QUALITY MANAGEMENT

Performance improvement. Continuous quality improvement. Quality assurance. Quality assessment. Total quality management.

Despite changes in terminology, the Governing Board of a hospital always has the moral, legal and fiduciary responsibility to monitor, evaluate and continuously improve the quality of the patient care and services provided. The Board must organize itself to carry out its oversight role effectively.

BOARD RESPONSIBILITIES         Top

The Governing Board bears ultimate responsibility for the quality of patient care rendered within the facility. Some of the Board’s key responsibilities in the quality area include:

• Maintaining a coordinated, systematic, hospital-wide approach to improving patient care and health outcomes
• Understanding the Board’s and trustees’ roles in the performance improvement program
• Approval of the written performance improvement or quality assessment plan
• Regularly reviewing the results of performance improvement activities
• Explaining their hospital’s performance improvement program and how quality of patient care is achieved
• Familiarity with Joint Commission on Accreditation of Healthcare Organization’s accreditation standards and the reasons for pursuing accreditation
• Familiarity with WA State Licensing Standards and Medicare Conditions of Participation

Effective performance improvement results in continuous improvement of patient outcomes and requires hospital-wide interdisciplinary collaboration and governing board involvement.

A meaningful performance improvement program:

• Is planned, systematic and ongoing
• Is comprehensive (applies to all of the functions of the hospital - clinical, support, managerial and governance)
• Uses objective measures of quality with predetermined indicators or performance expectations
• Uses goals, targets and benchmarks
• Ensures appropriate follow-up, that is, "closing the loop"
• Integrates across department lines and among different quality functions
• Involves all staff and providers
• Results in improvement of existing processes AND outcomes

Governing boards should ask themselves the following questions:

• How has our hospital defined quality?
• Do our hospital’s vision, mission statement and strategic plan incorporate a commitment to quality?
• Besides using patient demographics, how does our institution determine who its customers are and what aspects of quality are important?
• Does our hospital use the following mechanisms to determine the aspects of quality that are important to patients and other customers?
• Community surveys or other feedback
• Patient satisfaction instruments
• Review of patient and staff complaints
• Review of clinical services outcomes
• Interviews, surveys or focus groups with staff and physicians
• Reports from business coalitions or other purchasers of services
• Analysis of legal, regulatory and accreditation requirements
• Media reports
• Are minutes kept of each review activity? Are summary reports provided to hospital administration and, as appropriate to the Board?
• Does the Board review the effectiveness of performance improvement on an annual basis?

QUALITY IMPROVEMENT         Top

Accrediting and regulatory agencies play an important role in facilitating and promoting the quality of health care in hospitals. Below, the performance improvement roles of these agencies are highlighted (also see regulatory chapter).

As noted in the previous regulatory section, the Joint Commission on Accreditation of Healthcare Organizations has established standards for each component of the health care organization. Historically, the standards were very prescriptive. Today, the standards are broadly stated; emphasis is placed on achieving the outcomes, more generally allowing the hospital to define the process that results in continuous performance improvement.

The Joint Commission requires each accredited hospital to provide evidence of planning for performance improvement. Evidence may take the form of a written performance improvement plan or other planning documents. Regardless of the format of the planning document(s), the purposes of planning are to describe the hospital leaders’ approach to improving performance, ensure that the efforts are systematic and involve all applicable departments and disciplines.

Under the JCAHO’s new leadership standards, the Governing Board, senior management and medical staff must actively support and become involved in the hospital’s quality efforts. JCAHO also outlines several quality improvement and assessment efforts that must take place. While trustees do not necessarily have to know each area in detail, they should make sure that the CEO has pertinent review activities taking place on a scheduled basis, that significant results are reported and that needed follow-up is occurring. Trustees should note trends and patterns in performance of services and patient outcomes and compare the hospital’s performance with standards or data from other hospitals.

The Joint Commission publishes hospital performance reports to show accountability for quality of performance and patient care outcomes. Hard copies of these reports may be requested from JCAHO by the public, the media or health care organizations, or they may be accessed on the JCAHO web site at http://www.jcaho.org.

The Washington State Licensing Standards also address performance improvement. The purpose is to ensure continuous improvement of patient health outcomes through performance improvement activities of staff, medical staff and outside contractors.

Improving organizational performance standards include requirements for:

• A hospital-wide approach to process design and performance measurement, assessment, and improvement of patient care services to include:
• A written performance improvement plan that is periodically evaluated and approved by the governing authority
• Performance improvement activities which are collaborative and interdisciplinary and include at least one member of the governing authority
• Review of serious or undesirable patient outcomes (adverse events) in a timely manner

• Systematic collection and assessment of the data on important processes or outcomes related to patient care and organizational functions; followed by appropriate action to improve and/or continue measurement in response to data assessment. The minimum data set includes:

a. Processes or outcomes related to:

• Operative, other invasive, and noninvasive procedures that place patients at risk
• Infection rates
• Mortality
• Medication use
• Hospital incurred injuries, such as, falls
• Adverse events, such as, an infant abduction or patient suicide
• Discrepancies or a pattern of such between preoperative and postoperative diagnosis
• Significant adverse drug reactions (as defined by the hospital)
• Confirmed transfusion reactions
• Adverse events or patterns of adverse events during anesthesia use
• Other hospital specific measurements

b. The needs, expectations, and satisfaction of patients

c. Quality control and risk management activities

Most hospitals that are not JCAHO accredited are Medicare certified. Many of these hospitals are in rural Washington. Medicare-certified hospitals must meet the Medicare Conditions of Participation. These conditions require that the Governing Board ensure that there is an effective hospital-wide quality assurance program to evaluate the provision of patient care. No specific quality management strategy or approach is mandated.

The hospital must have a systematic plan for monitoring and evaluating the quality and appropriateness of patient care to improve patient care and to identify and solve problems.

In December 1997, the Health Care Financing Administration (HCFA) proposed revisions to the Medicare Conditions of Participation for hospitals. The revisions are anticipated to take effect by mid-2000 and will mirror JCAHO’s move toward meeting standards through flexible, outcomes-oriented approaches.

QUALITY INDICATORS         Top

A quality indicator is a measure of an important aspect of the quality of care or the quality of services. It is not itself a direct measure of quality but acts as a screening tool or reference point for monitoring, evaluating and improving care. Both clinical and nonclinical quality indicators are used and include those that relate to structure/function, process and outcome.

In general, indicators should represent those procedures, conditions or services that are:

• Frequently occurring
• Easy to monitor through the collection of readily accessible data
• High-risk, high-volume, high cost or problem-prone
• Amenable to intervention
• Highly variable in the way they are managed

STRUCTURAL/FUNCTIONAL	PROCESS	OUTCOME
Assesses whether the organization has the capability and resources to provide high-quality patient care appropriate staffing levels equipment standards safety codes being met	The process that occurs prior to a given point, intended to achieve optimal care (outcomes) "doing the right things" clinical protocols being followed surgery consent form completion appropriate ordering of lab tests	Outcome indicators answer the question, "Did the patient get better?" postoperative wound infections deaths within 24 hours of admission

Indicators also range in scope. Examples include:

• Hospital-wide, for example, readmissions within 30 days of discharge
• Departmental, for example, vaginal births following previous cesarean delivery
• Individual occurrence, particularly for adverse and unusual events, such as an anesthesia-related death (an event unexpected in the normal course of a patient’s illness). An adverse event indicates the need for further investigation each time it occurs because of the severity of the occurrence. The purpose of the investigation is to analyze the root cause of the event and prevent future occurrences.

Indicator data should be aggregated over time to show trends and patterns. Trustees should not receive reports on all indicators monitored throughout the hospital, but rather a broad and representative sample of indicators that address hospital and medical staff performance and enable the Board to respond appropriately. Once again, it is important to remember that indicators do not provide definitive answers about quality. Rather, they prompt users to ask questions about why particular events occurred.

PERFORMANCE IMPROVEMENT PROCESSES         Top

A common myth is that most quality problems can be blamed on individuals. In reality, it is estimated that at least 85 percent of these are related to system problems — bottlenecks in work flow, information breakdowns, poorly designed or inefficient work processes and inadequate resources.

Various approaches have been developed to improve performance and patient outcomes. Here we highlight JCAHO’s 10-step model for quality assessment and improvement. These are the basic steps to developing a quality assessment and improvement plan that will result in improved organizational performance. A hospital may use a customized approach or may select one developed by JCAHO or other experts in quality improvement.

The steps are:

• Assign responsibility
• Delineate the scope of care and service
• Identify important aspects of care and service
• Establish thresholds for evaluation
• Collect and organize data
• Initiate evaluation
• Take actions to improve care and service
• Assess effectiveness of the actions and ensure that improvement is maintained
• Communicate results to relevant individuals and groups

Hospital’s trustees are responsible to oversee performance improvement while the chief executive officer (CEO) and medical staff are charged with setting priorities (consistent with the board’s goals and vision), establishing responsibilities, and designing approaches for assessing and improving patient care

The key functions (patient-focused, organizational and structural), procedures, treatments and activities to be monitored and evaluated are identified.

Hospitals should focus their efforts on those activities that will make a difference (improve care and service) and on key functions, procedures and treatments. Priorities should be established on hospital-wide basis.

For each indicator, an expected, achievable level of performance or a threshold should be set. A more in-depth review should occur if for example, the threshold for the c-section rate is exceeded.

Hospital patterns or trends in performance should be monitored and compared with other hospitals or national standards.

Trustees should monitor hospital performance relative to its goals verifying the source and the appropriateness of selected indicators.

For each indicator, there should be evidence of ongoing data collection. Data should be aggregated to identify trends in care, services or outcome. Trustees should ensure that physicians, management staff and other staff receive training in methods of quality improvement.

An evaluation should begin when an unexpected pattern or trend is noted or when performance falls below the established goal. Problems identified are referred for an intensive review, particularly when the cause and scope of the problem or trend is unknown.

When unexplained or unacceptable variations in care are identified, peer review (i.e., more detailed examination of records by qualified "peer" professionals) may be necessary. In addition, other causes and effects, such as how the care is delivered, may also help explain variations in care. All peer and process review findings should be documented and summarized to help determine their effectiveness in identifying potential quality problems or situations.

This step can pose the greatest difficulty for hospitals. When there is a discrepancy between actual practice and the hospital’s performance expectations, there must be evidence that an improvement plan has been implemented.

Critical to the improvement of care or services is determining if the action taken actually improved the care or service and if that change is maintained. If not, staff should determine whether the:

• Nature and scope of the problem or trend were correctly identified
• Corrective actions were appropriate to the identified issue
• Corrective actions were reasonable and achievable
• Authority and responsibility for implementing corrective actions were clearly specified and understood
• Corrective actions or improvement plans were implemented

Data should be summarized concisely and reviewed in a timely manner by quality improvement teams, committees or councils, medical staff committees, senior management and the governing board. A schedule for the compilation and distribution of data should be identified. Special attention should be paid to identifying mechanisms for monitoring resolution of identified problems or situations and ongoing improvement of care and patient outcomes.

JCAHO’S ORYX INITIATIVE         Top

The JCAHO’s ORYX initiative, introduced in February 1997, seeks to integrate outcomes and other performance measurement data into the Joint Commission’s accreditation process. The goal is to achieve a more continuous, data-driven and comprehensive accreditation process that not only evaluates a health care organization’s methods of doing the right things (standards compliance), but the outcomes of these methods as well.

Since early 1998, ORYX has required that each JCAHO accredited hospital must select a performance measurement system in which to participate. Hospitals also must select a sufficient number of performance measures to address 20 percent of its patient or resident population, or five measures, whichever is less. More than 200 performance measurement systems, including the JCAHO-developed IMSystem, have met the Joint Commission’s initial screening criteria for participation in the ORYX initiative.

WASHINGTON HEALTH FOUNDATION QUALITY ACTIVITIES         Top

For the last few years the Washington Health Foundation has been coordinating a number of quality activities. The primary effort began as the Northwest Quality Pilot. Utilizing two ORYX approved tools, the Picker Patient Satisfaction Survey and the Maryland Quality Indicators Project, the intent has been to improve quality of health care by developing collaborative processes that facilitate effective hospital-based efforts.

The Picker survey focuses on assessing patient satisfaction utilizing "dimensions of care" which include: respecting a patient’s values, preferences and expressed needs; access to care; emotional support; information and education; coordination of care; physical comfort; involvement of family and friends; and continuity and transition.

The Maryland tool measures more traditional aspects of care, such as total mortality, c-section, or return to the operating room (OR) rates. Comparisons are offered with other similar facilities, although the tool does not provide benchmarking data, per se.

Twice yearly user group meetings and an online discussion group are examples of how the hospitals share information and collaborate to improve quality of care. Although the Northwest quality project has now been completed, seventeen hospitals (eight are from the original Pilot) continue to use one or more of the project’s indicator sets.

Recently, the Foundation participated in a collaboration with the Oregon Association of Hospitals and Health Systems using Picker's Emergency Department and Outpatient Surgery surveys. Results are due in December.

To learn more visit the Foundation website, www.whf.org.

PERFORMANCE IMPROVEMENT ACTIVITIES         Top

Trustees should discuss the activities to be included in every performance improvement effort. Trustees do not need to know the specific activities undertaken but need to ensure that all functions occur regularly, that significant findings are documented and reported to the appropriate parties and that needed follow-up action is taken. Trends or patterns of performance over time should be noted and compared with national or local standards with data from similar hospitals.

• Quality performance indicators
  Annually or more frequently, the Board should receive a summary of selected indicators that reflect important dimensions of the quality of patient care and services at the hospital. Indicators serve the purpose of raising important questions and promoting meaningful discussion among Board members, medical staff and hospital management. A profile of hospital performance over time is provided – both in relation to the hospital itself and to other comparable hospitals. Indicators promote the examination and improvement of care across hospital departments, as well.
• Infection control
  The Board may review hospital-acquired infection rates as a part of the set of quality indicators. The Board should be aware of the hospital’s precautions to prevent bloodborne infections such as hepatitis B and HIV in both employees and patients.
• Safety and security
  The activities of hospital-wide safety and security committees should be summarized and reported on a routine basis, including physical plant requirements and conditions. Board members may also request evidence that policies and procedures are in place to ensure privacy, confidentiality and appropriate resolution of ethical issues.
• Utilization management and volume statistics
  On a regular basis, trustees should receive an overview of the volume and utilization of hospital services, not only to assess financial performance but also to have a framework for identifying trends and issues in quality. Data could include inpatient and outpatient volume, ancillary service use, average lengths of stay (e.g., by top DRGs), payer mix and PRO/insurance denials or quality problems.
• Patient, employee and physician satisfaction
  Positive staff morale is an important factor in the quality of patient care services. A procedure for monitoring patient, employee and medical staff perceptions, attitudes and opinions on an ongoing basis may be included as part of an institution’s overall quality improvement process.

• Departmental review
  The quality of patient care offered by each department or the medical staff as a whole must be evaluated. The results of this evaluation, and any conclusions, recommendations, action and follow-up, should be documented.
• Surgical case review
  High-risk, high-volume, high cost and problem-prone procedures should be reviewed according to a predetermined sample. A review of all surgical and other invasive procedures is not required. Reviews should also focus on the processes related to surgical and invasive procedures, including patient preparation and procedure selection. The rationale and methodology for selecting, reviewing and reporting surgical case review should be documented. Reporting should occur no less than quarterly.
• Blood usage review
  The appropriateness of the ordering, distribution, handling, administration and monitoring of blood and blood products should be reviewed quarterly and can be drawn from a sample of cases, as with surgical review. Each blood use category (e.g., packed red blood cells, platelets, fresh frozen plasma, transfusions) should be sampled, and reporting should occur no less than quarterly.
• Medication use review
  Review of a sample of medication use is permitted as long as frequently used, high-risk, high cost or problem-prone medications are included in the review. The review should focus on whether medications were appropriately prescribed, prepared, dispensed, administered and monitored. Reporting should occur no less than quarterly.
• Medical record review
  A representative sample of medical records must be reviewed for clinical pertinence, adequate and appropriate documentation and timely completion. Reporting should occur quarterly.
• Credentialing and privileging (also see medical staff chapter)
  The appointment and retention of a qualified medical staff are among the most important quality responsibilities of the Board. The composition of its medical staff largely determines a hospital’s quality of care. The Board must avoid a "rubber stamp" approach to granting medical staff appointments, reappointment and clinical privileges. Information to be reported to the Board on an ongoing basis should include, but is not limited to, the following:
• Evidence of valid license(s)
• Evidence of educational background and training and continuing education
• Evidence that no disciplinary actions have been taken by current or previous hospitals or Boards
• Evidence of current and adequate malpractice insurance
• Valid board certification
• Evidence of professional competence and ethics
• Statement of health
• Malpractice claims history
• Current privileges
• Clinical risk management
  A summary of incidents, claims, lawsuits, amounts paid to date and reports to the National Practitioner Data Bank should be provided on an ongoing basis to help trustees determine if patterns of loss or liability exist and whether they are being adequately addressed. Other clinical risk management issues, such as unexpected deaths or operations on incorrect limbs, and number of malpractice claims should also be addressed.

The review of nursing and ancillary departments in the carrying out of patient-focused functions should occur in at least the following areas:

• All nursing units
• Alcoholism and other drug dependence services
• Diagnostic radiology services
• Dietetic services
• Emergency services
• Hospital-sponsored ambulatory care services
• Nuclear medicine services
• Nursing services
• Pathology and medical laboratory services
• Pharmaceutical services
• Physical rehabilitation services
• Radiation oncology services
• Respiratory care services
• Social work services
• Special care units
• Surgical and anesthesia services

Currently, in Medicare-certified hospitals, two important aspects of care should be monitored for each service area. Two indicators per aspect of care should be reported at a minimum. The Board should receive reports from the various departments on a rotating basis throughout the year.

The Board should be updated on the hospital’s performance relative to accreditation, regulatory and licensure requirements. This report should occur following receipt of survey results. It should summarize the findings from surveys conducted by agencies such as the following:

• Joint Commission on Accreditation of Healthcare Organizations
• Washington State Department of Health
• Occupational Safety and Health Administration
• Medicare

The report should also summarize major recommendations and areas of noncompliance, as well as a schedule for corrective action and the results of those actions, developed by the hospital and medical staff.

To review, there are important questions for the board to consider in evaluating their effectiveness in assuring quality health care within their organization. The questions below should be added to the board self assessment noted at the beginning of the section.

• Are summary reports provided to hospital administration and, as appropriate, to the Board? Does this information provide a comprehensive overview of the hospital’s performance, highlighting prioritized indicators, reflecting patterns and trends, needed actions and offering comparison to local and national standards?
• Are the reports the Board receives manageable in number, clear and concise, routine and ongoing and explained in the appropriate level of detail?
• Is additional education or training needed by Board members to understand more completely the information being presented to them?

SUMMARY         Top

The Board is responsible for its hospital’s quality of care, including that of the medical staff. An effective hospital performance improvement program is necessary for a hospital to receive accreditation, licensure and certification from voluntary and governmental entities, to obtain third-party reimbursement and to use as a malpractice defense. It is used to market the services of the hospital and to maintain good relations with and the support of the hospital’s community.

REFERENCES         Top

Carey, Raymond G. and Robert C. Lloyd, Measuring Quality Improvement in Healthcare, New York, NY: Quality Resources, 1995.

Grose, Louise, Owner, Shiloh & Associates, Thrall, TX, January, 1998.

Health and Safety Code, Vol. 1, Chapter 108, Vernon’s Texas Codes Annotated, St. Paul, MN: West Publishing Co., 1992 and 1998 Supplement.

"JCAHO Tip-of-the-Month: First, QA - Then, QA&I - Now, PI. Is It All the Same?" Medical Staff Briefing, December, 1993, pp.6-7.

Joint Commission on Accreditation of Healthcare Organizations, Sentinel Events: Evaluating Cause and Planning Improvement, Oakbrook Terrace, IL, 1998.

Joint Commission on Accreditation of Healthcare Organizations, 1998 Hospital Accreditation Standards, Oakbrook Terrace, IL, 1998.

Joint Commission on Accreditation of Healthcare Organizations, Hospital Accreditation Standards and Survey Process: Small or Rural Hospitals, Oakbrook Terrace, IL, 1996.

Joint Commission on Accreditation of Healthcare Organizations, The Complete Guide to the 1998 Hospital Survey Process, Oakbrook Terrace, IL, 1998.

Joint Commission on Accreditation of Healthcare Organizations, "Joint Commission Modifies ORYX Performance Measure Selection Requirements," Oakbrook Terrace, IL, December 15, 1997, press release.

Medicare Conditions of Participation, 42CFR Subpart C 482.21.

Orlikoff, James and Mary K. Totter, The Board’s Role in Quality Care, Chicago, IL: American Hospital Publishing, Inc., 1991.

Orlikoff, James, "Trustee Orientation," Fort Worth, TX, 1997.

O’Rourke, Lisa and Barry Bader, The Quality Letter for Healthcare Leaders, Vol. 5, No. 2, March, 1993.

Pointer, Dennis D., Jamie E. Orlikoff, Board Work: Governing Health Care Organizations, Jossey-Bass, San Francisco, 1999

PISL Consulting Group, Developing Critical Pathways in Behavioral Health, Englewood CO: 1994.

Sullivan, Raymond and et.al., "Does Your Board of Trustees Really Know Your Hospital?" JHQ, Vol. 15, No. 4, July/August, 1993.

Totten, Mary et.al., The Guide to Governance for Hospital Trustees. Chicago, IL: American Hospital Association, 1990.

Washington Administrative Code 1999

Wayenknecht, Teresa, A Resource Manual for the Healthcare Quality Professional of the 90s, Austin, TX: The Texas Society for Healthcare Quality, 1993.