The increasingly complex needs of patients, an explosion of medical knowledge, and seismic shifts in healthcare systems have set the stage for a need for more effective communication. Success demands team-based approaches that are centered on close collaboration among all types of providers from across the care continuum. As a result, achieving the triple aim of improving quality, lowering costs and enhancing the patient experience can only be done with a significantly altered and improved communication strategy. The statistics cited by the Institute of Medicine IOM in a report 1 illustrate some of the challenges.
Processes that are inefficient and variable, changing case mix of patients, health insurance, differences in provider education and experience, and numerous other factors contribute to the complexity of health care.
The goals of measuring health care quality are to determine the effects of health care on desired outcomes and to assess the degree to which health care adheres to processes based on scientific evidence or agreed to by professional consensus and is consistent with patient preferences.
Because errors are caused by system or process failures, 5 it is important to adopt various process-improvement techniques to identify inefficiencies, ineffective care, and preventable errors to then influence changes associated with systems.
Each of these techniques involves assessing performance and using findings Effective practices in improving the quality inform change. This chapter will discuss strategies and tools for quality improvement—including failure modes and effects analysis, Plan-Do-Study-Act, Six Sigma, Lean, and root-cause analysis—that have been used to improve the quality and safety of health care.
The rationale for measuring quality improvement is the belief that good performance reflects good-quality practice, and that comparing performance among providers and organizations will encourage better performance. In the past few years, there has been a surge in measuring and reporting the performance of health care systems and processes.
One of the challenges in using measures in health care is the attribution variability associated with high-level cognitive reasoning, discretionary decisionmaking, problem-solving, and experiential knowledge. These measures are generally developed through a process including an assessment of the scientific strength of the evidence found in peer-reviewed literature, evaluating the validity and reliability of the measures and sources of data, determining how best to use the measure e.
Benchmarking in health care is defined as the continual and collaborative discipline of measuring and comparing the results of key work processes with those of the best performers 26 in evaluating organizational performance.
There are two types of benchmarking that can be used to evaluate patient safety and quality performance. Internal benchmarking is used to identify best practices within an organization, to compare best practices within the organization, and to compare current practice over time.
The information and data can be plotted on a control chart with statistically derived upper and lower control limits.
However, using only internal benchmarking does not necessarily represent the best practices elsewhere. Competitive or external benchmarking involves using comparative data between organizations to judge performance and identify improvements that have proven to be successful in other organizations.
Quality Improvement Strategies More than 40 years ago, Donabedian 27 proposed measuring the quality of health care by observing its structure, processes, and outcomes.
Structure measures assess the accessibility, availability, and quality of resources, such as health insurance, bed capacity of a hospital, and number of nurses with advanced training. Process measures assess the delivery of health care services by clinicians and providers, such as using guidelines for care of diabetic patients.
Outcome measures indicate the final result of health care and can be influenced by environmental and behavioral factors. Examples include mortality, patient satisfaction, and improved health status.
Twenty years later, health care leaders borrowed techniques from the work of Deming 28 in rebuilding the manufacturing businesses of post-World War II Japan. The TQM model is an organizational approach involving organizational management, teamwork, defined processes, systems thinking, and change to create an environment for improvement.
This approach incorporated the view that the entire organization must be committed to quality and improvement to achieve the best results. CQI has been used as a means to develop clinical practice 30 and is based on the principle that there is an opportunity for improvement in every process and on every occasion.
CPI, an approach lead by clinicians that attempts a comprehensive understanding of the complexity of health care delivery, uses a team, determines a purpose, collects data, assesses findings, and then translates those findings into practice changes.
From these models, management and clinician commitment and involvement have been found to be essential for the successful implementation of change. Shojania and colleagues 38 developed a taxonomy of quality improvement strategies see Table 1which infers that the choice of the quality improvement strategy and methodology is dependent upon the nature of the quality improvement project.
The lack of scientific health services literature has inhibited the acceptance of quality improvement methods in health care, 4344 but new rigorous studies are emerging.
It has been asserted that a quality improvement project can be considered more like research when it involves a change in practice, affects patients and assesses their outcomes, employs randomization or blinding, and exposes patients to additional risks or burdens—all in an effort towards generalizability.
This is a method that has been widely used by the Institute for Healthcare Improvement for rapid cycle improvement. Langley and colleagues 51 proposed three questions before using the PDSA cycles: The PDSA cycle starts with determining the nature and scope of the problem, what changes can and should be made, a plan for a specific change, who should be involved, what should be measured to understand the impact of change, and where the strategy will be targeted.
Change is then implemented and data and information are collected. Results from the implementation study are assessed and interpreted by reviewing several key measurements that indicate success or failure. Lastly, action is taken on the results by implementing the change or beginning the process again.
This method is applicable to preanalytic and postanalytic processes a. This method is suitable for analytic processes in which the precision and accuracy can be determined by experimental procedures.
One component of Six Sigma uses a five-phased process that is structured, disciplined, and rigorous, known as the define, measure, analyze, improve, and control DMAIC approach. Next, continuous total quality performance standards are selected, performance objectives are defined, and sources of variability are defined.
As the new project is implemented, data are collected to assess how well changes improved the process. To support this analysis, validated measures are developed to determine the capability of the new process.
This methodology overlaps with the Six Sigma methodology, but differs in that Lean is driven by the identification of customer needs and aims to improve processes by removing activities that are non-value-added a.
Steps in the Lean methodology involve maximizing value-added activities in the best possible sequence to enable continuous operations.Improving Healthcare Quality The National Quality Forum (NQF) is one of the many organizations working to improve the quality of healthcare in the U.S.
The quality of the healthcare that Americans receive varies greatly across social, economic, and geographic boundaries. This Primer introduces CQI concepts, strategies, and techniques a practice can use to design an effective CQI strategy for EHR implementation, achieve Meaningful Use of the system, and ultimately improve the quality and safety of patient care.
A practice can use CQI throughout the EHR implementation lifecycle. There is now a plethora of different quality improvement strategies (QIS) for optimizing health care, some clinician/patient driven, others manager/policy-maker driven.
improving practice management without access to timely metrics Texas Children’s efforts to improve operational efficiency and productivity were hindered by inadequate access to timely data and a lack of effective tools to manage key processes. 5 Ways to Improve Quality Whether you sell a product or a service, these five steps will help you ensure that you are constantly improving the way you do business--to the delight of your customers.
Improving Primary Care Practice Primary care is the cornerstone of health care that is effective and efficient and meets the needs of patients, families, and communities.
Our primary care system currently has significant—and perhaps unprecedented—opportunities to emphasize quality improvement (QI) and practice redesign in ways that could.