Professional Documents
Culture Documents
Q Soln 1
Q Soln 1
I nformation Management
Robert J. Rosati, PhD
Glenview; IL
Other titles in the Q So/ufions Suite
and Manqement
L e ader ship
Copyright @ 2OI2 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.
Contents
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l.HistoricalPerspective,Background,andCurrentlnitiatives ........,
A. QualityManagementPhilosophy. ......1
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C. PolicyandHealthcareQuality. ........ 13
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l.Releaseof lnformation..... ........18
lnformation.....
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2.Authorized Releaseof ......l8
B. MedicalPeerReview .........19
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C. Utilization Management ... . .. t9
1. lnternal Review. . .. . .19
2. ExternalReview .....19
D. MedicalRecords/ElectronicHealth Records(EHR, ..........20
l.lnformation Covered by Privilege . .. 20
2. Patients'Billof Rightsand Responsibilities ...........21
vi Q SoluUions
lX.QlStudyDesignandAnalysis .......58
A. Getting Started on QPI Projects .. .. .. 38
B. DataandDataManagement ..........39
1. Categorical...... ..........39
2.Continuous...... .........40
3. Statistical Power of Different Data Types ... . 40
C. Data Collection Plan . . ...... .4O
D. BasicSamplingDesigns .......41
1. Types of Sampling ..........41
a. Probability ......41
b. Nonprobability .. ...... . 41
2.SampleSize.. ......42
E. DataAnalysis. ........42
l. Reporting ..........42
2. lmportanceof Context ......43
S.Variation ...........43
4.Tiend ldentification .........43
F. StatisticalAnalysisand lnterpretationof Findings ......43
1. MeasurementTools .........43
2.Reliabiliry ..........43
a. ReliabilityCoefficient. ..........43
b. lnterraterReliability .....44
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:. Validity .... 44
a. Content(Face)Validity..... ....44
b. ConstructValidlty ......44
c. Criterion-RelatedValidity ..... .........44
4.StatisticalTechniques .......45
a. Measuresof Central Tendency ..........45
1) Mean. ......45
2) Median. .....45
3) Mode. ......46
b. Measures of Variability. ... .. .. . .46
1) Range, ......46
2) StandardDeviation. .........46
c. lnterpercentile Measures..... -. ----.-..47
S.Tests of StatisticalSignificance. .... '.47
a. ParametricTests.. ......48
b. NonparametricTests ....49
I 6. Concepts Related toTests of Significance..... ... ' ' 50
a. Confidencelntervals ....50
b. Levelof Significance..... ...'..51
G. PerformancelmprovementTools ...." 51
1. Decision-Making MethodsandTools ........51
2. Data Analysis and Process Improvement
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3. Statistical Process Control ....... '..62
a.Typesof Variation ----.....64
X. Summary .. ..... 70
References 71
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Suggested Reading. 74
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Tables
Table 1. Comparison of Six Sigma Breakthrough Strategy and Juran! Problem-Solving Strategy .... . 9
Gble 2. Process.
Research ProcessVersusQl ......21
Table s. Projects.
Examples of Benchmarking .... . 28
Figures
Figurel. TheTiaditionalPlan-Do-Check-ActModel . ......4
Figure2. QualityMovementTimeline ......6
Figure 3. Health lnsurance Portability and Accountability Act of pga. . . . . , , .18
Figure4. Patients'Billof Rightsand Responsibilities. .......22
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 quality 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 qualiry 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 Solurions
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 Solutions was informed by the most recent
Healthcare Qualiry Certification Commission's (HQCC's) practice analysis. The practice
analysis assesses the current functions and competencies for certified professionals in
healthcare qualiry. Organized under the HQCC detailed content outline, the following
modules were created:
, Leadership andManagement
. quality andPeformance Improvement
. Healthcare Safety
. Information Management
. ReSu lat ion, Accre ditation, and C ontinuous Readiness.
These modules feature critical components of healthcare qualiry 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 emerging 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 qualiry
challenges. This is accomplished in many ways including affiliations with professional
groups such as the National Association for Healthcare Qualiry (NAHQ).
Q Solurions 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
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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; Sr.rsan 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
examinaticln by our external review panel members-James B. Conway, MS LFACHE;
Gerald N. Glandon, PhD; John Hansen, MD MPH; Bernarcl 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 successflil launch of the third
edition of Q Solutions.
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 nobiliry 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
. 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 continuoLls readiness, including health
information technology that supports the continuous quality improvement paradigrn
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 growing body of healthcare qualiry science by sharing evidence-
based, outcomes-oriented qualiry 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 So/urions 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 national
healthcare safery 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.
xll Q SoluEions
Christy L. Beaudin, PhD LCSW CPHQ FNAHQ, is national director of quality for AIDS
Healthcare Foundation in Los Angeles, CA. In her current role, Dr. Beaudin is responsible
for healthcare safety, 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 development 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
Quality Assurance (NCQA), URAC, Accreditation Association for Ambulatory Health
Car.e (AAAHC), 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 University, 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.
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Acknowledgment
We would like to acknowledge Jacqr-reline F. Byers, PhD RN NEA-BC CPHQ FAAN, who
co-authored relevant content in the first two editions of Q .So/utions.
lnformation Management
Learning objectives
1. Develop an understanding of activities required for the design and collection of data (e.g., activities,
records, reports and committee meetings).
2. Recognize tools and approaches useful in designing and constructing quality and performance
improvement activities (e.g., principles of qualitative and quantitative data collection).
5. Apply process analysis tools, basic statistical techniques and methods for statisticaI process control.
4. lnterpret data to support decision making and promote change to advance qLraliry- and performance
excellence in healthcare.
B.
Early Strategies of Managing for Quality
The need for quality has always existed. However, the means for meeting that need-the
processes of managing for quality-have undergone extensive and continuing change (Ju-
ran,1977). Before the 20th century managing for quality was based on ancient principles
that included product inspection by consumers, which is still widely used in today's villages,
and marketplaces concept, with which buyers rely on the skill and reputation of trained, ex-
perienced craftsmanship. Some craftsmen develop reputations that extend far beyond their
village boundaries. They are viewed as lirring national treasLlres.
As commerce expanded beyond village boundaries and with the $owth of technology,
additional methods and tools were invented to assist in managing for quality:
. Specifications by sample
. Quality warranties in sales contracts.
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In large towns, the craftsmen organized into monopolistic guilds, which generally were
strict in their enforcement of product quality. Their strategies included
. mandated specifications for input materials, processes, and finished goods;
. audits of the performance of guild members; and
o export controls on finished goods.
The early approach to managing for quality in the United States followed the prevail-
ing practice in European countries that had colonized the North American continent. Ap-
prentices learned a trade, qualified to become craftsmen, and in due course might become
masters of their own shops.
The Industrial Revolution, which originated in Europe, created the factory system,
which soon outproduced the small independent shops and made them largely obsolete. The
craftsmen became factory workers, and the masters became factory foremen. Quality was
managed as before, through the skills of the craftsmen, and supplemented by departmen-
tal inspection or supervisory audits. When the Industrial Revolution spread to the United
States, Americans again followed European practice. The Industrial Revolution also accel-
erated the growth of additional strategies, including
. written specifications for materials, processes, finished goods, and tests;
. measurement and the associated measuring instruments and testing laboratories; and
. standardization in many forms.
1. World War ll and lts lmpact
During World War II, U.S. industry was faced with the added burden of producing enormous
quantiiies of military products.Apart of thewar strategywas to shutdown production of many
civilian products such as automobiles, household appliances, and entertainment products.
A massive shortage of goods developed amid a huge buildup of purchasing power. It took the
rest of that decade (the 1940s) for supply to catch up with demand. In the interim, manufac-
turing companies gave top priority to meeting delivery dates, so quality of products suffered.
The practice of givingtop prioriry to delivery dates persisted longafter the shortages ended.
A new strategy emerged during World War II: statistical quality control (SQC). The War
production Board, in an effort to improve the qualiry of military goods, sponsored numer-
ous training courses on the statistical techniques developed by the Bell System during the
1920s. (Interestingly, W. E. Deming, who became widely known during the 1980s, was one
of the lecturers at some of the War Production Board courses) Many training course at-
tendees became enthusiastic and organized the American Society for Quality Control (now
known as American Sociery for Qualiry [ASQ). In its early years ASQ was strongly oriented
toward SQC, thereby stimulating further enthusiasm for the method.
As it turned out, most SQC applications in the manufacturing companies were tool-
oriented rather than results-oriented. As long as government contracts paid for everything,
the companies could not lose. In due course the government contracts came to an end and
the SeC proglams were re-examined from the standpoint of cost-effectiveness. Most of
them failed the test, resulting in wholesale cutbacks.
2. The Japanese Quality Revolution and lts lmpact
After World War II, the Japanese embarked on a course of reaching national goals through
trade rather than military means. The major manufactttrers, which had been extensive-
ly involvetl in military production, were faced with converting to civilian products. A ma-
jor obstacle to selling these products in international markets was a reputation for shoddy
merchandise, created by the export of poor-qualiry goods before World War II.
lnformation Management 3
To solve their quality problems, the Japanese learned how other countries managed for
quality, sending teams abroad t6 visit foreign companies and study their approaches. They
also invited foreign lecturers to Japan to conduct trainingcourses for managers.
As the result of this educational process, the Japanese devised unprecedented strategies
to create a revolution in quality. Several of those strategies proved crucial:
. Upper managers personally took charge of leading the revolution.
. All levels and functions underwent training in managing for quality.
. QPI was undertaken at a continuing, revolutionary pace.
. The workforce was enlisted in QPI through the qualiry circle (QC) concept. QCs in-
volve employee participation in decision making and problem solving to improve the
quality of work.
During the early postwar period, American companies logically considered competi-
tion from the Japanese to be based on price rather than quality. Their response was to
shift the manufacture of labor-intensive products to low-labor-cost areas, often offshore.
As time went on, price competition declined while quality cornpetition increased (Juran,
1981). During the 1960s and t970s, numerous Japanese manufacturers greatly increased
their share of the American market; a major reason was the superior quality of their prod-
ucts. Numerous industries were affected (e.g., consumer electronics, automobiles, steel,
and machine tools).
U.S. companies generally failed to notice the trend, continuing to believe that competi-
tion from the Japanese primarily was price-based rather than qualiry-based. Some observ-
ers sounded warning signals: "The Japanese are headed for world quality leadership and
will attain it in the next two decades because no one else is moving there at the same pace"
(Juran, 1967). The alarm was sounded at the conference of the European Organization for
Quality Control in Stockholm in June 1966.
The most obvious effect of the Japanese qualiry revolution was the massive export of
goods. The impact on the United States was considerable, especially in sensitive areas such
as manufacturing, steel, and electronics. The affected manufacturing companies were dam-
aged by the resulting loss of sales. The workforce and their unions were damaged by the
resulting "export of jobs." The national economy was damaged by the resulting unfavorable
trade balance.
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solutions
2. Deming
"gurus." A statis-
W. Edwards Deming is probably the most famous of the industrial quality
tician with doctorates in mathematics and physics, he ultimately became the "philosopher"
of qualitv and the learning organization. The story of post-World War II America's rejec-
tion of Deming's quality exhortations-and of his subsequent dealings with a receptive Ja-
pan-now is legend (Merry, l9g2).In the 1950s Deming had visited the Western Electric
Hawthorne plant in Chicago (while the Harvard University study regarding motivation of
workers was in progress). Following this experience he proposed replacing traditional
management techniques with a statistically controlled management process to determine
when-and when not-to intervene in a process. Statistical process control (SPC) techniques
allow management to determine a range of random variation that always occurs in a pro-
cess. SpC describes two types of random variation causes: common cause and special cause.
Common-cause problems are rooted in basic processes and systems. Special-cause problems
stem from isolated occurrences that are outside the system. Deming said that 85% of the
problems detected are process- or system-related, and 157o are traceable to individuals; this
is known as the "B;f11theory" (Deming 2000a). Deming's management philosophy is based
on his t4 points for business to be competitive.
l. Create a constancy of purpose toward QPI.
2. Adopt a philosophy that expects good products and services.
3. Cease dependence on mass inspection and build qualiry into the product or service.
4. Do not award business solely on price tag.
5. Improve constantly the system of production and service-
6. Institute on-the-job training.
7. Institute leadership with an arm to help people and machines do better jobs.
8. Drive out fear.
9. Break down barriers between departments.
10. Eliminate slogans, exhortations, and targets.
[. Eliminate number quotas and management by objective, and substitute leadership.
12. Remove barriers to pride of workmanship.
13. Institute education and self-improvement.
14. Take action to accomplish the transformation (Deming, 2OOOa,2000b).
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lnformation Management
3. Juran
Joseph Juran's background was in errgireering and law. He followed Deming to Japan after
World War II, emphasizing the key role of top organizational leadership and the quality pro-
cess in the organi zatior. (Merry, Lg92).In Juran on Leadership for Quality (1989), Juran states
that quality is "product performance that results in customer satisfaction; freedom from
product deficiencies which avoid customer dissatisfaction" (pp. 16, 31). This concept is known
as fitness for use and is explained in Juran's Trilogy@. Juran states that the cost of quality ac-
coLu-rting means there is a break-even point of less than 1007o. Beyond a certain point, the
cost of providing quality exceeds the value of the incremental improvement in quality. Juran's
Trilogy is analogous to certain familiar financial processes. Quality planning is equal to bud-
geting, quality control (sometimes called measurement) is comparable to cost control, and
QPI relates to cost reduction and margin improvement (Gaucher & Coffey, 1991).
4. Crosby
In the 1970s and t980s Philip B. Crosby developed an important concept known as the cost
of fpoorl quality. His work documented that high qualiry (what he terms "conformance to ex-
pectations') is less costly than the waste and rework that characterizes poor-quality pro-
cesses. Crosby demonstrated conclusively that investment in qualiry can offer an enormous
financial return (Merry lg92). Five stages of management maturity are identified by Cros-
by in his book, Quality ls Free (tgzg). Crosby's underlying philosophy is "Do it right the first
time." The stages are
l. Uncertainty (when an organization is characterizedby the statement, "We don't know
why we have qualiry problemsJ')
2. Awakening
3. Enlightenment
4. Wisdom
5. Certainty (reserved for organizations in which top management proclaims, "We know
why we don't have quality problems." The mature company is equipped to initiate a
quality improvement (QI) program [Hunt, 1992])-
Crosby identifies 14 steps to improve qualify and move a company toward "certainty."
1. Management is committed to qt.
2. A QI team is formed to oversee actions.
3. Qualiry measurement is undertaken appropriate to the activities undergoing
improvement.
a. Qualiry cost is evaluated, using estimates as necessary'
5. Quality awareness is promoted through various methods and supervisor involvement'
6. Corrective actions are generated in response to steps 3 and 4.
7. Zero-defects planning is tailored to the company and its products.
8. Supervisory training is undertaken at all management levels.
9. A zero-defects day is held to celebrate a new performance standard.
10. Goals are set for individuals and groups.
11. Error cause is removed by management after notification.
D. Goals are met and recognized.
13. The qualify council's experiences, problems, and ideas are shared.
14. The process is repeated. (QI is a never-ending process.)
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5.lshikawa
Kaoru Ishikawa \Mas'one of Deming's early Japanese hosts and inventor of the cause-and-
effect, or fishbone, diagram and is credited with using the term total quality control to imply
not just the operational but also the total organizational commitment (marketing, finance,
research) needed to fully actualize all components of the modern quality-committed orga-
nization. The preferred American term is total quality management (TQM; Merry, 1992).
D. Healthcare Quality Management Pioneers
A timeline for the quality movement, which began in the lgth century and continues into
the 21st century, is described in this section and in Figure 2.
191 8 The American College of Surgeons develops minimum standards for hospitals and conducts its first
1950 Donabedian formulates a theoretical framework for patient care evaluation (structure, process, out-
comes). The Joint Commission on Accreditation of Hospitals (now The Joint Commission) is
formed; accreditation of hospitals begins in 1953.
1960 Japan focuses on becoming a world quality leader; adopts the Deming management philosophy.
1970 Juran and Crosby build on Shewhart and Demingi work; Plan-Do-Check-Acti Plan-Do-Study-Act
cycles emerge.
2000 Six Slgma, Lean Enterprise, rapid cycle improvements, safety, and pay for performance begin to have
an impact on healthcare quality.
2002 Medicare begins a series of quality measurement and reporting initiatives starting with nursing homes,
followed by home health care, and eventually hospitals and physicians.
2010 The Patient Protection and Affordable Care Act is signed into law.
2. The Second Era: Donabedian and The Joint Commissioni Monitoring and
Evaluation Process
Accreditation standards evolved slowly throughout the 1950s and early 1960s. At the aca-
demic level, the Universiry of Michigan's Avedis Donabedian, MD, examined existing re-
search, formulating a theoretical framework for patient care evaluation (Donabedian, 1980).
He is best recognized for his'structure, process, outcomes" model of quality evaluation.
This model suggests the importance of relating healthcare structures (qualifications
of practitioners and facilities and technology available to ttrem) and processes (activi-
ties involved in prevention, diagnosis, and treatment) to outcomes (how patients fare as a
result of their care). In the past Joint Commission standards mainly reflected the structure
and process elements of this model. Surveyors, who reviewed the structures and processes,
assessed hospital plans and technology, qualifications of clinicians and administrators,
and organizational structures against the annually updated requirements contained in the
Comprehensive Accreditation Manualfor.Flospitals. Specialized standards for behavioral health
and other services were also developed. Surveyors inferred process from documentation and
discussion. They reviewed minutes and interviewed clinical and administrative leaders to as-
certain whether designated individuals were following proper quality evaluation processes.
As a matter of policy and practical considerations, accreditation standards did not address
patient outcomes directly. First, there were problems with the way "quality" was measured.
Second, no professional consensus existed on systematic measures of patient outcomes. Fi-
nally, uniform and comparable clinical databases were nonexistent. The problems of mea-
suring and interpreting patient outcomes precluded their practical use in accreditation. As
a consequence, the accreditation process was necessarily built on an implicit assumption
that if proper structures and processes were in place, good outcomes were likely to follow.
3. The Third Era: Berwick, Batalden, and James "Discover" Deming, Juran,
and'Japan, lnc."
The names of Donald Berwick, MD, Paul Batalden, MD, and Brent James, MD, stand out
in the field of healthcare quality management. Like many of their colleagues, these physi-
cians were dissatisfied with traditional healthcare quality assurance (QA) practices. These
pioneering physicians, however, went beyond a mere critique of existing QA. Both Ber-
wick and Batalden researched the industrial methods publicized by the Japanese experi-
ence. Arising from this research, Berwick's article describing healthcare QA as based upon
the "Theory of the Bad Apples' has become a classic (Berwick, 1989). Among his many con-
tributions, Batalden translated Deming's famous 14 points (Crosby, 1979) into a healthcare
context (Batalden & Buchanan, 1989). InL987, these two physicians played key roles in link-
ing with the Juran Institute and a variety of industrial quality consultants to create the Na-
tional Demonstration Project on QPI in Healthcare. This multiyear project and its'original
21 forward-looking healthcare organizations conclusively demonstrated the applicability of
TQM processes to healthcare (Berwick, Godfrey, & Roessner, 1990).
James, of the Intermountain Health System, also was a pioneer in applying QPI pro-
cesses directly to patients and clinical outcomes. The success of James and his team has
been measured not only in improved results in a single hospital, but also across the entire
multihospital system (James, 1990). James founded the Institute for Health Care Deliv-
ery and Research at Intermountain Health in Utah with a vision "to improve quality and
reduce the cost of healthcare services by providing technical support and education for
clinical research and process management within the Intermountain Healthcare system"
(Intermountain Healthcar e, 2Ol2).
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Measure
Characterization Diagnostic journey 3. Analyze symptoms
Analyze 4. Formulate theory of causes
(Understand current 5. Test theories
performance levels) 6. ldentif,v root causes
Optimization lmprove Remedialjourney 7. Consider alternative solutions
Control 8. Design solutions and controls
(Achieve breakthrough 9. Address resistance to change
improvement) 10. lmplement solutions and
controls
and medication errors and eliminating duplicated tests (Barry, Murcko, & Brubaker,
2002).
2. Lean Enterprise
The Japanese automotive industry initiated the concept of lean manufacturing, whereby
great importance is given to reducing waste and focusing on activities that add value for
the custom er. Lean enterprise has in its roots the work of Deming but also includes a Japa-
nese approach to business management. There has been growing interest in applying sim-
ilar principles in service industry environments including healthcare. Lean enterprise in-
cludes the application of value stream analysis, a tool for exposing waste, and root cause
analysis, which is a method for pursuing perfection. Lean enterprise also includes the use
of new technologies to facilitate more efficient practices. Jones and Womack (2003) de-
scribe the philosophy in their book,LeenThinking.
The major focus in a lean enterprise is to eliminate waste in the following areas: produc-
tion, waiting time, inappropriate processing, inventory, transporting, and defects (Jones &
Womack, 2OO3; Martin,2003). One of the major distinctions of the lean approach versus tra-
ditional QPI is its emphasis on investigatingnewways to get things done and makingchanges
in a short period of time. The basic idea is to identify new procedures that should be more
effective than existing systems in eliminating waste. QPI typically has used the incremental
change model, but lean enterprise is more about total redesign. A key element of success is
the commitment and involvement of workers in the change process. The typical project will
include cross-functional teams that have been trained in lean enterprise principles and tools.
It is probably better for an organization to implement lean methods before considering Six
Sigma because waste should be eliminated before fine-tuning the system to deliver excellence.
3.
Reengineering
In the 1990s reengineeringwas one of the major initiatives in hospitals. Most of these efforts
were focused on workforce redesign. There typically was a focus on restructuring systems
10 Q SoluEions
and departments into more efficient processes. For example, hospitals experimented with
creating new positions that combined work from several different areas. A focus on cross-
functional capabilities led to the dissolution of departmental "silos." A "patient services asso-
ciate" or "technical associate" would deliver meals, clean patient rooms, stock supplies, and
provide patient transportation. Many hospitals thought that reengineering would increase
profit margins and create financial stability. The problem 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 favor and been replaced by other improvement models and initiatives.
The more contemporary approach is to consider adopting the lean enterprise method to
increase financial stability by eliminating waste.
4. Rapid Cycle lmprovement
The IHI developed the "collaborative" approach, termed the "Breakthrough Series," to
bring about rapid cycle improvements. Fundamental to the collaborative approach is the
acceptance of a model and establishment of infrastructure through which collaborating or-
ganizations can identify and prioritize aims for improvement and gain access to methods,
tools, and materials that will enable them to conduct sophisticated, evidence-based QPI
activities they could not conduct individually. The key elements of success are enlisting a
broad range of "partners," using evidence-based practice (EBP) to improve quality of care,
and developing tool kits that contain essential information and resources for change. At the
core of the collaborative approach are PDCA cycles that build on incremental improvements.
The primary benefit to organizations that participate in the Breakthrough Series is they can
learn from other organizations' successes and failures. Another key principle to the IHI ap-
proach is the concept of spread. IHI has proposed that successful small-scale improvement
efforts initially will affect individual organizations and spread later to the industry (i.e., oth-
er hospitals) and eventually to the entire healthcare system. The spread is fostered through
learning sessions during which organizations share their experiences. The IHI approach also
can be adapted to a single organization (the work begins within a few units or teams and then
is spread to other units and, eventually, the entire organization).
The IHI also developed virtual support tools for improvement. For example, IHI re-
cently launched expeditions, which are "topic-specific, action-focused program[s], lasting
3-5 months, designed to help frontline teams make rapid improvements in key components
of the Improvement Map" (a free, interactive, Web-based tool designed to bring together
the best knowledge available on the key process improvements that lead to exceptional
patient care; IHI, 2012, para.2).
F. Focus on Patient Safety
In the 21st century eliminating medical errors has become the major push throughout the
healthcare industry. Whether the focus is on medications or surgery the goals are the same-
to assure patients they are being treated in an absolutely safe environment. There also is a
regulatory component to patient safety, as identified in Joint Commission, federal, and state
mandates for the reduction of medical errors. There are many proposed solutions to im-
proving patient safefy, from computerizing order entry systems to having patients indicate
I
on their bodies, using markers, the area to be operated on. To increase patient safery health-
I
care organizations need to conduct a thorough analysis of where and how patients are at risk
for potential medical errors. Byers and White QoO4) suggested that approaching patient
safety within an organization requires a review in six key areas: structure, environment,
I
equipment/technologies, processes, people, and leadership/culture.
l
I nformation Management 11
Evaluating structure involves reviewing whether the general facilities are designed to
promote safety and if the righf supplies are being ordered and if policies and procedures
address safery considerations. Factors related to the environment include an assessment of
lighting, temperature, noise levels, surfaces, storage, and ergonomics. Reviewing equipment/
technologies involves an examination of labels, instructions, and safety features to ensure
potential errors can be avoided when using various devices. Processes can lead to errors and
there is a need to assess if redesign can improve safety by looking at some of the following
factors: complexity, inconsistencies, time constraints, and the amount of human intervention
(i.e., lack of automation).
Understanding the effect of people (specifically staff) on patient safery is complex and
requires attention to many factors. For example, employee attitudes, motivation, health
(physical and psychological), education, training, and cognitive functioning can impact the
likelihood of a medical error. Further, a body of research has explored the ways in which
humans interact with machines and the potential for deadly accidents. The leadership and
culture of an organization can drive safety issues when there is a willingness to allocate ap-
propriate resources (staff and equipment), analyze processes, implement changes, support
nonpunitive error-reporting, and promote EBP.
In summary, any improvement efforts focused on eliminating medical errors will
require a detailed analysis of the care-delivery process and the resources to bring about
systematic change.
G. Patient-Centered Care
Patient-centered care is defined asinvolving patients and their families in the design of new
care models and in decision making about individual options for treatment (IOM, CQH-
CA, 2000). The focus on patient-centered care has shifted the measurement of quality
to include whether patient expectations regarding their healthcare goals are being met
(Sepucha, Uzogarra & O'Connor, 2008). Data collection methods include traditional ap-
proaches such as patient surveys (such as the CAHPS'Hospital Survey) and, more recent-
ly, interviews and focus groups with patients, family members, and other informal care-
givers. As an example, the Mayo Clinic in Arizona has developed a multiprong QPI mod-
el that states "the needs of the patients come first" (Kennedy, Caselli & Berry, 201I, p. 386).
One of their "prongs" is to collect data that address the things customers find important.
The measures include patient perception metrics that capture information related to lis-
tening, involving the patient in decisions, and explaining medical conditions. Undoubtedly,
these types of measures increasingly will becoming part of internal QPI and external pub-
lic reporting.
H. TeamSTEPPS*
Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS")
is a teamwork system developed by the Department of Defense (DoD) and the Agency for
Healthcare Research and Quality (A.HRQ). It is
. a powerful solution to improving patient safety within your organization,
. an evidence-based teamwork system to improve communication and teamwork skills
among healthcare professionals,
. a source for ready-to-use materials and a training curriculum to successfully integrate
teamwork principles into all areas of your healthcare system, and
. scientifically rooted in more than 20 years of research and lessons from the application
of teamwork principles (AHRQ, n.d.).
12 Q SoluUions
and delivering care, and routine and active engagement of consumers in healthcare deci-
sion making. Purchasers are diiectly encouraged to shift their resources to better provid-
ers, to educate their employees about the importance of comparing the performance of
healthcare providers, and to assist them in using the measures to make informed healthcare
choices.
The federal government also is exploring the "pay-for-performance" benefits. CMS
has tested the link between direct Medicare payments to hospitals and qualiry of care. In
July 2003 CMS launched a 3-year pilot program with Premier, Inc., a large, nationwide
hospital alliance. The test provided financial awards to hospitals that showed high-qualiry
performance in a number of acute care areas. The hospitals used evidence-based clinical
protocols to treat patients with five conditions: heart failure, coronary artery bypass graft,
pneumonia, hip/knee replacements, and myocardial infarction. The hypothesis was that pa-
tients treated using these protocols would fare better, with fewer expensive complications,
postoperative infections, surgical wounds, readmissions, and other problems that occur as a
result of less than optimal care.
In the Premier pilot, CMS calculated the performance of participating hospitals in
treating these five conditions using established protocols. In total, 35 different measures
related to the five clinical conditions. Hospitals that ranked in the top lOo/o received a 2o/o
bonus for cases above the standard diagnosis-related $'oup (DRG) payment. Hospitals that
ranked in the top LOo/o to 2Oo/o received a 1% bonus.
The pay-for-performance initiative was extended to physician reimbursement. CMS
has implemented the Doctors' Office Quality (DOO project, designed to develop and test
a comprehensive, integrated approach to measuring the quality of care for chronic disease
and preventive services in physician offices. The goals of the DOQ project are to provide
information for informed decision making and to support adoption of QPI strategies by
physicians. The project measures clinical performance and patient experience. Ultimately,
CMS hopes the initiative will lead to new methods of service delivery, expanded coverage of
new types of service, and new payment approaches. Physicians will be directly rewarded for
improving the health outcomes of their patients by using EBPs.
In 2003 General Electric (GE), along with Ford, Proctor and Gamble, UPS, and Verizon,
started "Bridges to Excellence" (de Brantes, 2003). Using the framework established by
the IOM and creating a crosscutting group of healthcare professionals from the provider,
purchaser, and administrative sides, GE set out to develop programs that would encourage
leaps-not baby steps-in quality. The programs' objective is straightforward: Achieve a
certain level of performance and get a per-patient bonus. They work outside the current
scope of provider compensation so that incentives are visibly and clearly linked to QPI.
The programs also work across all purchasers regardless of their contractual or network
arrangements with health plans-self-insured or fully insured, health maintenance organi-
zation, preferred provider organization, point of service, or indemnity. Examples of pay-for-
performance programs developed by GE include
, Physician Ofice linlt-Physicians who demonstrate that they have adopted better sys-
tems and processes of care in their offices receive up to a $50-per-patient bonus ev-
ery year for all patients who are covered by participating purchasers and plans. These
better processes are focused on clinical information systems that have evidence-based
decision guides, robust patient education and support, and appropriate care manage-
ment for patients most at risk.
. Diabetes Care Link-Physicians who meet the performance measures defined in the ex-
isting Diabetes Physician Recognition Program (a program developed by the American
r
l6 Q SoluEions
Diabetes Association and the National Committee for QualityAssurance), which include
maintaining adequate blood sugar, lipid, and blood pressure controls in patients, receive
a $t00-per-diabetic-patient bonus every year they meet the performance
measures.
For programs that measure patient outcomes (Diabetes Care Link) rather than systems
(physician Offi." Link), allowances are made for physicians who care for sicker patients,
and incentives and rewards are deployed to patients who better manage their conditions.
The latter includes deploying comprehensive tools to help patients become more engaged
in their care, partnering with their physician. The goal is to align incentives of patients and
purchasers to focus their energy on achieving leaps in qualiry.
De Brantes, who developed these programs at GE, founded the Health Care Incentives
Improvement Institute, a not-for-profit organization, guided by a board of directors that in-
range of
cludes physicians, employers, health plans, and others. They have created a broad
proglams to measure ou,aornar, reduce care defects, promote a team approach to caring for
pr,[rrar, realign payment incentives around quality, and reward excellence wherever they
iina i,. One of their programs, Bridges to Excellence, recognizes and rewards practitioners
who provide superior care (HCI3, 2010). The program is a component of CMS'S Center
for Medicare & Medicaid Innovation's (CMMI) Bundled Payments for Care Improvement
initiative, "a bold, broad and flexible approach to moving the country away from fee-for-
service and into value-based payment" (HCI3, 2OLO,para' 1)'
Third-party payers also have started pay-for-performance initiatives. All the major pay-
ers (including BIue Cross, Aetna, Cigna, and United Healthcare) have begun testing some
form of linking reimbursement to quality. For example, in California a group of health plans
(Integrated Healthcare Association; www.iha.org) has taken the lead in pay for performance
and is proposing that indicators (such as preventive care, disease management, and pa-
tient satisiaction) based on the previous Health Plan Employer Data and Information Set
(HEDIS, now the Healthcare Effectiveness Data and Information Set; National Committee
for euality Assurance, 2011) be used to determine reimbursement. These payers have stated
that they are strongly committed to value-based purchasing and quantifiable results.
In 2010 the patient protection and Affordable Care Act (PPACA) was signed into law,
putting in place comprehensive U.S. health insurance reforms that will greatly impact
accountability (public Law, l[-I48, PPACA). The law creates new structures to support
.Accountable Care Organizations," "bundled payments;' "reductions in re-hospitalizations"
and other initiatives, which will foster future efforts that have pay-for-performance compo-
nents. There will be a fundamental shift to trying to "value" healthcare delivery in terms
of
effectiveness and cost control.
1. Release of lnformation
A written consent is required for an organization to release patient information to anyone
el-
outside the organization. A rypical release of information form should have the following
ements:
. patient name,
. name of individu alf organization requesting information,
. reason for release of information,
. anticipated use of information released,
. exact material to be released, including reference to PHI,
. period during which the release of information is valid,
. documentation that information is released only to the individual/organization named
above, and
. signature and date of the patient or legal representative (as defined by policy/state
law).
2. Authorized Release of lnformation
Information from medical records and studies may be released without written authoriza-
tion from patients to individuals or groups who have a need for the information. Release of
information is regulated by national and state statutes. These people rnay include the
. governing body representatives,
. organization director (chief executive),
. healthcare personnel involved in the care of a patient,
I nformation Ma nagement 19
C. Utilization Management
Numerous issues surround preservation of patient confidentiality within the utilization
management function.
1. lnternal Review
Policies and procedures should ensure confidentiality during the medical peer review pro-
cess. They should be consistent urith organizational policies and procedures (usually with-
in the HlM/medical records department) and may include completion of a confidentialiry
statement signed by staffand practitioners involved in the peer review process.
Mechanisms also should be established to inform patients of utilization management
review policies and procedures. A common method to inform and obtain consent is to in-
clude a statement on the admission consent form or consent for treatment form.
2. External Review
Review by telephone is a legally risky aspect of external review. The utilization manage-
ment program should have written policies governing how a telephone review is con-
ducted. These policies should address such things as methods to verify caller identiry
20
Q SoluEions I
man-
determination of who in the organization may provide information to utilization/care
agement entities, limits on the lnformation provided, and HIPAA compliance.
Of particular
concern is provision of the reason for hospitalization, such as substance use
or abuse, men-
com-
tal health, iffVTefOS, and other PHI as identified by HIPAA. These policies must be
process'
municated to the insurance company as part of the managed care contract review
of,
Onsite review by external agencies also requires development and communication
proper identification
and adherence to, poli.l"r and piocedures. Areas to be covered include
I
of the on-site reviewer (photo narne badge), issuance of passes to enter patient care
areas,
V. Evidence-BasedQualityManagement
A. The Quality Management Research Continuum
QPI activities and research exist on a continuum of rigor, as seen in Table 2. Both are based
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
inductive 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, authority, and
experience. Integrating the "right pieces" of data and information into a research-based
framework for the study of people was a contribution of the earliest pioneers in the field of
healthcare quality.
The underlying assumptions of design, measurement, and interpretation are the same.
Healthcare qualiry professionals should use the level of research rigor that best answers the
specific performance-improvement question. There needs to be a balance between rigor
and practicality (Byers & Beaudin,2OO2). Research studies and systematic reviews can be
evaluated for usefulness to a practice setting trsing critical appraisal tools. These tools guide
Define the variable(s) or the elements for which data Deflne the customers and problem.
are required.
Choose or design the research design and collection Choose one or a combination of basic or quality-
tools/instruments. management and planning tools.
Analyze the data. Analyze the data and look for root causes.
Report the data and findings. Report the data and findings.
Act upon recommendations deduced from the Act upon recommendations deduced from the
conclusions. conclusions.
process.
Continue to monitor the Continue to monitor the process'
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lnformation Ma nagement 23
healthcare quality professionals- through the research critique process, allowing effective
evaluation and synthesis of research findings for use in performance-improvement activi-
ties (Byers & Beaudin, 2001), Additional online resources provided at the end of this book
provide websites that facilitate searching for evidence relating to a particular topic.
B. Evidence-Based Practice
Evidence-based medicfne is the "conscientious, explicit and judicious use of current best ev-
idence in making decisions about the care of individual patients" (Sackett, Rosenberg,
Muir-Gray, Haynes, & Richardson, 1996, p. 71). Because multiple disciplines are involved
in healthcare delivery, however, the term evidence-based practice is more appropriate than
evidence-based medicine from a healthcare quality perspective. Clinicians should base their
care not only on experimental evidence but also consider experiential evidence, physiolog-
ic principles, patient and professional values, and system features in their decision making
(Tonelli, 2o0l). This practice allows individualized application and diffusion of aggregate
research evidence (Greenhalgh, 1999; Tonelli).
EBP promotes patient safety through the provision of effective and efficient healthcare
resulting in less variation in care and fewer unnecessary or nontherapeutic interventions
(IOM, CQHCA, 2001). EBP and outcomes measurement are iterative; one facilitates the
other (Deaton, 200D. EBP complements the principles of continuous QPI (CQD. Outcomes
evaluation at the individual and aggregate level is an essential step in evaluating the influ-
ence ofEBP.
Evidence-based clualiry management is based on clinical research and health services
research. Clinical research evaluates the impact of interventions on patient outcomes. Out-
come measures may include clinical outcomes, functional outcomes, and patient satis-
faction. This type of research helps healthcare quality professionals determine 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 quality profes-
sionals in improving work processes and systems of care.
To promote research utilization, healthcare quality professionals must collaborate with
organizational leadership to promote a culture of excellence. Healthcare providers must be
motivated to provide the best possible care and use the best system processes based on the
evidence in the literature or data obtained within their own organizations. A key strategy is
to base all discussions on improving patient experiences and outcomes, and to keep person-
ality conflicts out of the conversation (according to previously established ground rules).
Research utilization is a key aspect of the QPI process and critical to achieving healthcare
quality as defined by the IOM.
C. Applying Epidemiological Principles to Ql
The influence of QPI can be enhanced through the application of clinical epidemiolo-
gy (e.g., case control studies, cohort studies, propensity score matching) to data collected
on a large number of patients for relatively little cost. This comports to a recent emphasis
in the healthcare industry related to "population health." Comprehensive linked databases
have enormous potential to provide information on the influence of tests and treatments on
health. The potential value of these data can be realized if (1) actual receipt of these inter-
ventions, health outcomes, and potentially confounding variables can be ascertained accu-
rately for individual patients; and (2) selection bias can be minimized by identifying an ap-
propriate basis for comparison (Weiss, 2011). For example, it is possible to assess changes in
patient outcomes after an "improvement intervention" on a specific nursing unit by com-
paring those outcomes to a matched gfoup of patients from other units in a hospital or over
24 Q SoluEions
a prior period of time for the-same unit when adjusting for any confounding variables. Us-
ing data available in electronic records and appropriate statistical methods makes it possi-
ble to test for statistical differences related to a QPI initiative compared to current practice.
This level of analysis generally makes the results found more robust, lending to wider ac-
ceptance across an organization and broad adoption of the improvement effort.
B. Risk Adjustment
Risk adjustment is a technique used to take into account or to control the fact that different
patients with the same diagnosis may have additional conditions or characteristics that can
affect how well they respond to treatment. Risk-increasing variables reflect that a patient
has a high probability of dying. Analysis of outcomes data using statistical techniques can
take into account and control for patients' characteristics or conditions that are clinically
meaningful, and have demonstrated a statistical effect on the rates for each condition. This
removes the bias effect that can result when practitioners prirnarily treat patients who are
more likely to experience desirable outcomes, such as those with fewer risk factors or co-
occurring illnesses (morbidities).
Some outcomes measurement systems define the differences between rislt adjustment
and severity, whereas other systems use the terms interchangeably. However, there is a
difference. Patients in a particular study population may respond with either "yes" or "no"
when asked if they have had certain outcomes; the outcomes variable in this case is binary.
The probability of a "yes" answer is the risk of the outcome. Statistical methodologies to
adjust for risk are applied to the outcomes data to predict patient-specific variables such
as certain diagnoses that are risk factors. The validity of each risk adjustment model is as-
sessed on the basis of the choice of risk factors, including both potential risk factors and
those acttrally included in the model, and through measures of how well the predictions
match overall experience. This assessment includes indicators such as measures of patient
subpopulations, including patients with more than one risk factor, and the concordance
statistic, which shows, in perccntages, how accurate the model is at predicting the outcome.
The yes-or-no nature of outcomes data means that outcomes can refer to clinical out-
comes, such as inpatient C-section complication rates. Outcomes also can be defined by
using LOS and charges or cost, such as when an LOS exceeds a certain number of days and
results in a "yes" or "no" answer. When the categories are in two or more groups, a set of
outcomes can be defined and the risk adjustment methoclologies can be applied to the full
set of outcomes at the same time.
An important distinction must be made between the statistical analysis of binary and
continuous data. Risk adjustment methodologies do not apply to dependent variables that
are continuous, like cost or LOS. The answer cotrld be any number on a continuum, not
"yes" or "no." Severity adjustment methodologies are applied to the cost of LOS data to
predict severity by using patient-specific variables, called severity factors. Frequently, the
presence of additional diagnoses helps to define the severity of a group of patients within
a DRG, on an individual patient level, or both. Both risk-adjusted and severity-adjusted data
are extremely important outcomes system tools.
Using unadjusted or raw data means that all patients in the clinical topic category, re-
gardless of their health status or the existence of varying clinical conditions, are included in
the rate calculation. Both raw and risk-adjusted data can be made available on the same out-
comes topic because payers frequently use risk-adjusted data in their initial decision making.
Healthcare quality professionals also must be familiar with the ways in which their deci-
sion-support databases handle statistical "outliers." Are all patients included, or are patients
more than two standard deviations from the mean removed from data analysis? Most deci-
sion-support databases have a consistent approach regarding patients who are outliers. It is
critical during data comparisons to make sure that all data sources have managed patient
outliers in a consistent fashion. For example, a hospital physician group was trying to com-
pare its performance on resource utilization and LOS for community-acquired pneumonia.
One patient was hospitalized for more than 100 days because he was ventilator-dependent
26 Q SoluUions
l' and did not have adequate resources to be placed in an extended care faciliry. This patient's
record needed to be removed fiom the data before a fair comparison could be made.
I
Another factor to consider in the analysis and interpretation of outcomes data is the
I
level of detail. The best system includes every payer's, practitioner's, and patient's clinical
and financial information. This integrated data repository can mine data for
.
benchmarking qualiry performance against established standards;
. comparing physician performance within given outcome topics;
. examining details at the patient level;
. viewing patients'diagnoses, procedures, and other information;
. determining the impact of managed care on costs and outcomes; and
. analyzing product lines to evaluate their effectiveness and to increase or downsize ser-
vice offerings.
D. Benchmarking
When comparison reveals differences, the healthcare organization's management staff can
begin to ask questions internally to determine the cause of these variances. The challenge
for QPI staff is to display outcomes data in a meaningful way that will be used by the in-
volved departments or teams. Graphic display of the data enhances the understanding and
use of results.
Benchmarking is the comparison of an organization's or individual practitioner's re-
sults against a reference point. Ideally, the reference point should be a demonstrated best
practice. Healthcare quality professionals assist an organization and its practitioners in in-
terpreting benchmarking results. It is important to clarifii two important aspects of bench-
marking. The organization or practitioner's actual performance or outcomes always stay
the same. However, depending upon to whom the organization or physician is compared,
the expected value can change. For instance, an organization's complication rate may only
be 60/o higher than expected when compared to a selected market. However, the same orga-
nization may have an llo/o higher-than-expected complication rate rvhen compared to the
U.S. average. In other words, the comparison value and the magnitude of difference change.
Healthcare quality professionals need to ask the right questions to learn how their or-
ganization works and then ask more questions to compare it to the best performers. The
goal is to identify how to improve an organization's outcomes, not to identify the differenc-
es between it and the benchmarking partner. It is important to be able to take benchmark-
ing data and provide 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 identify performance gaps. Bench-
marking needs to be an essential element of clinical pathway development to ensure the
highest-cost, highest-opportunity DRGs are prioritized. Data-driven internal and external
comparisons help to set best practices and also appeal to healthcare professionals by pro-
viding objective data for clinical pathway development. In general, three steps must be
followed when be nchmarking clinical pathways.
1. Identify high-resource-utilization DRGs.
2. Assess internal variabiliry.
3. Benchmark against external sources.
Table 3 illustrates examples of benchmarking projects. Benchmarking enables an orga-
nization to set a target or goal for its performance improvement activities. It is up to the
performance improvement team to determine whether it wants to be "average" (the industry
standard) or raise the bar to a much higher level of performance. To improve performance,
the goal depends on the level of current performance and the commitment of the perfor-
mance team and healthcare providers. One of the most critical decisions an organization
makes when launching a benchmarking initiative is selecting the source of its benchmark-
ing comparative data. Healthcare quality professionals often coordinate an organization's
benchmarking efforts. Most healthcare regulatory agencies require benchmarking as part of
a comprehensive QPI program.
-Y
I
Q SoluEions I
28
I
' scatter diagram: displays possible cause and effect, illustrates whether one variable
might have an impact upot another variable, and can illustrate the strength of that
impact;
. run chart: used to monitor processes over time;
' control chart: used to statistically illustrate upper and lower limits of a process and the
variation of an organization's process within those limits ; and
' stratification: breaks down single values into meaningful categories or classifications
to focus on improvement opportunities or corrective action (nrassard & Ritter, 1994).
In recent years organizations have developed "dashboards" to represent key manage-
ment and performance indicators (Rosati, 2oog). They can be used asdata-mining toolsto
synchronize and synthesize vast amounts of data into visual representations. Dashboards
can be used to analyze and forecast various organizational systems. These dashboards
frequently incorporate external benchmarks, which allow organizations to compare per-
formance to national, state, or regional norms. These benchmarks are available frtm CMS,
state health department websites, medical specialty groups, published literature, and orga-
nizations such as Leapfrog.
Step 5. TakingAction
"Taking action" implies that people, teams, departments, and committees are empowered
to make decisions and implement changes based on information discovered through data
analysis. Actions may occur in several forms: education and training of stafl education and
reporting of findings to outside vendors or the public, changes in organizational or depart-
mental policies and processes, and changes in practice patterns.
Q SoluUions I
32
I
I
Ii
lnformation Management
33
a system, access to accurate and timely information is an ongoing requirement of any MIS.
The qualiry ofjudgments and dicisions directly correlates with availabiliry and reliability
of
data and its synthesis into information.
Choices for the design or flow of information are so important that
they can be a deter-
mining factor in the survival of a patient or organization.
Although accurate and timely healthcare information should provide the rationale
for
management decisions, this often is not the case. Information, according
to O,Rourke and
Bader (rggg), often is incomplete, confusing, and not sufficiently relevant
to the organiza-
tion's mission, strategic goals, or customer and stakeholder needs when it is presented
in
many governing body reports. These authors make a strong point that
organizations should
clarify the difference between data and information, and that data mu.st be carefully
se-
lected, validated, and formatted to make them useful. This often is easier
to mandate than
accomplish. However, the goal remains that governing body reports contain
only the criti-
cal information needed for effective decision making-Achieving this goal would
eliminate
healthcare data being presented as a pile of computer printouts and various fragmented
reports.
According to O'Rourke and Bader (1993), the information contained in data helps lead-
ers to
' assess how well the mission and values are being achieved by applying quantitative
measures to the ideals espoused in their mission and vision statements;
' understand changes in community needs, financial resources, and technology;
. develop a vision and evaluate program achievements;
. identifii the need for policy implementation effectiveness;
' prioritize strategic goals, including programs, to support or discontinue;
. judge progress toward strategic goals and objectives;
. weigh long- and short-term financial viability;
' weigh the impact of budgetary decisions on quality of care/services;
. determine priorities for continuous improvements;
' monitor aspects of organizational performance and take corrective action;
' understand the mechanism for physician appointment and recredentialingwhile
knowing their performance review process is effective;
' decide on individual credentialing recommendations effectively;
' determine goals for improving the health status of the communify;
' evaluate the effectiveness of programs designed to improve health;
' defend an organization's resources, efficiency, and effectiveness based on accurate in-
formation; and
' help the governingbody evaluate and improve its performance.
34 Q SoluEions
1.
Clinical lnformation Systems
Designed to support direct patient care processes, automated clinical information systems
have great potential for analyzing and improving the quality of patient care.
Barriers to healthcare leaders' and healthcare organizations' implementation of MIS
include normal resistance to change, the mindset that patients can best be tended to by the
human mind, lack of exposure to information science and computers in healthcare educa-
tional and training pro$ams, and inadequate resources. One study found that, on average,
Florida hospitals use only 38o/o of available clinical healthcare informati<ln technologies as-
sociated with the six IOM care aims (Burke, Menachemi, & Brooks, 2005).
Currently, expanded clinical information systems in use include electronic medical
records and their retrieval systems; computer-assisted medical decision making for his-
tory and physicals and antibiotic selection; clinical application progtams for health-risk
progfr-r, health maintenance organization encounter data, clinical algorithms, predictive
modeling, and simulation.
From a managed care perspective, Rontal (1993) outlined the following criteria as being
needed for an MIS: appropriate use, place of service, specific procedures, preventive care,
cost-effectiveness, patient satisfaction, chronic illness management, access to care, and
patient education. Also needed are outcomes of care for mortaliry morbidity, complications,
readmissions, quality of life, and disability. Clinical information systems often depend on
integration with administrative information systems for some data.
2. Administrative Support lnformation Systems
Aclministrative support information systems aid day-to-day operations in healthcare organi-
zations, including
1. Financial information systems
. payroll
. accounts payable
. patient accounting
. cost accounting
. forecasting
. budgeting
2. Human resources information systems
' employee record
. position and performance management
. labor analysis
. turnover and absenteeism
3. Office automation systems
. word processing
. e-mail
. scheduling
. facsimile/scanning
' electronicspreadsheets.
3.
Decision Support SYstems
Decision support systems deal with strategic planning functions (see Section VI, Decision
Support, niskedlustment, Data Interpretation, and Benchmarking). Included in this area are
lnformation Management 35
36 Q SoluEions
. Can staff provide necessary documentation, training, support, and maintenance for
the system on an ongoing basis? If so, will changing priorities interfere with the sus-
tainability of the program?
. How will the organization be able to sustain the system? Are resources available to
keep the program up to date in an ever-changing environment?
. Is there atrue understandingof the future data demands of accreditation organizations,
regulatory agencies, third-party payers, employers, and other external data demands?
. Will there be long-term dedicated resources to enhance such an application for QI (in-
cluding various functions such as credentialing, profiling, etc.)?
. What would be gained by being part of an established vendor network or user group
addressing the needs of credentialing and QI?
. Is it more cost-effective alternative to develop such applications in-house or would
the faciliry be better served by purchasing softu.are dedicated to these needs?
' Safety is an emergent property of a larger system that takes into account not just the
software but also how it is used by clinicians.
' The'sociotechnical system" includes technology (software, hardware), people (cli-
nicians, patients), processes (workflow), organization (capacity, decisions about how
health IT is applied, incentives), and the externalenvironment (regulations, public
opinion).
' Safer implementation and use of health IT is a complex, iiynamic process that re-
quires a shared responsibility benveen vendors and healthcare organizations.
' Poor user-interface design, poor workflow, and complex data interfaces threaten pa-
tient safety.
' A lack of system interoperability is a barrier to irnproving clinical decisions and pa-
tient safety.
' A constant, ongoing commitment to safety-from acquisition to implementation and
maintenance-is needed to achieve safer, more effective care (IOM ,2ol2,pp. S2-Sa).
The HHS office of the National Coordinator (oNC) was charged with developing a
Nationwide Health Information Nenryork (NHIN) to "provide a secure, nationwide, interop-
erable health information infrastructure that will connect providers, consumers, and others
involved in supporting health and healthcare" (HHS, oNC, 2008). The NHIN's purpose
is to allow health information to be accessible to healthcare providers regardless of where
patients are treated. NHIN will achieve this goal by
' developing capabilities for national standards-based, secure data exchange;
' improving the coordination of care information among hospitals, laboratories, physi-
cian offices, pharmacies, and other providers;
' ensuring that appropriate infbrmation is available at the time and place of care;
' ensuringthat consumer health information is secure and confidential;
' giving consumers new capabilities to manage and control their personal health re-
cords, as well as providing access to their health information from EHRs and other
sources;
' reducing risks from medical errors and supporting the delivery of appropriate,
evidence-based medical care;
' lowering healthcare costs resulting from inefficiencies, medical errors, and incom-
plete patient information; and
' promoting a more effective marketplace, more competition, and increased choice
through accessibility to accurate information on healthcare costs, quality, and out-
comes (HHS, ONC,2008).
Advances in health IT will facilitate an evolving quality agenda in coming years. Health
IT provides the infrastructure to enhance patient safery transparency, public reporting, and
pay for performance. An exemplar of this strategJ is the Veterans Affairs (VA) implementa-
tion of a Virtual Lifetime Electronic Record (VLER). The VLER Health program ensures
that each veteran has an electronic health record that can be accessed, with the veteran's
permission, by public and private sector healthcare providers. The first pilot of this pro-
gram occurred in San Diego, CA, between the VA, the U.S. DoD, and Kaiser Permanente.
The program is now being implemented nationwide.