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Continuous Quality Improvement in Healthcare

Continuous Quality Improvement in Healthcare Unit Assignment #5 Lesson #s 13, 14, & 15

Note: Highlighted Questions must need to be fully answered for each lesson

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LESSON 13

Understanding External Influence in Quality

LEARNING OUTCOMES

In this lesson, you will do the following:

Demonstrate knowledge of the regulatory mechanisms that promote quality and safety.

Distinguish the individual external influences on organizational improvement.

Relate quality reporting and accountability to continuous quality improvement.

READINGS

Sollecito & Johnson Text: Chapter 14 – page 408 and 409; Chapter 18

  1. In no less than three to four paragraphs construct a comparative analysis of the benefits and disadvantages of the accreditation model and continuous quality improvement.
  1. In no less than three to four paragraphs discuss external influences on organizations to provide quality care, and the impact they have on healthcare organization’s continuous quality improvement approach.
  1. Describe how quality-reporting requirements serve as an external influence in organization’s transparency and accountability to those they serve.

Please find Lecture Notes below to help answer the questions for Lesson#13

LESSON: 13

Understanding External Influence in Quality

LECTURE NOTES Lesson# 13:

There are many external influences that move the quality agenda for health care organizations.  One segment of external influences includes licensure, accreditation, and certification.  Meeting minimum standards to protect patients (licensure), meeting standards designed to encourage continuous improvement efforts (accreditation), or indicating the organization has additional services, technology, or capacity beyond those found in similar organizations (certification) all influence the continuous quality improvement approach of organizations.  (Rooney and van Ostenberg, 1999)

Licensure standards define the level necessary in order for patient care or health services to be safety delivered and are always mandatory.  Accreditation is a voluntary assessment of the organization by a multi-disciplinary team of health professionals against published standards to acknowledge that organization’s professional performance, health service delivery, management systems, and quality systems are optimal and provide safe and effective patient care.  (Shaw, 2000) Improvement gradients are embedded into the health care accreditation process. First, the standards encourage organizations to achieve particular criteria. Second, accrediting bodies revise their standards over time so they are based on up-to-date research and accepted best practices. Both

of these elements ensure continuous quality improvement efforts in order to contribute to the provision of high-quality and safe health care services and to improve patients’ health outcomes.  There are many stated quality improvement benefits of accreditation including (Nicklin, 2013):

  • A framework to help create and implement systems and processes that improve operational effectiveness and advance positive health outcomes
  • Structure for communication and collaboration internally and with external stakeholders in order to move quality projects and initiatives
  • Decrease in variances in practice among health care providers and decision-makers to ensure quality outcomes
  • a vision for sustainable quality improvement initiatives
  • Engender a spillover effect, whereby the accreditation of one service helps to improve the performance of other service areas
  • Promotion of a quality and safety culture through established standards based on evidence based/best practices

Other segments of external influences in continuous quality improvement in healthcare include the transparent public reporting required by regulatory agencies.  One of the most commonly stated objectives for publicly reporting a hospital’s performance data is to stimulate performance improvement and public reporting of this type of data has indeed been associated with improvements in health care organizations.  (Hafner, et.al., 2011).  Publicly reporting causes attention to be paid to the gaps between organizations, allows for best practices to be shared among organizations, and serves as motivation for leaders seeking to be a part of a learning organization.

REFERENCES

Abdullah, A., Shaw, C. (2011)  Impact of Accreditation on the Quality of Healthcare Services.  Annals of Saudi Medicine. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3156520/.

Nicklin, W. (2013) The Value and Impact of Health Care Accreditation.  Accreditation Canada. http://www.accreditation.ca/sites/default/files/value-and-impact-en.pdf

Public Reporting and Pay for Performance in Hospital Quality Improvement, Lindenauer, R., Remus, D., Roman, S., Rothberg, M., Benjamin, E., Ma, A., Bratzler, D. The New England Journal of Medicine. 2007.  http://rds.epi-ucsf.org/ticr/syllabus/courses/68/2009/05/05/Lecture/readings/Dudley.pdf

Ransom, Elizabeth, Joshi, Maulik, Nash, David, Ransom, Scott.  (2008).  The Healthcare Quality Book (2nd Edition). Health Administration Press, Chicago.

Rooney, A., van Ostenberg, P. (1999) Licensure, Accreditation, and Certification:  Approaches to Health Services Qualtiy.  Quality Assurance Methodology Refinement Series. www.ihf-fih.org.

Shaw, C. (2000) External Quality Mechanisms for Health Care.  International Journal for Quality in Health Care. Volume 12, Number 3: page 170.

LESSON 14

Value Added Health Care

LEARNING OUTCOMES In this lesson, you will do the following:

In this lesson, you will describe approaches organizations can take to achieve improved quality and decreased costs to ensure value added health care for their patients.

READINGS

Sollecito & Johnson Text: Chapter 20 – pages 589-590

ACTIVITIES / ASSESSMENTS

1. In no less than three to four paragraphs describe continuous quality improvement as approach organizations can take to achieve improved patient safety and decreased related costs.

2. The Affordable Care Act provides funding for Partnerships for Patients that supports partnerships to improve the quality, safety, and affordability of health care. In no less than three to four paragraphs describe how the continuous quality improvement approach will help organizations to meet the identified targets for this program.

LESSON 14

Value Added Health Care

LECTURE NOTES Lesson#14

In his article, What Is Value in Health Care, Michael Porter defines value and speaks to the overarching need for continuous quality improvement (Porter, 2010),

“Achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved per dollar spent. This goal is what matters for patients and unites the interests of all actors in the system. If value improves, patients, payers, providers, and suppliers can all benefit while the economic sustainability of the health care system increases.

Value — neither an abstract ideal nor a code word for cost reduction — should define the framework for performance improvement in health care. Rigorous, disciplined measurement and improvement of value is the best way to drive system progress. Yet value in health care remains largely unmeasured and misunderstood.

Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system. Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge. Nor is value measured by the process of care used; process measurement and improvement are important tactics but are no substitutes for measuring outcomes and costs.”

The value proposition has been stated as a mathematical equation:

Value = Health Outcomes (Quality)

Costs of Delivery

Within this equation costs related to delivery include costs associated with medical errors, harm to patients, waste, and ineffective processes (i.e. avoidable readmissions).

The transition to high-value care can be assured by a system-wide approach to continuous improvement. The sustainability of these efforts to improve the quality and value of care is contingent on an institutional culture of continuous improvement. Evaluating tasks and processes to identify better approaches allows hospitals to reduce waste, improve outcomes, and yield significant savings. Rather than prescribing behavior, managers and executives who teach problem solving, develop standard work, and remove barriers to improvement help their employees excel. This requires a management system built on the tenants of respect for all people in the organization, in which leadership behavior is focused on humility, facilitation, and mentorship. Front-line staff is taught to

  1. analyze processes to identify waste and inefficiency,
  2. propose changes to eliminate wasted resources and effort,
  3. test proposed solutions on a small scale, and
  4. if successful, scale the improvements to the entire organization. This process is never complete. Existing workflows must be continually refined and
  5. new opportunities for improvement continually sought.

A culture of continuous improvement demands that all workers apply this method to their tasks to drive iterative improvements in the efficiency of hospital operations. (Cosgrove, et. al., 2012)

The demand for high value care is growing as employers, individuals, private insurers, and public payers are all reaching for answers in cost containment while maintaining the quality of care in partnerships with health care delivery organizations. Reimbursement for care that is value based has been the approach that the Centers for Medicare & Medicaid Services has taken over the years, but the Affordable Care Act (ACA) has accelerated this approach. Provisions in the ACA establish programs for bundled payments, value-based purchasing, and for reducing Medicare payments to hospitals for errors and avoidable readmissions. For example, the Medicare Shared Savings Program holds Accountable Care Organizations (ACOs are those organizations who come together voluntarily to give coordinated high quality care to Medicare patients) responsible for providing high-quality care and in turn share in the savings in the reduction of costs for Medicare patients. (Cosgrove, et. al., 2012)

REFERENCES

Cosgrove, D., Fisher, M., Gabow, P., Gottlieb, G., Halvorson, G., James, B., Kaplan, G., Perlin, J., Petzel, R., Steele, G., Toussaint, J. (2012) A CEO Checklist for High-Value Health Care. Institute of Medicine. http://www.iom.edu/~/media/Files/Perspectives-Files/2012/Discussion-Papers/CEOHighValueChecklist.pdf.

Porter, M. (2010) What Is Value in Health Care. New England Journal of Medicine. http://www.nejm.org/doi/full/10.1056/NEJMp1011024.

LESSON 15

The Business Case for Quality

LEARNING OUTCOMES In this lesson, you will do the following:

Define the business case for quality.

Describe the barriers to a strong business case for reducing misuse, overuse, and underuse of health care services.

Describe the analysis to be conducted in continuous quality improvement that will impact the business case for quality

READINGS

Sollecito & Johnson Text: Chapter 2 – pages 57 -59

ACTIVITIES / ASSESSMENTS

1. Describe the alignment between an organization’s mission and the business case for quality in no less than three to four paragraphs.

2. Consider the barriers to the business case for quality and in no less than three to four paragraphs describe why you believe that these barriers will either gain strength or be eliminated in the future of health care.

3. Using the example of hand hygiene as a continuous quality improvement opportunity, answer the four questions Leatherman proposed to determine if this initiative would have a positive impact on the business of a health care organization. Describe your rationale for each of your four answers in no less than one to two paragraphs.

LESSON 15

The Business Case for Quality

LECTURE NOTES Lesson#15:

Sheila Leatherman and colleagues in their recent consideration of several case studies of various efforts to improve quality and have a positive impact on the business of health care defined a business case for a health care improvement intervention.  They stated that this exists if the entity that invests in the intervention realizes a financial return on its investment in a reasonable time frame, using a reasonable rate of discounting. This may be realized as ‘bankable dollars’ (profit) a reduction in losses for a given program or population, or avoided costs. In addition a business case may exist if the investing entity believes that a positive indirect effect on organizational function and sustainability will accrue within a reasonable time frame. (Gosfield and Reinertsen, 2003)

Gosfield and Reinertsen surveyed health care providers who identified that there are several barriers to realizing the positive impact on the business of healthcare through quality improvement efforts. (Gosfield and Reinertsen, 2003)  They include: 

  • Inadequate recognition of quality in payment for healthcare – weak rewards for higher quality
  • Absence of true consumer demand for quality
  • Lack of infrastructure and organizational capacity to make necessary changes (i.e. information technologies to support quality initiatives, absence of an integrated patient medical record)
  • Lack of policy agreement on quality targets by those who would seek improvement – lack of regulatory program overarching principles related to quality improvement

Leaders in continuous quality improvement hold many keys to unlocking some of these stated barriers.

  1. Provision of education of consumers in order that informed consumers of health care understands the level of care provided by their organization.
  2. Full transparency in the community so that consumers understand the high quality clinical outcomes that an organization can provide them, with additional information provided about changes in the event the outcomes are below the comparative standards
  3. Provision of strategic approaches to the resources necessary for successful quality improvement initiatives.  Provision of ROI information for specific initiatives related to quality improvement efforts.
  4. Provision of alignment of organizational priorities for improvements with local, state, national, and professional priorities to establish an overarching approach to improvement.

In addition, there are specific questions that leaders should pose in order to evaluate what efforts may best serve the business case for quality (Leatherman, et.al., 2003):

  1. Will the proposed innovation actually result in improved care?  Will the limitations of the innovation or the limitations of the organization to implement prevent real improvements in care?
  2. Is the improvement considered a part of the core of health care or an optional feature?  Is there a compelling argument for the improvement?
  3. Is there a financial benefit to the organization?  In both short term and long term financial pictures?
  4. What nonfinancial consequences matter to the organization and will there be collateral benefits that in turn impact the organization? (i.e. retained market share, increased staff retention, reputation among employers in the community)

REFERENCES

Gosfield, A., Reinertsen, J. (2003)  Doing Well By Doing Good: Improving the Business Case for Quality. 

Leatherman, S., Berwick, D., Iles, D., Lewin, L., Davidoff, F., Nolan, T., Bisognano, M.  (2003)  “The Business Case for Quality: Case Studies And An Analysis,” Health Affairs. http://content.healthaffairs.org/content/22/2/17.full 

Sollecito, William A and Johnson, Julie. (2013). McLaughlin and Kaluzny’s Continuous Quality Improvement in Health Care. (4th ed.). Sudbury, MA: Jones sand Bartlett Publishers, Inc. ISBN 13: 978-0763781545.

Lighter, Donald. (2011).  Advanced Performance Improvement in Health Care.  Jones and Bartlett Publishers.  Massachusetts.

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