewpoints of key players should be considered:
Internal Customers Executive Management External Customers Regulators Accreditation Agency
Group Process Techniques
Development of Ideas
Brainstorming Brainwriting Nominal Group Technique
Idea Selection
Benefits and Barriers List Reduction Multivoting
Brainstorming
Produces ideas quickly and eliminate team stalemates Two key priniciples
Allows total team participation No commentary allowed
Wealth of Ideas generated
Brainstorming Steps
Single statement problem definition A "Who, What or How" Statement Idea consideration w/o discussion Record ideas verbatim with little or no editorializing (written or verbal) Continue process until no new ideas are generated
Brainwriting
The exercise is most beneficial when
The subject is controversial One or more persons may dominate the team thwarting brainstorming Steps
Provide paper Present problem like in brainstorming case Place five ideas on each sheet and place in center of the table Continue cycle until no new ideas are generated after 10 minutes Consolidate ideas from sheets and create a final list
Nominal Group Technique
Modified brainstorming exercise Useful when the team has
(1) dominant members (2) idea generation problems due to difficult interpersonal relationships (3) team is unusually reticent to deal with the issue or (4) reserved team interactions and creativity needs encouragement
Benefits and Barriers
Purpose is to clear identify the benefits of a particular idea and the potential barriers to implementation. The exercise can help overcome implementation problems and increase organizational acceptance Usually the exercise is utilized after idea generation but it can be used to determine the extent and locus of organizational resistance to change
Issues w/Benefits and Barriers
Clearly identifies but does not devise a plan to eliminate barriers Can create tension and "block" generation of idea interventions Always explore benefits before barriers to defuse emotions An outside facilitator may be beneficial Distribution of details regarding the proposed change must occur before the meeting Crucial when change is difficult for an organization to achieve
List Reduction
Used at the end of a brainstorming session to consolidate ideas in order to make them more usable. Provide opportunity for group dynamics to encourage teamwork to determine...