Department of Health Management and Policy

HMP-5100-01

Quality Improvement in Health Care Management

Resident MHA Program

Fall 2020

Syllabus

Tuesdays, 9 AM – Noon, Salus Center, Room 1411

Instructor:
Michael A. Counte, Ph.D.
Professor of Health Management
377 Salus Center
Office -314-977-8118, Fax – 314-977-1674
countem@slu.edu

Office Hours:
Tuesday, 8-9 AM or 12-1 PM, 377 Salus
or upon request
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Course Overview

Course Purpose and Objectives

HMP 5100 is an essential part of our Performance Improvement concentration in the SLU MHA
program. This course will critically examine the tasks and role of management in achieving
quality in an organization’s design, production, and delivery of health care services. Thus, it will
create a foundation for the student to begin to increase their knowledge and skills in the
continually evolving field of Performance Improvement. Its primary learning objectives are to
enable the student to:

1. Understand and apply theories, concepts, and tools for improving quality in health care
(Cognitive).
2. Identify, understand, and explain the roles and responsibilities of health services managers,
health professionals and organization employees for improving quality (Cognitive).
3. Understand and apply organizational and individual processes and skills essential to
continuous improvement and innovation (Affective)
4. Define who customers are, understand those customers, their needs and use that information
and create services to meet these defined needs (Affective).
5. Analyze and apply organizational and individual change strategies for improving quality in
health care organizations (Cognitive).

Background

In this course, we will adopt the following definition of quality improvement:

Quality improvement refers to a management system that aims at the continual increase of
customer satisfaction while reducing real costs. Quality improvement requires an organization-
wide strategy that involves all employees and requires knowledge of customer needs and
expectations. Quality improvement demands the application of systematic methods and tools for
data collection and group work to study and improve work and work processes and to evaluate
the impact of changes to reduce rework and waste. The foundation of quality improvement is
based on the Scientific Method. Quality improvement includes systems, methods, and tools of
process improvement. Quality improvement and quality management are anchored in values
that stress the dignity of the individual and the power of community action.
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Course material is widely applicable across different sectors of the economy and types of
organizations. Thus, we shall discuss applications and implementation issues in different types
of enterprises including manufacturing and service industries, high and low technology firms and
even the public sector of the American economy. The course is also constructed on the premise
that quality management is a complex topic because it is both a social/political as well as a
technical challenge. Thus, we will address a wide range of topics and will use a variety of
methods in studying quality management. There will be lectures, seminar discussions, video
recordings, readings and cases addressing the historical, managerial, and cultural aspects of
quality management. Focus will also be placed on the traditional statistical tools of quality
control including control charts, acceptance testing and experimental design. Terms such as
“Quality Improvement”, “Quality Management”, “Performance Improvement”, “Continuous
Quality Improvement (CQI)” and “Total Quality Management” will generally be
interchangeable. Finally, it is anticipated that students will enter this course with widely variable
levels of knowledge of quality management concepts and skills. Every attempt will be made to
provide all students with both a uniform basis of understanding and suitable opportunities to
apply relevant concepts and skills.

Competencies
MHA MHA Competency Level Course Assessment
Competency Learning Methods
Domain (B, I, A)
Objective(s)
2. Critical Thinking

2.1 Comprehend I 1, 3, 5 Case Studies

cause-and-effect
relationships Class
Discussion,
Midterm Exam
PI Project
4. Management

4.5 Understand I 2, 3, 4 Case Studies

principles and tools
of QI Class Discussion
Midterm Exam
PI Project
4.12 Understand I 1, 3, 4, 5 Case Studies
basic concepts of
management Class Discussion
engineering and work Midterm Exam
redesign
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PI Project
6. Communication
6.1 Develop, I 1, 2, 3, 5 Case Studies
organize, synthesize,
and articulate ideas Midterm Exam
and information PI Project
6.4 Write clearly and I 1, 2, 3, 4, 5 Midterm Exam
effectively
PI Project

Course Description

Course Format

This course will (at least initially) be presented in the traditional seminar format. Classes will
generally have a lecture-discussion (seminar format). To prepare for each session, the student
will need to thoroughly review assigned readings from the course texts (J. Johnson & W.
Sollecito, Continuous Quality Improvement in Health Care, Fifth Edition, Jones and Bartlett,
2020 and Thomas G. Zidel (Z), Lean Done Right, Health Administration Press, 2012), other
supplemental readings that are described later in this syllabus and case materials that are
distributed. It will always be assumed that class participants have reviewed assigned readings
and SLU Blackboard postings in depth prior to class sessions. Thus, class sessions will focus on
summarizing and clarifying concepts and issues versus simply reiterating what is in the assigned
readings. A special focus will be placed upon presenting every day, practical examples of the
concepts presented and describing the importance of such concepts to effective contemporary
quality improvement within health care organizations.

Another experiential-learning component this year will involve students working on Performance
Improvement projects (PIP). These small group projects will focus on analyzing operational
areas in different types of health care organizations. A major goal of these PIP projects will be to
allow students the opportunity to apply basic concepts and skills that they acquire in the class to
understand and hopefully improve operational issues encountered in everyday settings. In
addition, since quality improvement teams are a critical vehicle for change within organizations,
serving on a PIP will enhance personal understanding of the potential value of teamwork in
organizations and problematic issues that arise. A special emphasis this year will be placed on
projects that address Lean Design and Implementation. Cases for these PIP Projects are currently
under consideration and the final list of cases will be distributed by mid-September. Additional
descriptive details concerning the PI Projects are attached.
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During this course, there will be numerous occasions when relevant research findings are
presented and discussed. The results of health services management research projects are useful
because they help us to understand the importance of theoretical concepts and models in
explaining variation in everyday management practice in health care organizations and prompt
new directions for research in health services management.

Finally, if COVID 19 some variant returns in the Fall semester, the course will need to be shifted
to some type of online format. Thus, depending on the conditions and circumstances that may
arise, the learning format may continue to be face-to face, all online or hybrid (mix of both
modalities.) We all need to stay tuned!

Evaluation

Student performance in this course will be based on three criteria - a midterm exam, group
project performance (or final examination) and class participation. The midterm exam will cover
approximately the first one-half of the course material. The closed book exam will include 50
multiple choice questions that relate to significant issues addressed in course readings and class
sessions and the student will need to respond to all the questions presented. Class preparation
and participation in the group project case analyses and seminar discussions are important
components of graduate education in health services management. That is why part of the
student’s grade is based upon the extent to which students actively participate in class
discussions.

A student’s final grade will be based upon the following: midterm (45%), final project
presentation and report (45%) and class participation (10%). The grading scale will be:

A=95-100 A-=92-94 B+=89-91 B=86-88 B-=83-85

C+=80-82 C=77-79 C-=74-76

Feedback on Assignments
Timely feedback on assignments is needed in to assure that students are aware of their progress.
Students can expect prompt feedback on assignments. For example, for exams and project
reports, written evaluative feedback will be provided within two weeks after the due date. It will
be available either online or by distribution via the HMP Administrative Program Coordinator.
In the rare event that these deadlines cannot be met, students will be informed of the delay and
the extra time needed in providing feedback. Also, in-person meetings with the instructor are
readily available upon request.
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Attendance
Regular class attendance is an important part of one’s graduate education in health management
education. Students are expected to attend all scheduled class meetings. In rare circumstances
(e.g., illness, accident, death in one’s family), absences will be excused. However, if a student
misses more than seven (7) hours of a three-credit course, they may be asked to withdraw from
the course and re-take the course later.

Academic Integrity Expectations and Policy

Refer to the Google site for academic resources at https://sites.google.com/a/slu.edu/pdf-host-

site/policies-and-procedures for the module and policy. Note, you are responsible for completing
the academic integrity module during your first semester. If you do not complete it, you will not
be allowed to register for courses. Violation of Academic Integrity expectations and/or the Honor
Code Pledge may result in severe consequences/penalties, up to and including expulsion.

All students enrolled in College for Public Health and Social Justice courses are also expected to
abide by and uphold Saint Louis University’s Policy on Academic Integrity and Ethics. This
policy can be found at: the Google site for academic resources at
https://sites.google.com/a/slu.edu/pdf-host-site/policies-and-procedures.

Policy on Style for Citation and Plagiarism

Please refer to the Google site for academic resources at https://sites.google.com/a/slu.edu/pdf-
host-site/policies-and-procedures for the SLU policy on style and plagiarism.

Student Success Center Syllabi Statement

In recognition that people learn in a variety of ways and that learning is influenced by multiple
factors (e.g., prior experience, study skills or learning disability), resources to support student
success are available on campus. The Student Success Center, a one-stop shop, which assists
students with academic and career related services, is in suite 331 in Busch Student Center and in
suite 114 of the School of Nursing Building. Students who think they might benefit from these
resources can find out more about the SCC at the website listed below.
Course-level support (e.g., faculty member, departmental resources, etc.) is available by asking
your course instructor. University-level support (e.g., tutoring services, university writing
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services, disability services, academic coaching, career services, and/or facets of curriculum
planning) by visiting the Student Success Center or by going to slu.edu/success.

Disability Services Academic Accommodations

Students with a documented disability who wish to request academic accommodations are
encouraged to contact Disability Services to discuss accommodation requests and eligibility
requirements. Please contact Disability Services, located within the Student Success Center, at
disability_services@slu.edu or 314-977-3484 to schedule an appointment. Confidentiality will
be observed in all inquiries. Once approved, information about academic accommodations will
be shared with course instructors via email from Disability Services and viewed within Banner
via the instructor's course roster.
Additionally, if you would find it to be beneficial to your course content to list specific
information regarding writing assistance for undergraduate or graduate students, consider
including the following:
University Writing Services
We encourage you to take advantage of university writing services in the Student Success Center
because feedback benefits writers at all skill levels. Trained writing consultants can help with
writing projects, multimedia projects, and oral presentations. University Writing Services offers
one-on-one consultations that address everything from brainstorming and developing ideas to
crafting strong sentences and documenting sources. For more information, call 314-977-3484 or
visit the Saint Louis SLU Writing Services website.
Course Instructor

Dr. Counte is currently a Professor of Health Management and Director of the International Center
for Advances in Health Systems Management in the Department of Health Management and
Policy, College for Public Health & Social Justice, Saint Louis University. He has been on the
faculty of the Department of Health Management and Policy since August 1994. Previously
(1975-1994) he served as the Assistant Chairman of the Department of Health Systems
Management and Associate Director of the Center for Health Management Studies within Rush-
Presbyterian-St. Luke's Medical Center in Chicago, Illinois. He was a co-founder of the Rush
Center for Research on Health and Aging. Finally, while at Rush, he was also extensively
involved in the operational introduction and evaluation of quality management concepts and
methods and supported strategic planning efforts within the Rush System.

Since completing his graduate work in organizational behavior and health services research at the
University of Illinois in Urbana-Champaign, Dr. Counte has been extensively involved in the
design of multi-disciplinary programs within public health, medical and health services
management programs. His primary research interests focus upon evaluating the diffusion and
impacts of large-scale organizational change (especially the implementation of comprehensive
management information systems and quality management initiatives) and the effects of changes in
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health care policy such as value-based/pay-for-performance initiatives and managed care programs
upon affected populations, especially older adults. He has co-authored several professional texts
and over fifty refereed research articles and chapters. He recently led a team of academicians to
produce a new text entitled Advances in Global Health Management and Policy (2019, Health
Administration Press.)

Dr. Counte serves as a research and health care management development consultant to numerous
organizations and agencies including the National Institute for Nursing Research, National Institute
on Aging, National Institute on Drug Abuse, Agency for Health Care Policy and Research, US
Agency for International Development, Department of Veterans Affairs, Centers for Disease
Control, and the National Cancer Institute. He has also helped to design, implement, and evaluate
major international health care management development and education projects.
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Course Schedule

Session Date Topic(s), Learning Objectives and Reading

Introduction 8/18 Health Care Reform, Value Based Payment for Health Services
and Quality Assessment and Improvement (Independent Study &
Analysis-see Addendum for Details)

Assigned Reading (see Blackboard): 1. VISITPAY Report, pp 1-

29, 2020; 2. Overview of CMS Value Based Programs, 2019; and
3. Baldrige Excellence Builder (2019-2020)

1 8/25 Introduction, Course Expectations and Basic

Quality Management Concepts (1- 2, 4)
R&S 2020, Chapters 1-2
Commonwealth Fund, Framework for a High-Performance Health
System for the US, Commonwealth Fund Pub. #943, August 2006

2 9/1 Process Design and Redesign (3)

R&S 2020, Chapters 3-4
Chapters 1-3, Zidel, 2012
Liker & Morgan, “The Toyota Way in Services: The Case of Lean
Product Development,” Academy of Management Perspectives,
20(2): 5-20, 2006.
Berwick, “Taking Action”,
Quality Connection, 5(4): 1-3, 1996
Perry, “History of QI”, Journal of Oncology Practice, 2014\

3 9/8 PI Project Case Assignments and Initial Meetings (3-5)

R&S 2020, Chapter 5
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Chapters 4-6, Zidel, 2012

Marjona & Bozic, “Quality in US Healthcare,”
CRMM, 2012
Ronen & Pliskin, “The Hidden Hospital,” Quality Progress, 2020

4 9/15 Clinical Quality Assessment in Health Care (2, 4)

R&S 2020, Chapter 6
Chapters 7-8, Zidel, 2012
Batalden, “ Getting More from Healthcare”, BMJ, 2018

5 9/22 Quality Improvement & Assessment Tools (3, 5)

R&S 2020, Chapter 4
Chapters 9-12, Zidel, 2012
Hughes, “ QI Tools & Strategies,” NCBI, 2008

6 9/29 Process Variation and SPC Tools

7 10/6 Outcome Model of Health Care Quality (1,3, 5)

& Pre-Midterm Review
Teisberg, Wallace & O’Hara, “Value Based Health Care”,
Academic Medicine, 2020

--- 10/13 MIDTERM EXAMINATION (1-4)

8 10/20 Implementing Statistical Process Control (4-5)

Berwick, “Controlling Variation in Health Care,”
Medical Care, 29(12):1212-1225, 1991.
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PI Project Meeting 2 & Progress Report (3-5)

9 10/27 Importance and Assessment of Customer

Satisfaction (4)
R&S 2020, Chapters 7-8
Chapters 13-14, Zidel, 2012,
Goldman & McGlynn, “Cost, Quality
And Access,” RAND Corporation, 2005

10 11/3 Baldrige Award Evaluation Process

PI Project Meeting 3 & Progress Report
11/19 Implementing CQI Initiatives (3-5)
R&S 2020, Chapters 9-11
Chapter 6, IOM, 2001
Dixon-Woods, McNicol & Martin, “Challenges Facing QI,”
Health Foundation, 2018

11 11/10 Strategic Quality Planning & Performance Assessment (3-4)

R&S 2020, Chapters 12-13
Chapters 13-16, Zidel, 2012
Sahney & Warden, “Role of CQI in the
Strategic Planning Process,” QMHC, 1(4):1-11, 1993
Kaplan & Norton, “The Balanced Scorecard,”
HBR, January-February 1992
PI Project Oral Reports #1-4

12 11/17 CQI, Clinicians and Information Systems (2-3)

Guest Speaker: Beth Page, Director of Quality & PI, SLUCare
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PI Project Oral Reports #5-7

13 11/17 CQI Effects on Organizational Performance: The Evidence

R&S 2020, Chapter 14
.

14 11/24 PI PROJECT WRITTEN REPORTS (1-7)

DUE BY 12 NOON , ELECTRONIC SUBMISSION
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SYLLABUS ADDENDUM:

Health Care Reform, Value Based Payment for Health Services

and Quality Assessment and Improvement (Independent Study & Analysis)

During your first year in our MHA program and your summer internship you learned about
continual changes in US health policy and their impacts on the financing and management of
health service organizations. The general goal of this independent study and analysis to increase
your understanding of changing health care consumer expectations, the current and future
impacts of our new Value-Based Reimbursement System and the rapidly growing need to
accelerate Performance Improvement in Health Care Organizations. This independent study is
intended to ensure that all students understand the major underlying issues that will be addressed
throughout the semester.

Each student needs to individually prepare their analysis and comments. There are three
questions that I would like you to address:

1. What are 2-3 major and widespread changes in health care consumer expectations? How
do health care organizations need to respond?
2. What are the major goals of Value-Based Payment? Once again, how do health care
organizations need to respond?
3. What are the major goals of the Baldrige Excellence award? When and why should a
health care organization decide to seek out and prepare for a Baldrige award?
4. Did you work last summer on any Performance Improvement projects?

Please prepare your comments to the questions (restrict to one typed page) and send them to me
via email at countem@slu.edu by 8/18/20. All students will receive extra credit for this project.
We will discuss the results during the start of our in-class session (8/25) at 9 AM, 1417 Salus.
Good luck!
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GROUP PERFORMANCE IMPROVEMENT PROJECTS (PIP)

Background

In many respects, theories of Continuous Quality Improvement (CQI) and Total Quality
Management (TQM) represent a major shift in our thinking about understanding and improving
work processes in health care organizations and their outcomes. Namely, such approaches
assume that the only way to significantly improve any organization is to reduce process variation
through the application of “statistical thinking.” The basic ideas underlying statistical thinking
include the following:

 All work is a series of interconnected measurable processes.

 All processes exhibit variation, which impairs their predictability.
 Performance improvements are made through the understanding and reduction of
inappropriate and unintended variation.
Broad Goals
During this course you will be exposed to many new ideas and techniques that are
widely used in PI efforts. One major goal of the Group PI Projects is to help you learn how these
new ideas and techniques can be used to address complex organizational problems. Also, your
service as a team member should help to sensitize you to both the potential contributions of PI
teams and pitfalls that may arise. Thus, participating in these teams will hopefully prove to be
both interesting and educational.
Diagnostic Journey
Given the time constraints that you face and your limited knowledge of the operational
issues that are under study, your Group PI Project/Case Study will primarily focus on the
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diagnostic component of quality improvement. More specifically, your group will concentrate
on addressing one or more of the following issues:

1. What is the specific problem that the organization is confronting? How would you
characterize its symptoms?
2. What are the specific steps that comprise the process?
3. How can you measure variability in the process?
4. What are the major underlying causes of variability?
5. How can the organization fix major problems that are identified?
6. What additional performance improvement opportunities did you team identify?
7. How can the organization benchmark its current and future levels of operational
performance?
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>Oracle Service Humor Mailing List wrote:

>>
>> A Japanese company and a California company decided to have a canoe race on
>> the Columbia river. Both teams practiced hard and long to reach their peak
>> performance before the race.
>>
>> On the big day, the Japanese won by a mile.
>>
>> Afterwards, the California team became very discouraged and depressed. The
>> management of the California company decided that the reason for the
>> crushing defeat had to be found. A "Measurement Team," made up of senior
>> management was formed to investigate and recommend appropriate action.
>>
>> Their conclusion was that the Japanese had 8 people rowing and 1 person
>> steering, while the Californians had 1-person rowing and 8 people steering.
>>
>> So the management of the California company hired a consulting company and
>> paid them incredible amounts of money. They advised that too many people
>> were steering the boat and not enough people were rowing.
>>
>> To prevent losing to the Japanese again next year, the rowing team's
>> management structure was totally reorganized to 4 steering supervisors, 3
>> area steering superintendents and 1 assistant superintendent steering
>> manager. They also implemented a new performance system that would give
>> the 1 person rowing the boat greater incentive to work harder. It was
>> called the "Rowing Team Quality First Program," with meetings, dinners
>> and free pens for the rower. "We must give the rower empowerment and
>> enrichment through this quality program."
>>
Fall Semester 2020 - HMP5100-01 Page 18

>> The next year the Japanese won by 2 miles. Humiliated, the management of the
>> California company laid off the rower for poor performance, halted
>> development of a new canoe, sold the paddles and canceled all capital
>> investments for new equipment. Then they used the money saved by giving
>> a High-Performance Award to the steering managers and distributed the rest
>> of the money as bonuses to the senior executives.
>>