Patrice L. Spath Diane L. Kelly
FOURTH EDITION
Applying Quality Management IN HEALTHCARE
A SYSTEMS APPROACH
AUPHA/HAP Editorial Board for Graduate Studies
Nir Menachemi, PhD, Chairman Indiana University
LTC Lee W. Bewley, PhD, FACHE University of Louisville
Jan Clement, PhD Virginia Commonwealth University
Michael Counte, PhD St. Louis University
Joseph F. Crosby Jr., PhD Armstrong Atlantic State University
Mark L. Diana, PhD Tulane University
Peter D. Jacobson, JD University of Michigan
Brian J. Nickerson, PhD Icahn School of Medicine at Mount Sinai
Mark A. Norrell, FACHE Indiana University
Maia Platt, PhD University of Detroit Mercy
Debra Scammon, PhD University of Utah
Tina Smith University of Toronto
Carla Stebbins, PhD Des Moines University
Cynda M. Tipple, FACHE Marymount University
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Names: Spath, Patrice L., author. | Kelly, Diane L., author. Title: Applying quality management in healthcare : a systems approach / Patrice L. Spath, Diane L. Kelly. Description: Fourth edition. | Chicago, Illinois : Health Administration Press ; Washington, DC : Association of University Programs in Health Administration, [2017] | Revision of: Applying quality management in healthcare / Diane L. Kelly. | Includes bibliographical references and index. Identifiers: LCCN 2016055038 (print) | LCCN 2017001695 (ebook) | ISBN 9781567938814 (print : alk. paper) | ISBN 9781567938821 (Ebook) | ISBN 9781567938838 (Xml) | ISBN 9781567938845 ( Epub) | ISBN 9781567938852 (Mobi) Subjects: LCSH: Medical care—Quality control. | Health services administration. | Total quality management. Classification: LCC RA399.A1 K455 2017 (print) | LCC RA399.A1 (ebook) | DDC 362.1068—dc23 LC record available at https://lccn.loc.gov/2016055038
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To my lifelong friend and companion, my husband Robert O. Brown. —P. S.
To Isabella. —D. K.
vii
BRIEF CONTENTS
A Note from Diane L. Kelly ……………………………………………………………..xv Preface ……………………………………………………………………………………….xvii Acknowledgments ………………………………………………………………………….xxi
Section 1 Quality Management: A Systems Approach ………………………….. 1
Chapter 1. Quality Management Fundamentals ………………………….. 3 Chapter 2. Role of Policy in Advancing Quality ………………………… 17 Chapter 3. Characteristics of Complex Systems ………………………… 33 Chapter 4. Understanding System Behavior …………………………….. 49 Chapter 5. Visualizing System Relationships …………………………….. 65
Section 2 Setting the Stage for Success ……………………………………………81
Chapter 6. Establishing System Direction ………………………………… 83 Chapter 7. Setting Improvement Goals in Complex Systems …….. 107 Chapter 8. Fostering a Culture of Collaboration and Teamwork … 125
Section 3 Achieving Quality Results in Complex Systems …………………. 147
Chapter 9. Measuring Process and System Performance …………… 149 Chapter 10. Using Data Analytics Techniques to
Evaluate Performance …………………………………….. 167 Chapter 11. Designing and Implementing Improvements …………. 203 Chapter 12. Using Improvement Teams and Tools ……………………. 229 Chapter 13. Making Healthcare Safer for Patients …………………….. 253
Section 4 Practice Lab …………………………………………………………………. 283 Practice Exercise 1. Reflective Journal …………………………………..285 Practice Exercise 2. The Manager’s Role ………………………………..287 Practice Exercise 3. Dynamic Complexity ……………………………….289 Practice Exercise 4. System Relationships ……………………………….291 Practice Exercise 5. Meeting Customer Expectations ………………..293
viii Brief Contents
Practice Exercise 6. Organizational Self-Assessment ………………….295 Practice Exercise 7. Improving a Performance Gap
in Your Organization …………………………..301 Practice Exercise 8. Teamwork and Patient Safety …………………….309 Practice Exercise 9. Improvement Case Study …………………………313 Practice Exercise 10. Systems Error Case Study and Analysis ……….319 Practice Exercise 11. Failure Mode and Effects Analysis………………321
Glossary …………………………………………………………………………………….325 Index ………………………………………………………………………………………..335 About the Authors ………………………………………………………………………..353 About the Contributor ………………………………………………………………….355
ix
DETAILED CONTENTS
A Note from Diane L. Kelly ……………………………………………………………..xv Preface ……………………………………………………………………………………….xvii Acknowledgments ………………………………………………………………………….xxi
Section 1 Quality Management: A Systems Approach ………………………….. 1
Chapter 1. Quality Management Fundamentals …………………………… 3 Learning Objectives …………………………………………………3 Why Focus on Managing Systems? ……………………………….4 What Are Quality and Safety? ……………………………………..5 Creating a Common Understanding of Quality Methods …7 Three Principles of Total Quality …………………………………9 Quality Continuum for Organizations ………………………..12 Summary ………………………………………………………………14 Companion Readings ………………………………………………15 Web Resources ……………………………………………………….15 References ……………………………………………………………..15
Chapter 2. Role of Policy in Advancing Quality ………………………….. 17 Learning Objectives ………………………………………………..17 External Stakeholders Affecting Quality ……………………..18 Federal Health Policies and Oversight ………………………..20 Private Health Policies and Oversight …………………………26 Summary ………………………………………………………………28 Companion Readings ………………………………………………29 Web Resources ……………………………………………………….29 References ……………………………………………………………..31
Chapter 3. Characteristics of Complex Systems …………………………… 33 Learning Objectives ………………………………………………..33 Systems Thinking ……………………………………………………35 Dynamic Complexity ……………………………………………….37
x Detai led Contents
Summary ………………………………………………………………44 Companion Readings ……………………………………………..45 Web Resources ……………………………………………………….46 References ……………………………………………………………..46
Chapter 4. Understanding System Behavior ………………………………..49 Learning Objectives ………………………………………………..49 A Systems Metaphor for Organizations ……………………….49 Lessons for Healthcare Managers ……………………………….52 Going Below the Waterline ……………………………………….56 Summary ………………………………………………………………61 Companion Readings ………………………………………………62 Web Resources ……………………………………………………….62 References ……………………………………………………………..63
Chapter 5. Visualizing System Relationships ……………………………….65 Learning Objectives ………………………………………………..65 Interconnected Systems Model ………………………………….67 Three Core Process Model ……………………………………….68 Baldrige Performance Excellence Program
Framework ……………………………………………………….71 Socioecological Framework ………………………………………74 Summary ………………………………………………………………76 Companion Readings ………………………………………………78 Web Resource ………………………………………………………..78 References ……………………………………………………………..78
Section 2 Setting the Stage for Success ……………………………………………81
Chapter 6. Establishing System Direction …………………………………..83 Learning Objectives ………………………………………………..83 Purpose …………………………………………………………………84 The Purpose Principle ……………………………………………..90 Vision …………………………………………………………………..96 Context …………………………………………………………………99 Summary …………………………………………………………….102 Companion Readings …………………………………………….103 Web Resources ……………………………………………………..104 References ……………………………………………………………104
xiDetai led Contents
Chapter 7. Setting Improvement Goals in Complex Systems ………..107 Learning Objectives ………………………………………………107 Relationship Between Goals and Results ……………………109 Setting Improvement Goals in Complex Systems ………..111 Types of Goal Statements ……………………………………….114 Critiquing Goal Statements …………………………………….115 SMART Goals and Complex Systems………………………..119 Corollaries to Purpose and Goals ……………………………..120 Summary …………………………………………………………….121 Companion Readings …………………………………………….123 Web Resources ……………………………………………………..123 References ……………………………………………………………123
Chapter 8. Fostering a Culture of Collaboration and Teamwork ……125 Learning Objectives ………………………………………………125 Creating a Supportive Culture …………………………………126 Teams in Healthcare ………………………………………………128 Collaboration and Teamwork ………………………………….129 Mental Models Affecting Team Design ……………………..129 Mental Models About Work Team Differences……………131 Tools for Effective Teams ……………………………………….134 Summary …………………………………………………………….137 Companion Readings …………………………………………….141 Web Resources ……………………………………………………..142 References ……………………………………………………………143
Section 3 Achieving Quality Results in Complex Systems …………………. 147
Chapter 9. Measuring Process and System Performance ………………149 Learning Objectives ………………………………………………149 Quality Measures and Their Uses……………………………..150 Selecting Performance Measures ………………………………151 Choosing a Comprehensive Set of Measures ………………156 Performance Measures and the Quality Continuum …….160 Summary …………………………………………………………….163 Companion Readings …………………………………………….163 Web Resources ……………………………………………………..164 References ……………………………………………………………164
xii Detai led Contents
Chapter 10. Using Data Analytics Techniques to Evaluate Performance ………………………………………..167 Learning Objectives ………………………………………………167 What Is Data Analytics? ………………………………………….168 Introduction to Data Analytics Techniques ………………..169 Types of Data ………………………………………………………170 Applying Descriptive Statistics Techniques …………………171 Graphical Methods ………………………………………………..172 Predictive Analytics ……………………………………………….179 Numerical Summary Measures ………………………………..180 Using Graphical and Numerical Methods to Analyze
Process Performance ………………………………………….186 Bundling and Unbundling Data According to the User’s
Purpose …………………………………………………………..191 Summary …………………………………………………………….197 Companion Readings …………………………………………….200 Web Resource ………………………………………………………201 References ……………………………………………………………201
Chapter 11. Designing and Implementing Improvements …………….203 Learning Objectives ………………………………………………203 Systematic Critical Thinking in Designing
Improvements ………………………………………………….204 Implementing Improvements ………………………………….212 Summary …………………………………………………………….219 Companion Readings …………………………………………….222 Web Resources ……………………………………………………..222 References ……………………………………………………………222 Appendix 11.1 ……………………………………………………..225
Chapter 12. Using Improvement Teams and Tools ………………………229 Learning Objectives ………………………………………………229 Charter Improvement Projects ………………………………..230 Performance Improvement Teams ……………………………232 Improvement Tools and Techniques …………………………235 Summary …………………………………………………………….246 Companion Readings …………………………………………….247 Web Resources ……………………………………………………..248 References ……………………………………………………………248 Appendix 12.1 ……………………………………………………..250
xiiiDetai led Contents
Chapter 13. Making Healthcare Safer for Patients ………………………..253 Learning Objectives ………………………………………………253 Systems Model of Organizational Accidents ……………….254 Creating High Reliability ………………………………………..258 Measuring and Evaluating Safe Performance ………………262 Designing and Implementing Safety Improvements …….268 Summary …………………………………………………………….273 Companion Readings …………………………………………….276 Web Resources ……………………………………………………..278 References ……………………………………………………………278
Section 4 Practice Lab …………………………………………………………………. 283 Practice Exercise 1. Reflective Journal …………………………………..285 Practice Exercise 2. The Manager’s Role ………………………………..287 Practice Exercise 3. Dynamic Complexity ………………………………289 Practice Exercise 4. System Relationships ……………………………….291 Practice Exercise 5. Meeting Customer Expectations ……………….293 Practice Exercise 6. Organizational Self-Assessment …………………295 Practice Exercise 7. Improving a Performance Gap in Your
Organization …………………………………….301 Practice Exercise 8. Teamwork and Patient Safety ……………………309 Practice Exercise 9. Improvement Case Study …………………………313 Practice Exercise 10. Systems Error Case Study and Analysis ……….319 Practice Exercise 11. Failure Mode and Effects Analysis ……………..321
Glossary …………………………………………………………………………………….325 Index ………………………………………………………………………………………..335 About the Authors ………………………………………………………………………..353 About the Contributor ………………………………………………………………….355
xv
A NOTE FROM DIANE L. KELLY
T he quality landscape has changed dramatically since the first edition of Applying Quality Management in Healthcare: A Process for Improvement (2003). At that time, the Institute of Medicine reports To Err Is Human (1999) and Crossing the Quality Chasm (2001) were still relatively new and patient safety was in its early stages. The Premier Hospital Quality Incentive Demonstration, the precursor to today’s value-based purchasing initiatives, was just getting started. Transparency was in its infancy.
Fast-forward to today. The concept of systems is widely embraced in healthcare and has become a cornerstone for driving improvements toward achieving the Institute for Healthcare Improvement’s Triple Aim. Perverse financial incentives, which punished organizations for reducing utilization by improving care, are being challenged with a wide array of innovative payment models that reward improvements in quality, safety, and health promotion. The numerous and often disparate parts of the US healthcare system are working together to improve the health of populations, not just to care for sick individuals. The quality, safety, and systems concepts discussed in this book have become foundational, essential, and timeless. They may be applied to any type, size, level, or complexity of organizational forms.
I would like to thank the many students whom I have had the privilege to get to know, work with, and learn from as a result of writing and teaching with this text. I would also like to thank my mentor and friend, Dr. Arnold Kaluzny. I am delighted that Patrice Spath is collaborating on this fourth edition so that the book may continue to bring value to future students.
Diane L. Kelly, DrPH, MBA, RN Principal Consultant Quantix Health Capital Columbus, OH
xvii
PREFACE
S everal years ago, I partnered with a physician, Dr. William Minogue, to respond to an article in a medical journal that bemoaned the lack of successful patient safety improvement initiatives. The article’s authors suggested a new model was needed for conducting patient safety investigations because the current way of doing things was not working. At the time, I was facilitating training workshops for the Maryland Patient Safety Center, where Dr. Minogue was the medical director. We both agreed that a new safety investigation model was not the answer. This belief resulted in our coauthoring an article on the subject for WebM&M, an online case-based forum on patient safety sponsored by the Agency for Healthcare Research and Quality.
Our article began by reminding readers of the insights of Louis Pasteur, who, throughout his career, “insisted that germs were the cause of disease, not the body.” Near the end of his life, Pasteur changed his opinion and “declined treatment for potentially curable pneumonia, reportedly saying, ‘It is the soil, not the seed.’ In other words, a germ (the seed) causes disease when our bodies (the soil) provide a hospitable environment” (Spath and Minogue 2008).
This lesson, discovered by Pasteur so many years ago, has application to all quality improvement activities and is reinforced by the topics covered in this book. The systems in health services organizations must be carefully nurtured to create a hospitable environment for the many tools and techniques of improvement to thrive. If the soil is not properly prepared, the seeds of improvement will not take root or be sustainable. Dr. Diane Kelly, author of the first three editions of this book, was insightful in taking a systems approach to quality improvement. Dr. Kelly understood that preparing the “soil” of the organization is just as important as learning how to use the various quality tools. I am honored to have the opportunity to build on Dr. Kelly’s contributions in this fourth edition.
This book is intended for managers—anyone who influences the design of healthcare systems for the purpose of improving quality. It is not necessary to hold the official title of manager in an organization to be instrumental in creating and supporting higher-quality services. Many frontline, nonmanagerial clinical and administrative staff members are directly or indirectly involved in
xviii Preface
shaping patient care systems and in using improvement techniques to design more efficient, safer processes. Although the word manager is used liberally throughout this book, it is not intended to narrow the audience or the purpose. Anyone interested in making improvements in the quality and safety of health services will benefit from the learning in these pages.
Changes from the Third Edition
The emphasis on systems in the third edition is still evident in this fourth edition. What has changed is an expansion of information about quality tools, data analysis techniques, and patient safety. As with all editions of this book, concepts covered in the chapters are supported by real-life examples, illustrations, and thought-provoking end-of-chapter exercises. Some chapters have been added and others reordered. The book is now divided into three major sections instead of two.
Section 1 provides students with the foundational principles of healthcare quality and explains how systems affect an organization’s ability to accomplish quality goals. The chapter on the role of policy in advancing quality (chapter 8 in the third edition) was moved to this section so students can better appreciate how external forces affect system behavior and relationships as well as the quality methods used by health services organizations (covered in later chapters). Some of the material relevant to reliability and patient safety covered in this section in the third edition has been moved to a new chapter dedicated solely to the topic of patient safety.
Section 2 contains three chapters designed to illustrate what health services organizations must do to set the stage for success in quality management efforts. Because teamwork and collaboration are essential for advancing healthcare quality, the teamwork chapter at the end of the third edition has been expanded and moved to this section (chapter 8, “Fostering a Culture of Collaboration and Teamwork”). Much of the information from chapter 10 has been moved to chapter 9 (“Measuring Process and System Performance”), and some topics have been shifted to other related chapters.
The nuts and bolts of quality management are found in section 3. The chapters in this section are expansions of topics covered in the third edition. Instructors using the third edition in a quality course indicated the need for more detailed explanations of quality models and the tools and techniques of healthcare quality management. In addition, a new chapter has been added (chapter 10, “Using Data Analytics Techniques to Evaluate Performance”). This chapter covers basic concepts of healthcare data analytics, including how to use various statistical and graphical methods for reporting and evaluating
xixPreface
performance data. Some of these methods were covered briefly in the third edition, and some of the discussion is new to the fourth edition.
Materials on improvement models, project teams, and quality tools are greatly expanded from the third edition and now covered in two separate chapters (chapter 11, “Designing and Implementing Improvements,” and chapter 12, “Using Improvement Teams and Tools”). In the third edition, the various topics related to patient safety were dispersed among several different chapters. Now, most of the material concerning patient safety is in a new chapter (chapter 13, “Making Healthcare Safer for Patients”). This chapter is focused entirely on systems issues affecting patient safety and methods for reducing mistakes and preventing patient harm.
Health Administration Press now offers educators the opportunity to build custom textbooks comprising chapters from several different books. To accommodate this service, the chapters in the fourth edition of this book have been written to stand alone as much as possible. Within each chapter, references to material in other chapters have been minimized, or the concepts summarized and repeated when necessary. Where there are linkages between materials in various chapters, instructors are encouraged to point out these relationships because the connections are not as clearly stated as in the third edition.
Resources
Listed at the end of each chapter are companion readings and web resources. Instructors can expand students’ learning experience by assigning a companion reading or directing them to explore one or more of the online resources. These readings and websites are particularly useful in the chapter on data analysis techniques, if instructors want to cover more than just basic concepts. The web resources also provide instructors and students with sources of the most current information on relevant quality management and patient safety topics.
Patrice L. Spath, MA, RHIT President Brown-Spath & Associates Forest Grove, OR
xx Preface
Instructor Resources
This book’s Instructor Resources include explanations of the exercises, a test bank, and PowerPoint slides.
For the most up-to-date information about this book and its Instructor Resources, go to ache.org/HAP and browse for the book’s title or author names.
This book’s Instructor Resources are available to instructors who adopt this book for use in their course. For access information, please e-mail hapbooks@ ache.org.
Student Resources
For students, end-of-chapter exercises and web resources are available on this book’s companion website at ache.org/books/qualitymanagement4.
Reference
Spath, P., and W. Minogue. 2008. “The Soil, Not the Seed: The Real Problem with Root Cause Analysis.” Perspectives on Safety. Agency for Healthcare Research and Quality. Published July. https://psnet.ahrq.gov/perspectives/perspective/62/ the-soil-not-the-seed-the-real-problem-with-root-cause-analysis.
xxi
ACKNOWLEDGMENTS
The primary person that I must thank is Diane Kelly, author of the first three editions of this book. Her contributions to the learning experience of innumerable students and seasoned professionals have been outstanding. I am also grateful to the many people over the years who afforded me opportunities to share knowledge through my books and journal articles. In particular, I’d like to thank Janet Davis and Audrey Kaufman (the current and former acquisitions managers at Health Administration Press, respectively) and Richard Hill (senior editor at Health Forum, a unit of the American Hospital Association).
SECTION
1QUALITY MANAGEMENT: A SYSTEMS APPROACH
CHAPTER
3
1QUALITY MANAGEMENT FUNDAMENTALS Learning Objectives
After completing this chapter, you should be able to
• describe the vital role of management in achieving quality patient and client health services;
• differentiate among key healthcare quality characteristics, common approaches to quality improvement, and total quality principles; and
• recognize management practices and traits as organizations mature along the quality continuum.
A mother arrives at the pediatrician’s office for her daughter’s six-month well-child checkup. As she has for previous checkups, she arrives 10 minutes early. Her daughter’s scheduled appointment time of 10:00 am passes and she is still waiting at 11:30 am. The front desk receptionist politely tells the mother that the pediatrician has been called to an emergency, saying, “I’m sure you understand. If it was your child, you would want the doctor to attend to her.” Although the mother understands the reason for the delay, this explanation does not change the fact that she has to pick up her son from preschool at noon. The mother asks if her daughter can at least get the immunizations today and have the rest of her checkup at another time. A clinic nurse hurriedly administers the child’s immunizations while quietly complaining to the mother that she is often too busy to get a lunch break.
Dissatisfied with the hours wasted at the pediatrician’s office and disappointed with the need to return to finish her daughter’s checkup, the mother begins to investigate other healthcare options for her children. While the doctor at her current pediatric clinic seems highly trained and knowledgeable, the mother has concerns about the organization in which the doctor practices. The organizational aspects of the pediatric clinic are not meeting the mother’s expectations. In the broadest definition, an organization is a structured system designed to accomplish a goal or set of goals. In this example, the care providers and office staff are a pediatric health services organization designed to deliver healthcare to children.
organization a structured system designed to accomplish a goal or set of goals
Applying Qual i ty Management in Healthcare: A Systems Approach4
This book focuses on managing the quality of the structured system in which health services are delivered. Like any organization, the structured system in the pediatric clinic is a by-product of numerous variables that affect the design and execution of many interrelated factors. What are the specific goals of the healthcare organization and how are they determined? Does everyone in the organization understand and agree with these goals? How are patient appointments, office workflow, and staff hours scheduled to enable the practice to meet these goals? How are patient and family needs and expectations taken into account? How are clinic employees recruited, hired, trained, and evaluated? Does the pediatrician devote all of her time to the office or does she also have hospital commitments? How is the pediatrician compensated for services? How does reimbursement influence the office structure and work systems? Does the practice operate according to a budget? Does the practice employ an office manager? If so, how is the manager’s role defined? How do the pediatrician and the staff communicate with each other and with patients and their families?
These are just some of the questions that influence managerial decisions about how the structured system will operate. In the example, the mother’s experience resulted from how her pediatrician’s practice addressed such organizational questions. This mother’s perception of quality had nothing to do with the quality of the medical care. It had everything to do with the organizational quality of the health services. The focus of this text is on managing the structured systems of health-related services—within and between organizations—to provide the highest-quality and safest healthcare.
Why Focus on Managing Systems?
Providing the medical care (e.g., performing cardiac surgery) and producing the service (e.g., maintaining a clean environment) are functions of the clinical and technical professionals. Creating and managing the structured system in which clinical and technical professionals work is the role of management. The manager’s perspective and tactics may vary depending on his organizational level (e.g., senior administrative, middle management, frontline supervisory) and his scope of responsibilities (e.g., team, project, department, division, agency, organization-wide). Regardless, all persons holding management responsibilities in an organization are charged with finding ways to carry out, coordinate, and improve the organizational functions.
As illustrated by the mother’s experience at the pediatric clinic, patients may not receive the benefits of good medical care when the system of delivery is poorly managed. Quality is not simply the obligation of clinical and technical professionals. The task of achieving quality outcomes from healthcare
Chapter 1 : Qual i ty Management Fundamentals 5
organizations is a shared responsibility belonging to those who provide medical care and produce services and the management professionals who oversee the system. Management determines how and what organizational goals are set; how human, fiscal, material, and intellectual resources are secured, allocated, used, and preserved; and how activities in the organization are designed, carried out, coordinated, and improved. The material presented in this book is intended to assist managers in the decision-making processes related to quality and safety in health services organizations.
What Are Quality and Safety?
A widely accepted definition of quality as given by the Institute of Medicine (IOM) is this: “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Lohr 1990, 21). To further clarify the concept of quality, the IOM (2001) identified the key components of quality care: safe, effective, patient centered, timely, efficient, and equitable. Patient safety, a key component of quality care, is defined as, “freedom from accidental or preventable injuries produced by medical care” (Agency for Healthcare Research and Quality [AHRQ] 2016b).
The way managers in health services organizations define and prioritize quality in the context of their daily responsibilities is often influenced by their own background and experiences. For example, a physician manager may emphasize the importance of achieving optimal patient outcomes through implementation of evidence-based medicine. A nurse manager or pharmacist may stress the importance of interpersonal skills, teamwork, and patient-centered care. A manager with public health credentials may take a population-based approach to improving healthcare quality. Likewise, the educational focus of nonclinical managers may influence the preferred quality definition and priorities. A manager educated in a business school may emphasize operations management, whereas someone trained as an accountant may focus on how quality affects the financial bottom line. A manager with a health services administration background may stress the importance of organizational structures and stakeholder relationships.
These examples illustrate the assortment of perspectives and preferences about health services quality and the numerous ways quality concerns may be expressed in healthcare organizations. The multifaceted nature of quality poses several additional questions and challenges for healthcare managers: What is quality in healthcare? Which approach is best? How are the approaches related?
Since the early 1970s, Avedis Donabedian’s work has influenced the prevailing medical paradigm for defining and measuring quality. In his early
quality “the degree to which health services for indi- viduals and popu- lations increase the likelihood of desired health outcomes and are consistent with current profess- ional knowledge” (Lohr 1990, 21)
key components of quality care quality care is safe, effective, patient centered, timely, efficient, and equi- table (IOM 2001)
patient safety “freedom from accidental or pre- ventable injuries produced by medi- cal care” (AHRQ 2016b)
Applying Qual i ty Management in Healthcare: A Systems Approach6
writings, Donabedian (1980) introduced the two essential components—the technical and the interpersonal—that comprise quality medical care. He also identified three ways to measure quality (structure, process, outcome) and the relationships among them. Donabedian (1980, 79, 81–83) described the measures in the following way:
I have called the “process” of care . . . a set of activities that go on within and between
practitioners and patients. . . . Elements of the process of care do not signify quality
until their relationship to desirable health status has been established. By “structure”
I mean the relatively stable characteristics of the providers of care, of the tools and
resources they have at their disposal, and of the physical and organizational settings
in which they work. . . . Structure, therefore, is relevant to quality in that it increases
or decreases the probability of good performance. . . . I shall use “outcome” to mean
a change in a patient’s current and future health status that can be attributed to
antecedent healthcare. The fundamental functional relationships among the three
elements are shown schematically as follows: Structure → Process → Outcome.
For example, in a family medicine group practice, the number and credentials of physicians, nurse practitioners, physician’s assistants, nurses, medical technicians, and office staff are considered structure measures. The percentage of elderly patients who appropriately receive an influenza vaccine is considered a process measure, and the percentage of elderly patients who are diagnosed and treated for influenza is considered an outcome measure for this practice. The staff members in the office (structure) influence the ability of the practice to appropriately identify patients for whom the vaccine is indicated and to correctly administer the vaccine (process), which in turn affects the number of patients developing influenza (outcome). If a process measure has a clearly demonstrated link to an outcome, the process measure may be used as a proxy measure for an outcome (Parast et al. 2015)
When the IOM recognized patient-centered care as a key component of twenty-first-century healthcare quality in 2001, the Donabedian model for measuring quality expanded to include patient experience. Patient experience measures are a subcategory of outcomes that represent the voice of patients— their “report of observations of and participation in health care, or assessment of any resulting change in their health” (AHRQ 2016a). For example, a family practice clinic may have a good process for identifying patients needing an influenza vaccine and qualified staff to correctly administer the vaccine, yet patients may report their experience to be unsatisfactory if caregivers do not listen to their concerns and adequately answer questions about the vaccination.
process of care “a set of activities that go on within and between practitioners and patients” (Donabedian 1980, 79)
structure “the relatively sta- ble characteristics of the providers of care, of the tools and resources they have at their disposal, and of the physical and organizational set- tings in which they work” (Donabe- dian 1980, 81)
outcome “a change in a patient’s current and future health status that can be attributed to antecedent health- care” (Donabedian 1980, 83)
patient experience a patient’s “report of observations of and participation in health care, or assessment of any resulting change in their health” (AHRQ 2016a)
Chapter 1 : Qual i ty Management Fundamentals 7
While a health services manager can easily become overwhelmed by the complexity and extensive range of views on the topic of healthcare quality, she may also consider this array of perspectives as a vast pool from which to draw quality-related knowledge and lessons.
Creating a Common Understanding of Quality Methods
As with most elements of management, the subject of quality in healthcare organizations has been the object of numerous trends, fads, and attempts at quick fixes. Because departments and professionals with “quality” responsibilities may change their job titles with the latest trend, managers must understand what is behind the label; in other words, they must understand the philosophy and actions used to promote quality in an organization. The first step for managers is to develop a common understanding of quality terminology. Definitions of frequently used terms to describe quality are provided here.
Quality control. Mostly used in the manufacturing setting, quality control (QC) encompasses “the operational techniques and activities used to fulfill requirements for quality” (American Society for Quality [ASQ] 2016). In health services, quality control activities usually refer to equipment maintenance and calibration, such as for point-of-care and laboratory testing, imaging machines, and sterilization procedures.
Quality assurance. A quality assurance (QA) approach is focused on the outputs of a process. Products are inspected after they are produced, and imperfect products are discarded. In some cases, the defect may not be readily noticeable and is replaced at a later time, as with a new automobile warranty. In service organizations fields such as healthcare, defects refer to unsatisfactory or defective outputs from a received service. The quality of the service is inspected after it is received and, if not acceptable, the customer may ask for the service to be repeated. For example, when the customer discovers that a retail pharmacy includes only half the number of tablets in a prescription refill, he asks for the refill to be corrected. Sometimes the service defect is not readily noticeable, as in the case of a surgical sponge left in a patient after an operation. As the patient’s condition deteriorates, tests are performed to identify causes of the defective output. The patient must return to surgery for the defect to be corrected.
Hearing QA and QC used interchangeably when “referring to the actions performed to ensure the quality of a product, service or process” is not uncommon (ASQ 2016).
Quality improvement. A quality improvement (QI) approach, also referred to as continuous quality improvement (CQI), is focused on the ongoing improvement of processes as a way to improve the quality of the outputs (i.e.,
quality control (QC) “the operational techniques and activities used to fulfill requirements for quality” (ASQ 2016)
quality assurance (QA) actions performed to eliminate defective outputs
quality improvement (QI) “ongoing improve- ment of products, services or processes through incremental and breakthrough improvements” (ASQ 2016)
Applying Qual i ty Management in Healthcare: A Systems Approach8
reduce the number of defective outputs). Preoperative checklists, sponge counts, and team briefings are examples of operating room process improvements designed to prevent defective outputs or surgical complications. By implementing incremental and breakthrough improvements, QI seeks to produce defect-free outputs and provide consistent high-quality services.
Total quality. The term total quality (TQ), also referred to as total quality management or TQM, is often used interchangeably with “QI” and “CQI.” This tendency can cause students and managers to be confused by the two related but different concepts. Total quality is “a philosophy or an approach to management that can be characterized by its principles, practices, and techniques. Its three principles are customer focus, continuous improvement, and teamwork . . . each principle is implemented through a set of practices . . . the practices are, in turn, supported by a wide array of techniques (i.e., specific step-by-step methods intended to make the practices effective)” (Dean and Bowen 2000, 4–5).
As shown by this definition, TQ is a strategic concept, whereas CQI is one of three principles that support a TQ strategy. Numerous techniques— including performance management, Six Sigma, and Lean—are available for managers in implementing the principles of CQI on a tactical level and an operational level. A brief description of these techniques is provided in the following section with more detail in subsequent chapters.
Performance management. The business literature defines performance management as “an umbrella term that describes the methodologies, metrics, processes and systems used to monitor and manage the business performance of an enterprise” (Buytendijk and Rayner 2002). Performance management is also referred to as enterprise performance management (EPM), corporate performance management (CPM), and business performance management (BPM).
Six Sigma. Six Sigma is a rigorous and disciplined approach using process improvement tools, methods, and statistical analysis. Its precepts are based on the philosophy “that views all work as processes that can be defined, measured, analyzed, improved and controlled” (Muralidharan 2015, 528). Six sigma is a statistical term referring to the goal of achieving zero defects or failures. Six Sigma quality is considered a “rate of less than 3.4 defects per million opportunities, which translates to a process that is 99.99966 percent defect free” (Spath 2013, 125). Although the technique originated in manufacturing, the use of Six Sigma is being encouraged in health services organizations as a way of achieving high reliability (Chassin and Loeb 2013).
Lean. Sometimes called Lean thinking, Lean “is about finding and eliminating waste in all processes” (Black 2016, 6). This quality philosophy and set of tools, which also originated in manufacturing, is used to remove wasted effort from healthcare processes without compromising quality (Chassin and Loeb 2013). Lean techniques have helped health services organizations
total quality (TQ) “a philosophy or an approach to management that can be char-acterized by its principles, practices, and techniques. Its three principles are customer focus, con- tinuous improvement, and teamwork . . . each principle is imple- mented through a set of practices . . . the practices are, in turn, supported by a wide array of techniques (i.e., specific step-by- step methods intended to make the practices effective)” (Dean and Bowen 2000, 4–5)
performance management “an umbrella term that describes the methodologies, metrics, processes and systems used to monitor and manage the business performance of an enterprise” (Buytendijk and Rayner 2002)
Six Sigma a rigorous and dis- ciplined process improvement approach using defined tools, methods, and statisti- cal analysis with the goal of improving the outcome of a process by reducing the fre- quency of defects or failures
Lean (or Lean thinking) an improvement phi- losophy and set of tools that “is about finding and eliminating waste in all processes” (Black 2016, 6)
Chapter 1 : Qual i ty Management Fundamentals 9
increase patient staff satisfaction, create more efficient processes, lower expenses, reduce patient wait times, improve capacity management, and make many other value-added, customer-focused enhancements (Black 2016). The Toyota Production System (TPS) is a common method of applying Lean in health services organizations.
Organizational effectiveness. Several models or definitions of effectiveness in management literature exist, and the meanings are derived from the values and preferences of evaluators (Cameron 2015). From the perspective of TQ, organizational effectiveness means accomplishing goals.
Change management. Whether quality improvement is aimed at reducing defects, removing wasteful process steps, or achieving better patient outcomes, the work people do in the organization will be modified in minor and sometimes major ways. Change management is a “systematic approach that prepares an organization to accept, implement, and sustain the improved processes” (Chassin and Loeb 2013, 481). A structure for managing the changes that result from quality improvement efforts is essential for ensuring that quality does not deteriorate as time passes, staff turnover occurs, and new priorities emerge. Components of this strategy can include human resources planning, financial and resource management, and implementation of a control system that involves measurement and oversight of performance results (McLaughlin and Olson 2012). A phrase often associated with change management is “sustain the gains.”
Exhibit 1.1 provides a summary of the quality-related terms described in this section and the influence these concepts have on the actions of healthcare managers.
Quality management. Continuously improving products and services to achieve better performance is often referred to as quality management. In this book, the term quality management is used to describe the manager’s role and contribution to organizational effectiveness. Quality management, for our purposes, refers to how managers working in various types of health services organizations and settings understand, explain, and continuously improve their organizations to allow them to deliver quality and safe patient care, promote quality patient and organizational outcomes, and improve health in their communities.
Three Principles of Total Quality
Total quality is based on three principles: customer focus, continuous improvement, and teamwork. While these topics are explored in depth in later chapters, a brief introduction to these principles is provided in this section.
Toyota Production System a common method of applying Lean in health services, first developed at the Toy- ota Motor Company
organizational effectiveness the ability to accom- plish goals
change management a “systematic approach that pre- pares an organization to accept, implement, and sustain the improved processes” (Chassin and Loeb 2013, 481)
quality management the manager’s role and contribution to organizational effectiveness; how managers working in various types of health services orga- nizations and settings understand, explain, and continuously improve their orga- nizations to allow them to deliver qual- ity and safe patient care, promote quality patient and organi- zational outcomes, and improve health in their communities
Applying Qual i ty Management in Healthcare: A Systems Approach10
Customer. A customer is defined as a user (or potential user) of services or programs. Patients are customers, as are referring healthcare providers, as well as payers such as patients’ family members and health plans (Baldrige Performance Excellence Program [BPEP] 2015).
External customers are the parties outside the organization, and the primary external customers for health services providers are patients, families and partners, clients, insurers and other third-party payers, and communities. An internal customer is a user inside of the organization. Internal customers have been described as “someone whose inbox is your outbox.” For example, in a hospital, when patient care is handed off from one provider to another at shift change, the incoming provider is considered the internal customer of the outgoing provider. Completing the requisite shift responsibilities in a timely manner, communicating relevant information, and leaving a tidy work space demonstrate one’s recognition of coworkers as internal customers.
The contemporary view of quality management expands the concept of “customer” to include stakeholders and markets in which the organization operates. The term stakeholder is used to refer to “all groups that are or might be affected by an organization’s services, actions or success” (BPEP 2015, 53). In healthcare organizations, key stakeholders may include “customers, the community, employers, health care providers, patient advocacy groups,
customer the user or potential user of services or programs
external customer a user outside the organization
internal customer a user inside the organization
stakeholder “all groups that are or might be affected by an organization’s services, actions or success” (BPEP 2015, 53)
Quality-Related Term Relevant Manager Actions
Quality control Fulfill process requirements
Quality assurance Find and repair faulty processes causing defective outputs
Quality improvement/continuous quality improvement
Incrementally and continuously improve processes
Performance management Continuously review, evaluate, and improve performance to meet changing customer, stakeholder, and regulatory requirements
Six Sigma Aggressively improve processes and reduce variation to achieve zero defects
Lean/Lean thinking Seek better ways to organize human actions and processes to eliminate waste
Total quality/total quality management
Manage using a customer focus, continuous improvement, and teamwork
Organizational effectiveness Understand and improve the system to achieve goals
Change management Use systematic methods to transition individuals, teams, and the organization
EXHIBIT 1.1 Quality-Related
Terms
Chapter 1 : Qual i ty Management Fundamentals 11
departments of health, students, the workforce, partners, collaborators, governing boards, stockholders, donors, suppliers, taxpayers, regulatory bodies, policy makers, funders, and local and professional communities” (BPEP 2015, 53).
Customer-focused quality means that key patient and other customer requirements and expectations are identified and drive improvement efforts (BPEP 2015). Defining customers and stakeholders is a prerequisite to determining their requirements and, in turn, to designing organizational processes that meet these requirements.
Continuous improvement. When the manager of an environmental services department in a large hospital picks up something from the hallway floor and throws it away in the nearest trash can, her action exemplifies the principle of continuous improvement. While other hospital employees might walk past the trash, the environmental services manager realizes the importance of being committed to continuous improvement for her department and for the hospital; if at any time the manager sees something that needs fixing, improving, or correcting, she takes the initiative. If managers want to achieve continuous improvement in their organizations, they must demonstrate continuous improvement through their everyday actions.
The principle of continuous improvement may also be expressed through managers’ execution of their managerial functions. Managing by fact and depending on performance data to inform decisions is requisite to this principle. Though they might vary according to the nature of the work and the scope of management responsibility, performance data may be reported at various time intervals. For example, a shift supervisor for the patient transportation service in an 800-bed academic medical center watches the electronic dispatch system that displays a minute-by-minute update on transportation requests, indicators of patients en route to their destinations, and the number of patients in the queue. By monitoring the system, the supervisor is immediately aware when a problem occurs and, as a result, is able to take action quickly to resolve the problem. If the number of requests unexpectedly increases, the supervisor can reassign staff breaks to maximize staff availability and minimize response times.
Each day, the supervisor posts the total number of transports performed the previous day, along with the average response times. This way, the patient transporters are aware of the department’s statistics and their own individual statistics, which helps the transporters take pride in a job that is typically underappreciated by others in the organization. The daily performance data also enable the supervisor to quickly identify documented complaints and to address them within 24 hours, which in turn increases employee accountability and improves customer relations. On a monthly basis, the department manager and the shift supervisors review the volume of requests by hour of the day to determine whether employees are scheduled appropriately to meet demand.
customer-focused quality a type of quality in which key patient and other customer requirements and expectations are identified and drive improvement efforts
Applying Qual i ty Management in Healthcare: A Systems Approach12
The manager also reviews the statistics sorted by patient unit (e.g., nursing unit, radiology department) to identify any issues that need to be explored directly, manager to manager. The manager reviews the monthly statistics with his administrator, and the annual statistics are used in the budgeting process. A performance management system such as this promotes continuous improvement, which is defined as steady, incremental improvement in the organization’s overall performance.
Teamwork. When the terms teamwork and quality are used together, management is usually referring to cross functional or interdisciplinary project teams. Healthcare organizations seeking to make changes in complex processes or activities that involve more than one discipline or work area often use a team approach. Quality improvement is fundamentally a team process in which significant and lasting improvements rely on the “knowledge, skills, experience, and perspectives of different individuals” (Health Resources and Services Administration 2011, 3).
In relation to quality management, managers should also consider teamwork when they carry out functions inherent in the managerial role—in particular, organizational design, resource allocation, and communication. Designing and implementing decision-making, documentation, and communication processes (which ensure individuals and teams have the information they need, when they need it, to make effective and timely clinical and organizational decisions) reflect a manager’s understanding of the quality management principles. For example, in one hospital, the manager of the materials management department negotiates with a supplier to obtain surgical gloves at a discounted rate compared with the rate of the current supplier. The decision is made based on vendor and financial input. The first time the new gloves are used, however, the surgeon rips out the fingers of the gloves while inserting his hand. Had the manager embraced the concept of teamwork in her approach to decision making, she would have sought out information and input from the patient care team—the people who actually use the product and know the advantages and disadvantages of different brands of gloves.
Quality Continuum for Organizations
Quality management is not a single event; rather, it is an organizational journey. Progress along the journey may be viewed on a continuum, with one end representing traditional or early attempts at quality and the other end representing more mature approaches (exhibit 1.2). Regulatory, accreditation, and cost-control pressures, as well as consumer activism, are accelerating the quality journey of health services organizations. These external factors are described in more detail in the next chapter.
continuous improvement steady, incremen- tal improvement in the organization’s overall performance
teamwork a team process involving the “knowledge, skills, experience, and perspectives of dif- ferent individuals” (Health Resources and Services Administration 2011, 3)
Chapter 1 : Qual i ty Management Fundamentals 13
Less Mature Developing More Mature
Quality priorities Complying with quality requirements of external stakeholders is an operational imperative
Internal quality improvement is one of three or four strategic priorities
Internal quality improvement is the organization’s top strategic priority
Quality scope Internal customers
Internal and external customers and stakeholders
Internal and external customers and stakeholders and the community served
Quality transparency
Key quality measures not reported internally throughout the organization and not reported publicly
Key quality measures reported internally throughout the organization; few reported publicly
Key quality measures reported internally and publicly; reports include benchmark data from best practice organizations
Quality methods No organization- wide approach to quality improvement
Data-driven, statistical methods used in some improvement initiatives
Managers trained in data-driven, statistical methods that are used for all improvement initiatives
Performance measures
Only measures used are those required by external stakeholders
In addition to measures required by external stakeholders, internal measures are used to evaluate quality priorities of managers
In addition to measures required by external stakeholders, internal measures linked to the quality goals of the organization are used
Information technology (IT)
There is little or no IT support for quality activities
IT supports some quality activities, but many are still paper based
IT support is provided for all quality activities
Source: Adapted from Chassin and Loeb (2013).
EXHIBIT 1.2 Quality Continuum for Healthcare Organizations
Applying Qual i ty Management in Healthcare: A Systems Approach14
Although a healthcare organization may occupy a point anywhere along this maturity continuum, the goal of quality management is to continually strive toward the most mature end of the continuum. An understanding of the quality continuum in health services organizations begins to explain differences in operations and outcomes in organizations that all claim to be “quality organizations,” such as
• how an organization can be successful at quality projects but not attain a quality organizational culture;
• why some organizations have adjusted better than others to current oversight practices of regulatory groups and accreditation agencies;
• why implementing clinical practice guidelines does not in itself guarantee healthcare quality;
• why operations management efforts, independent of clinical context, may not yield expected results; and
• why, without leadership’s involvement in establishing a quality philosophy and strategy for the entire organization, only pockets of excellence may be found in an organization.
Summary
Achieving organizational effectiveness requires leaders to combine the knowledge of management and quality to understand and improve the organization. This chapter has introduced various terms and approaches to help managers establish a common vocabulary for quality in their organizations. The path to becoming a mature, quality organization is a process characterized by transitions in managerial philosophy, thinking, and action.
Exercise 1.1 Objective: To explore the current state of healthcare quality in the United States.
Instructions:
• Go to the AHRQ website (https://nhqrnet.ahrq.gov/inhqrdr) and find the most current version of the National Healthcare Quality and Disparities report.
• Read the Executive Summary. • Browse the rest of the report.
Chapter 1 : Qual i ty Management Fundamentals 15
• Based on your brief review of this report, summarize the state of healthcare quality and disparities in the United States in one or two paragraphs.
Companion Readings
Health Resources and Services Administration. 2011. Quality Improvement. US Department of Health and Human Services. Published April. www.hrsa.gov/ quality/toolbox/508pdfs/qualityimprovement.pdf.
Institute of Medicine (IOM). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press.
Web Resources
Agency for Healthcare Research and Quality: www.ahrq.gov American Society for Quality: www.asq.org National Association for Healthcare Quality: www.nahq.org Public Health Foundation: www.phf.org
References
Agency for Healthcare Research and Quality (AHRQ). 2016a. “Domain Framework and Inclusion Criteria: Domain Definitions.” Updated March 17. www.quality measures.ahrq.gov/about/domain-definitions.aspx.
———. 2016b. “Patient Safety Network Glossary.” Accessed June 25. www.psnet .ahrq.gov/glossary.aspx.
American Society for Quality (ASQ). 2016. “Quality Glossary.” Accessed June 25. www.asq.org/glossary/index.html.
Baldrige Performance Excellence Program (BPEP). 2015. 2015–2016 Baldrige Excellence Framework: A Systems Approach to Improving Your Organization’s Performance (Health Care). Gaithersburg, MD: US Department of Commerce, National Institute of Standards and Technology.
Black, J. 2016. The Toyota Way to Healthcare Excellence: Increase Efficiency and Improve Quality with Lean, 2nd ed. Chicago: Health Administration Press.
Buytendijk, F., and N. Rayner. 2002. “A Starter’s Guide to CPM Methodologies.” Research Note TU-16-2429. Stamford, CT: Gartner, Inc.
Applying Qual i ty Management in Healthcare: A Systems Approach16
Cameron, K. 2015. “Organizational Effectiveness.” In Wiley Encyclopedia of Management, vol. 11, 1–4. Published January. http://onlinelibrary.wiley.com/ doi/10.1002/9781118785317.weom110202/abstract.
Chassin, M. R., and J. M. Loeb. 2013. “High-Reliability Health Care: Getting There from Here.” The Milbank Quarterly 91 (3): 459–90.
Dean, J. W., Jr., and D. E. Bowen. 2000. “Management Theory and Total Quality: Improving Research and Practice Through Theory Development.” In The Quality Movement and Organization Theory, edited by R. E. Cole and W. R. Scott, 3–22. Thousand Oaks, CA: SAGE Publications.
Donabedian, A. 1980. Explorations in Quality Assessment and Monitoring. Vol. 1 in The Definition of Quality and Approaches to Its Assessment. Chicago: Health Administration Press.
Health Resources and Services Administration. 2011. Quality Improvement. US Department of Health and Human Services. Published April. www.hrsa.gov/ quality/toolbox/508pdfs/qualityimprovement.pdf.
Institute of Medicine (IOM). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press.
Lohr, K. N. (ed.). 1990. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academies Press.
McLaughlin, D. B., and J. R. Olson. 2012. Healthcare Operations Management, 2nd ed. Chicago: Health Administration Press.
Muralidharan, K. 2015. Six Sigma for Organizational Excellence: A Statistical Approach. New York: Springer.
Parast, L., B. Doyle, C. L. Damberg, K. Shetty, D. A. Ganz, N. S. Wenger, and P. G. Shekelle. 2015. “Challenges in Assessing the Process–Outcome Link in Practice.” Journal of General Internal Medicine 30 (3): 359–64.
Spath, P. L. 2013. Introduction to Healthcare Quality Management, 2nd ed. Chicago: Health Administration Press.
CHAPTER
17
2ROLE OF POLICY IN ADVANCING QUALITY Learning Objectives
After completing this chapter, you should be able to
• describe the types of oversight organizations that influence healthcare quality;
• recognize how public and private policies encourage quality improvement at the organizational, community, and national levels; and
• identify resources to maintain current knowledge about policy changes, new initiatives, and updates on current initiatives.
T he most visible or well-known topics of healthcare policy tend to be those related to funding, payment, and access. Examples include Titles XVIII and XIX, the Social Security Act amendments of 1965 that created Medicare and Medicaid; the Balanced Budget Act of 1997 that created the Children’s Health Insurance Program (CHIP); and the Patient Protection and Affordable Care Act of 2010 (ACA). There are many other public and private policies that play an integral role in ensuring the quality of healthcare services.
Licensure is an example of how healthcare quality is affected by public health policies. Physicians, nurses, nurse practitioners, pharmacists, physical therapists, and other care providers must have licenses to practice their professions. These requirements are guided by the statutes and rules outlined in the professional practice acts and occupational licensing bodies of their respective states. There are many other examples of how public and private policies influence healthcare quality. The Americans with Disabilities Act requires health facilities to have ramped sidewalks to the front door and Braille numbers on the elevator buttons. Sprinklers in the ceilings, signs labeled “fire exit,” and alarm-activated doors that close automatically are mandated by state building codes and the fire safety requirements of state regulations and private health facility oversight groups. Inappropriate or excessive radiation exposure to patients and healthcare personnel during diagnostic exams is prevented when facilities comply with the requirements of the Occupational Safety and
Applying Qual i ty Management in Healthcare: A Systems Approach18
Health Administration and private oversight entities. The safety and efficacy of medications are investigated by the US Food and Drug Administration before they are released for patient use.
Considering the Donabedian (1980) model for measuring quality (structure, process, outcome), policy initiatives have historically targeted the quality of the structural elements of the healthcare delivery system, such as people, physical facilities, equipment, and drugs. Outcome measures, such as infant mortality rates and life expectancy, and aggregate process measures, such as immunization rates, have been collected for many years by the public health infrastructure at state, national, and international levels. Current health quality policy initiatives target outcomes and processes at the organization, provider, and population levels.
This chapter discusses the increasingly important role of public and private policies on healthcare quality by providing a brief overview of health policy concepts, explaining the role of quality oversight bodies, and introducing several healthcare quality initiatives that demonstrate the use of public and private policies to drive system change and improvement.
External Stakeholders Affecting Quality
A variety of external stakeholders—federal, state, and local government agencies and private organizations—set quality expectations and assess and monitor services delivered by health plans, health facilities, integrated delivery systems, and individual practitioners. Types of quality oversight organizations are summarized in exhibit 2.1.
External stakeholders use three primary approaches to influence healthcare quality: licensure, accreditation, and certification. Licensure is granted by a governmental body and represents minimum quality standards, while accreditation and certification are granted by nongovernmental
licensure status granted by a governmental body and confirming mini- mum standards
accreditation “a public recogni- tion by a healthcare accreditation body of the achievement of accreditation stan- dards by a healthcare organization, dem- onstrated through an independent external peer assessment of that organization’s level of performance in relation to the standards” (Smits, Supachutikul, and Mate 2014, 66)
certification a form of external quality review for health services professionals and organizations; when applied to individ- uals, it represents advanced education and competence; when applied to organizations, it represents meeting predetermined stan- dards for a special- ized service provided by the organization (Rooney and van Ostenburg 1999).
State licensing bodies. States, typically through their health departments, have long regulated healthcare delivery through the licensure of healthcare institutions such as hospitals, long-term care facilities, and home health agencies, as well as individual healthcare practitioners such as physicians and nurses. States also license, through their insurance and health departments, financial “risk-bearing entities,” including both indemnity insurance products and those managed care products that perform the dual function of bearing risk (like an insurer) and arranging for or delivering healthcare services (like healthcare-providing entities).
(continued)
EXHIBIT 2.1 Types of
Healthcare Quality
Oversight Organizations in the United
States
Chapter 2: Role of Pol icy in Advancing Qual i ty 19
Private sector accrediting bodies. Accrediting bodies set standards for healthcare organizations and assess compliance with those standards. They also focus on the operation and effectiveness of internal quality improvement systems. In some functional areas, state and federal governments rely on or recognize private accreditation for purposes of ensuring compliance with licensure or regulatory requirements.
Medicare and Medicaid compliance. For a healthcare entity to receive Medicare or Medicaid reimbursement, the entity must meet certain federally specified conditions of participation (CoPs) or other standards. The Centers for Medicare & Medicaid Services (CMS) promulgates CoPs for hospitals, home health agencies, nursing facilities, hospices, ambulatory surgical centers, renal dialysis centers, rural health clinics, outpatient physical therapy and occupational therapy, and rehabilitation facilities. CMS also establishes standards for the participation of managed care organizations contracting under the Medicare program.
US Department of Labor. Oversight of certain aspects of employer-provided health plans is performed by the US Department of Labor. The Employee Retirement Income Security Act of 1974 sets minimum federal standards for group health plans maintained by private-sector employers, by unions, or jointly by employers and unions. The department oversees plan compliance with the following legal requirements of plan administration: reporting and disclosure of plan features and operations, fiduciary obligations for management of the plan and its assets, handling benefit claims, continuation coverage for workers who lose group health coverage, limitations on exclusions for preexisting conditions, prohibitions on discrimination based on health status, renewability of group health coverage for employers, minimum hospital stays for childbirth, and parity of limits on mental health benefits.
Individual certification and credentialing organizations. The American Board of Medical Specialties (an umbrella for 24 specialty boards) and the American Osteopathic Association have certification programs that designate certain medical providers as having completed specific training in a specialty and having passed examinations testing knowledge of that specialty. The Accreditation Council for Graduate Medical Education, sponsored by the American Medical Association and four other organizations, accredits nearly 7,700 residency programs in 1,600 medical institutions across the United States. For nursing, the American Board of Nursing Specialties sets standards for the certification of nursing specialties. The largest numbers of nurses, both in generalist and specialist practice, are certified by the American Nurses Credentialing Center on the basis of practice standards established by the American Nurses Association.
Source: Data from President’s Advisory Committee on Consumer Protection and Quality in the Health Care Industry (1998).
EXHIBIT 2.1 Types of Healthcare Quality Oversight Organizations in the United States (continued)
Applying Qual i ty Management in Healthcare: A Systems Approach20
organizations. Accreditation and certification represent optimal quality standards for organizations or advanced education and competence for individuals.
Quality oversight organizations are vital stakeholders of health services organizations. Their standards, regulations, and conditions of participation (CoPs) increasingly drive system change and improve quality of care and services. Details on the specific laws, regulations, and impact of healthcare quality may be found in other texts dedicated to health policy and healthcare management. In the next sections, a few key examples of external stakeholders (public and private) and how they influence healthcare quality are provided. Because the priorities and expectations of external stakeholders are constantly changing, students and managers charged with quality responsibilities will need additional resources to learn about the most current requirements of all stakeholder groups affecting their organization. The web resources at the end of this chapter are useful for this purpose.
Federal Health Policies and Oversight
The federal government is a vital stakeholder of health services organizations. Its regulations, CoPs, and health policy priorities are increasingly being used to drive system change and improve quality of care and services. Details on specific laws and regulations that affect healthcare quality may be found in other texts dedicated to health policy. This section presents a few key examples that illustrate the role of policy in system improvement. A brief background on the evolution of these initiatives is also provided so readers may appreciate the influence of history on the current healthcare quality landscape.
The US government serves the following generic purposes: “to provide for those who cannot provide for themselves, to supply social and public goods, to regulate the market, and to instill trust and accountability” (Tang, Eisenberg, and Meyer 2004, 48). To accomplish these purposes, the government uses public policy or “authoritative decisions made in the legislative, executive, or judicial branches of government that are intended to direct or influence the actions, behaviors, or decisions of others” (Longest 2010, 5). Some of these public policies are considered health policies because they “pertain to health or influence the pursuit of health” (Longest 2010, 6). Health policies are crafted to influence health determinants, which in turn influence health. The ACA (US Department of Health and Human Services [HHS] 2015) was the most significant legislation resulting from public health policy since enactment of the Medicare and Medicaid programs in 1965.
However, the federal government’s influence extends beyond the ACA. In 2011, the HHS published National Strategy for Quality Improvement in Health Care. This document outlined the National Quality Strategy, a road map
public policy “authoritative decisions made in the legislative, executive, or judi- cial branches of government that are intended to direct or influence the actions, behav- iors, or decisions of others” (Longest 2010, 5)
health policies policies that “pertain to health or influence the pursuit of health” (Longest 2010, 6)
Chapter 2: Role of Pol icy in Advancing Qual i ty 21
for achieving affordability, better care, and healthy people and communities. The recommendations in this document affect all healthcare stakeholders—patients; providers; employers; health insurance companies; academic researchers; and local, state, and federal governments (HHS 2011). Each year, the road map is reviewed and revised as needed to reflect current priorities and performance results (Agency for Healthcare Research and Quality [AHRQ] 2016b).
The three broad aims of National Strategy for Quality Improvement in Health Care guide the local, state, and national efforts to improve health and the quality of healthcare. These aims include the following (AHRQ 2014):
• Better care. Improve overall quality by making healthcare more patient- centered, reliable, accessible, and safe.
• Healthy people/healthy communities. Improve the health of the US population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.
• Affordable care. Reduce the cost of quality healthcare for individuals, families, employers, and the government.
The many legislative, regulatory, and reimbursement changes necessary to support the National Quality Strategy are affecting quality management at the provider level. Two notable changes came from federal legislation passed before the National Quality Strategy. The Health Information Technology for Economic and Clinical Health Act, enacted as part of the American Recovery and Reinvestment Act of 2009, promoted the adoption and meaningful use of health information technology (Jha 2012). This legislation has influenced the transition to electronic health records to improve the quality and safety of the healthcare system. The large federal subsidies for adopting this technology and financial disincentives have made the conversion from paper to electronic records possible in many organizations.
The ACA may also support the National Quality Strategy by encouraging healthcare organizations to form accountable care organizations (ACOs) to bring about efficiencies in consumption of services while lowering overall costs. An ACO is a network of providers (primarily doctors and hospitals) that share financial and medical responsibilities for providing coordinated care to patients in hopes of limiting unnecessary spending (Gold 2015).
Knowledge Acquisition Public policy at the federal level creates formal structures and mechanisms for acquiring new knowledge so that public and private policymakers may make informed, evidence-based decisions about health quality practices. For example,
accountable care organization (ACO) a network of pro- viders (primarily doctors and hos- pitals) that share financial and medi- cal responsibilities for providing coor- dinated care to patients in hopes of limiting unnec- essary spending (Gold 2015)
Applying Qual i ty Management in Healthcare: A Systems Approach22
the AHRQ sponsors and conducts research and disseminates information to advance healthcare quality (see exhibit 2.2).
Another example is the Innovation Center at CMS (2016a), which the ACA created “for the purpose of testing innovative payment and service delivery models to reduce program expenditures . . . while preserving or enhancing the quality of care for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) benefits.” Best practices and lessons learned from these tests are made available to all healthcare organizations to support quality improvement throughout the healthcare system at large. Several of the innovation models being tested have the potential to greatly affect quality and safety improvement activities at the provider level (see exhibit 2.3).
One initiative of the CMS Innovation Center is a nationwide public– private collaboration called Hospital Engagement Networks (HEN). These networks work at the regional, state, national, or hospital-system level to help identify solutions already working and disseminate them to other hospitals and providers. Initially, the CMS Innovation Center formed 26 HENs in 2012 as part of a campaign to reduce harm and improve the quality and safety of healthcare. Many of these networks were successful at achieving this goal. For instance, the 127 hospitals participating in the Iowa-based HEN prevented potential harm to more than 4,300 patients in 2013 and reduced healthcare costs by more than $51 million according to data released by the Iowa Healthcare Collaborative (Iowa Hospital Association 2014), which administers
Mission. To support research designed to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. The research sponsored, conducted, and disseminated by AHRQ provides information that helps people make better decisions about healthcare.
Created. The agency was founded in December 1989 as the Agency for Health Care Policy and Research, a public health service agency in the HHS. Reporting to the HHS secretary, the agency was reauthorized on December 6, 1999, as the Agency for Healthcare Research and Quality. Sister agencies include the National Institutes of Health, the Centers for Disease Control and Prevention, the Food and Drug Administration, the Centers for Medicare & Medicaid Services, and the Health Resources and Services Administration.
Main functions. AHRQ sponsors and conducts research that provides evidence- based information on healthcare outcomes; quality; and cost, use, and access. The information helps healthcare decision makers—patients and clinicians, health system leaders, purchasers, and policymakers—make more informed decisions and improve the quality of healthcare services.
Source: Adapted from AHRQ (2016a).
EXHIBIT 2.2 Agency for Healthcare
Research and Quality
Chapter 2: Role of Pol icy in Advancing Qual i ty 23
Accountable care. Accountable care organizations and similar care models are designed to incentivize healthcare providers to become accountable for a patient population and to invest in infrastructure and redesigned care processes that provide for coordinated care, high quality, and efficient service delivery.
Episode-based payment initiatives. Under these models, healthcare providers are held accountable for the cost and quality of care that beneficiaries receive during an episode of care, which usually begins with a triggering healthcare event (such as a hospitalization or chemotherapy administration) and extends for a limited time thereafter.
Primary care transformation. Primary care providers are a key point of contact for patients’ healthcare needs. Strengthening and increasing access to primary care is critical to promoting health and reducing overall healthcare costs. Advanced primary care practices—also called medical homes—use a team-based approach while emphasizing prevention, health information technology, care coordination, and shared decision making among patients and their providers.
Initiatives focused on Medicaid and CHIP populations. Medicaid and CHIP are administered by the states but are jointly funded by the federal government and the states. Initiatives in this category are administered by the participating states.
Initiatives focused on Medicare and Medicaid enrollees. The Medicare and Medicaid programs were designed with distinct purposes. Individuals enrolled in both Medicare and Medicaid (called dual eligibles) account for a disproportionate share of the programs’ expenditures. A fully integrated, person- centered system of care that ensures all enrollees’ needs are met could better serve this population in a high-quality, cost-effective manner.
Initiatives to accelerate the development and testing of new models. Many innovations necessary to improving the healthcare system will come from local communities and healthcare leaders from across the country. By partnering with these local and regional stakeholders, CMS can help accelerate the testing of models today that may be the next breakthrough tomorrow.
Initiatives to speed the adoption of best practices. Recent studies indicate that it takes nearly 17 years, on average, before best practices (practices backed by research) are incorporated into widespread clinical practice—and even then the application of the knowledge is very uneven. The CMS Innovation Center is partnering with a broad range of healthcare providers, federal agencies, professional societies, and other experts and stakeholders to test new models for disseminating evidence-based best practices and significantly increasing the speed of adoption.
Source: Data from CMS (2016b).
EXHIBIT 2.3 Categories of New Payment and Service Delivery Models Being Tested by the CMS Innovation Center
Applying Qual i ty Management in Healthcare: A Systems Approach24
the network. To sustain this national progress and momentum, in 2015 CMS awarded a second round of contracts to 17 HENs, which include more than 3,200 hospitals (CMS 2015a).
CMS also promotes local implementation of quality practices through its network of Quality Improvement Organizations (QIOs). The Medicare QIO Program (formerly referred to as the Medicare Utilization and Quality Control Peer Review Program) was created by statute in 1982 to improve quality and efficiency of services delivered to Medicare beneficiaries (Leavitt 2006, 2). Today, the QIO Program comprises 14 regional Quality Innovation Networks designed to “bring Medicare beneficiaries, providers, and communities together in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality” (Quality Improvement Organizations 2016).
Transparency Transparency is a vital component of an efficient and effective healthcare system, as it fosters improved management of the cost and quality of health services (Wetzel 2014). In 1987, an unprecedented effort at nationwide healthcare performance transparency occurred when the Health Care Financing Agency (HCFA), now known as CMS, produced its first annual report of “observed hospital-specific mortality rates for Medicare acute care hospitals” (Cleves and Golden 1996, 40). The goal of this HCFA transparency initiative was to produce “better information to guide the decisions of physicians, patients, and the agency, thus improving outcomes and the quality of care” (Roper et al. 1988, 1198).
This initial transparency strategy set the stage for using federal policy to systematically develop and implement expectations, requirements, methodology, and infrastructure to collect, publish, and disseminate performance data measuring beneficiaries’ quality of care. The mortality data reports were discontinued in 1994 and the focus turned to gathering and reporting performance data for high-volume, high-cost clinical conditions and patient experiences.
The specific performance data that healthcare organizations are required to report to CMS change each year. Many of the organization-specific quality performance data currently being reported can be found on the Medicare website (www.medicare.gov). In addition to quality measures for hospitals, the public has access to performance data for nursing homes, home health providers, and dialysis facilities. Making performance results more transparent—enabling stakeholders to assess healthcare quality and compare providers—is intended to encourage healthcare organizations to take steps toward improving health services. Refer to the web resources box for more information about these measurement and reporting initiatives.
Chapter 2: Role of Pol icy in Advancing Qual i ty 25
Financial Incentives The inpatient prospective payment system (IPPS) implemented by CMS in the 1980s focused on containing the increasing costs of hospital care. The next phase of financial incentives is focusing on improving the value of health services. Value is the ratio of quality to cost (value = quality/cost). Section 5001(c) of Deficit Reduction Act of 2005 required CMS to identify conditions that “could reasonably have been prevented through the application of evidence- based guidelines” (CMS 2015b). As of October 1, 2008, CMS denied additional payment for these hospital-acquired conditions (HACs), also known as never events, when patients developed one during a hospital stay (CMS 2015b). For example, when a patient got a HAC, such as a surgical-site infection following coronary artery bypass graft, the hospital would be paid as though this infection were not present.
To understand how CMS has refocused the IPPS on value, consider the historical role of clinical complications and hospital payment. If a surgical sponge was accidently left inside the patient after surgery and the patient required another surgery to remove it, both surgeries were billed to the payer. The HAC financial incentive in the IPPS was designed to ensure that CMS would not pay for complications that should not have occurred in the first place. In addition, it was intended to encourage hospitals to adopt evidence- based practices to prevent never events from occurring.
To date, the success of this approach to financially incentivizing hospital quality improvements has been mixed. Waters and colleagues (2015) studied the association between Medicare’s nonpayment policy and four of the more common HACs: central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure ulcers (HAPUs), and injurious inpatient falls. “Medicare’s nonpayment policy was associated with an 11% reduction in the rate of change in CLABSIs . . . and a 10% reduction in the rate of change in CAUTIs, but was not associated with a significant change in injurious falls . . . or HAPUs” (Waters et al. 2015, 347). The authors concluded that reductions in the rates of CLABSI and CAUTI resulted from implementation of better hospital processes, whereas little evidence exists that changing hospital processes can lead to reductions in HAPUs or injurious inpatient falls (Waters et al. 2015).
A continued focus on value is the theme of contemporary healthcare quality policy at the federal level. The Medicare Access and CHIP Reauthorization Act of 2015 introduced two value-based payment models for physicians that have an impact on quality management: a Merit-Based Incentive Payment System and alternative payment models. These value-based payment models are intended to strengthen the relationship between physician payment and quality practices such as efficient use of healthcare resources and clinical improvements. These changes to the Medicare payment system for physicians
value the ratio of quality to cost (value = quality/cost)
hospital-acquired conditions (or never events) medical conditions that “could reason- ably have been prevented through the application of evidence-based guidelines” (CMS 2015b)
Applying Qual i ty Management in Healthcare: A Systems Approach26
are not expected to be implemented for several years. It will be essential for physicians and healthcare facilities to understand how these payment models work so they can determine how and where to focus a systems approach to improving performance (Bassett 2016).
Private Health Policies and Oversight
Accreditation bodies are private, nongovernmental groups with policies and standards that encourage healthcare quality and safety improvement. Accreditation is voluntary, which means that, unlike public policies and oversight, healthcare organizations can choose whether to comply with an accreditation group’s private policies and be subject to its oversight.
The Joint Commission is a nongovernmental accreditation organization for several types of health services organizations: ambulatory care, behavioral health care, critical access, home care, hospitals, laboratory services, nursing care, and office-based surgery. The Joint Commission also offers certification for disease-specific services for conditions such as chronic kidney disease and stroke and for programs such as palliative and perinatal care and primary care medical homes. For more information, see its website at www.jointcommission.org.
The National Committee for Quality Assurance (NCQA) offers accreditation programs for health plans and related organizations and programs such as wellness and health promotion and disease management. The NCQA also offers a variety of certifications; for a fuller description, see www.ncqa.org.
The national Public Health Voluntary Accreditation Board was established to “improve and protect the health of the public by advancing the quality and performance of Tribal, state, local, and territorial public health departments” (Public Health Accreditation Board 2016). Additional accreditation organizations are listed in the web resources box.
Organizations seeking CMS approval to participate in federally funded insurance programs such as Medicare and Medicaid may undergo state surveys on behalf of CMS or be surveyed by an accrediting body approved by CMS. Some private accreditation groups such as The Joint Commission, DNV GL, the Healthcare Facilities Accreditation Program, and the Institute for Medical Quality have been granted deemed authority by CMS. An organization accredited by one of these groups “would have ‘deemed status’ and would not be subject to the Medicare survey and certification process because it has already been surveyed by the accrediting organization” (American Society for Healthcare Engineering 2016). Because of this private–public relationship, the policies and standards of accreditation organizations with deeming authority necessarily support and, in many instances, parallel the federal regulations governing the healthcare organizations they accredit.
Chapter 2: Role of Pol icy in Advancing Qual i ty 27
Knowledge Acquisition Accreditation bodies, like public agencies, work to identify and disseminate best practices that support healthcare quality and safety improvements. For example, since 1996, accredited facilities have been encouraged to report sentinel events to The Joint Commission. A sentinel event is a patient safety event that affects a patient and results in death, permanent harm, or severe temporary harm and intervention required to sustain life (Joint Commission 2016). “Reporting of the event enables ‘lessons learned’ from the event to be added to The Joint Commission’s Sentinel Event Database, thereby contributing to the general knowledge about sentinel events and to the reduction of risk for such events” (Joint Commission 2016). As of June 2016, The Joint Commission had published 56 sentinel event alerts describing process changes healthcare organizations can make to improve prevention.
Knowledge sharing is common practice in other accreditation and certification bodies. For example, more than 1,500 cancer care programs accredited by the Commission on Cancer report data to the National Cancer Database (NCDB). Data in the NCDB, jointly sponsored by the American College of Surgeons and the American Cancer Society, are used to analyze and track patients with malignant neoplastic diseases, their treatments, and their outcomes (American College of Surgeons 2016). This information is available to healthcare organizations to encourage the spread of cancer care best practices.
Laboratories accredited by the College of American Pathologists offer complimentary online access to resource guides that present new and evolving technologies in pathology and assist pathologists with ways to better understand, evaluate, and implement these technologies into their practices. For more information, see the group’s website at www.cap.org.
Transparency Since 2002, healthcare organizations accredited by The Joint Commission have been required to gather and report data for various performance measures. In 2002, hospitals reported data for eight measures of care provided for patients with heart failure, pneumonia, and myocardial infarction. By 2014, hospitals reported data for up to 49 different measures of disease-specific care as well as surgical care, venous thrombosis, and immunization care (Baker and Chassin 2016).
The Joint Commission’s performance measure project is intended to assist facilities in identifying important quality gaps and help them improve their care (Baker and Chassin 2016). This aim is achieved, in part, by making facility-specific data and comparative state and national data for various measures publicly available on The Joint Commission’s Quality Check website (www.qualitycheck.org). Several performance improvements have resulted from The Joint Commission’s transparent quality measurement
sentinel event a patient safety event that affects a patient and results in death, permanent harm, or severe temporary harm and intervention required to sustain life (Joint Commission 2016)
Applying Qual i ty Management in Healthcare: A Systems Approach28
efforts, including reduction of medically unnecessary early elective deliveries from 13.6 percent in 2011 to 3.3 percent in 2014 (Joint Commission 2015).
Financial Incentives Private accrediting bodies lack the authority to impose financial incentives on healthcare organizations to influence quality improvements. However, private sector health plans and business groups are encouraging payment strategies similar to those being advanced by CMS in order to improve the value of healthcare services.
Summary
This chapter discusses the role of quality oversight organizations and introduces public and private groups whose policies and initiatives target system change. These initiatives fall into three areas: knowledge acquisition, transparency, and financial incentives. Because of the dynamic and rapidly changing nature of healthcare quality policy, both public and private, readers are encouraged to review the accompanying Internet resources as a means to keep current on changes, new initiatives, and plans for the future.
Exercise 2.1 Objective: To become familiar with the current CMS quality initiatives and how they support the National Quality Strategy and organizational performance improvement.
Instructions:
• Based on your work setting or an area of interest, select and explore one of the CMS quality initiatives (e.g., hospitals, home health, nursing home, end-stage renal disease) at www.cms.gov/center/quality.asp and review the current National Quality Strategy report (www.ahrq.gov/ workingforquality).
• In two or three paragraphs, answer the following questions in reference to the quality initiative you selected:
a. What does the CMS quality initiative include? Describe the initiative and its relationship to the National Quality Strategy.
b. How can the data publicly available on the compare site for the quality initiative benefit a healthcare organization? Describe how the measurement data can be used in the setting you are interested in to improve performance.
Chapter 2: Role of Pol icy in Advancing Qual i ty 29
Exercise 2.2 Objective: To become familiar with the current quality measurement initiatives of The Joint Commission.
Instructions: Explore the current ORYX performance measures of The Joint Commission (www.jointcommission.org/performance_measurement.aspx). For each measure, describe which system or systems in your chosen setting will be improved by the use of the measure.
Companion Readings
Callender, A. N., D. A. Hastings, M. C. Hemsley, L. Morris, and M. W. Peregrine. 2007. Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors. US Department of Health and Human Services Office of Inspector General and American Health Lawyers Association. Published September 13. http://oig.hhs.gov/fraud/docs/complianceguidance/ CorporateResponsibilityFinal%209-4-07.pdf.
Chassin, M. A., J. M. Loeb, S. P. Schmaltz, and R. M. Wachter. 2010. “Accountability Measures—Using Measurement to Promote Quality Improvement.” New England Journal of Medicine 363 (7): 683–88.
Commonwealth Fund. 2013. “Better Care at Lower Cost: Is It Possible?” Published November 21. www.commonwealthfund.org/publications/health-reform- and-you/better-care-at-lower-cost.
Partnership for Sustainable Health. 2013. Strengthening Affordability and Quality in America’s Health Care System. Robert Wood Johnson Foundation. Published April. www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf405432.
Skyve, P. M. 2009. Leadership in Healthcare Organizations: A Guide to Joint Commission Leadership Standards. Governance Institute. Published Winter. www.jointcommission.org/leadership_in_healthcare_organizations.
Web Resources
Accreditation Accreditation Association for Ambulatory Health Care (AAAHC):
www.aaahc.org Accreditation Commission for Education in Nursing (ACEN):
www.acenursing.org (continued)
Applying Qual i ty Management in Healthcare: A Systems Approach30
Accreditation Council for Graduate Medical Education (ACGME): www.acgme.org
Accreditation Council for Pharmacy Education (ACPE): www. acpe-accredit.org/
Center for Improvement in Healthcare Quality (CIHQ): http://cihq.org College of American Pathologists (CAP): www.cap.org Commission on Accreditation of Rehabilitation Facilities (CARF):
www.carf.org Commission on Cancer: www.facs.org/quality-programs/cancer/coc Commission on Collegiate Nursing Education (CCNE): www.aacn.nche
.edu/Accreditation/index.htm Community Health Accreditation Program (CHAP): www.chapinc.org DNV GL: http://dnvglhealthcare.com Healthcare Facilities Accreditation Program (HFAP): www.hfap.org Institute for Medical Quality: www.imq.org The Joint Commission: www.jointcommission.org National Committee for Quality Assurance (NCQA): www.ncqa.org National Public Health Performance Standards Program (NPHPSP):
www.cdc.gov/od/ocphp/nphpsp/index.htm Public Health Accreditation Board (PHAB): www.phaboard.org URAC (formerly the Utilization Review Accreditation Commission):
www.urac.org
Reports CMS Quality of Care Center (with links to compare websites):
www.cms.gov/center/quality.asp The Joint Commission Quality Check: www.qualitycheck.org National Cancer Databases: www.facs.org/quality%20programs/cancer/
ncdb
Federal Policymakers CMS Innovation Center: https://innovation.cms.gov CMS Partnership for Patients: https://partnershipforpatients.cms.gov CMS Quality Improvement Programs: www.qioprogram.org National Quality Strategy: www.ahrq.gov/workingforquality Patient Protection and Affordable Care Act of 2010: www.hhs.gov/
healthcare US Department of Health and Human Services, priority goals and
objectives: www.performance.gov/agency/department-health- and-human-services
Chapter 2: Role of Pol icy in Advancing Qual i ty 31
References
Agency for Healthcare Research and Quality (AHRQ). 2016a. “About AHRQ.” Reviewed March. www.ahrq.gov/cpi/about/index.html.
———. 2016b. “NQS Reports and Annual Updates.” Accessed June 25. www.ahrq .gov/workingforquality/reports.htm.
———. 2014. “The National Quality Strategy: Fact Sheet.” Revised September. www.ahrq.gov/workingforquality/nqs/nqsfactsheet.htm.
American College of Surgeons. 2016. “National Cancer Database.” Retrieved June 27. www.facs.org/quality-programs/cancer/ncdb.
American Society for Healthcare Engineering. 2016. “Deemed Status.” Retrieved June 25. www.ashe.org/advocacy/orgs/deemedstatus.shtml.
Baker, D. W., and M. R. Chassin. 2016. “Measuring and Improving Quality.” Journal of the American Medical Association 315 (24): 27–33.
Bassett, M. 2016. “MACRA, MIPS: Slated to Make an M-pressive Impact.” For the Record, May, 17–19.
Centers for Medicare & Medicaid Services (CMS). 2016a. “About the CMS Innovation Center.” US Department of Health and Human Services. Updated July 8. https://innovation.cms.gov/about/index.html.
———. 2016b. “Innovation Models.” Retrieved June 26. https://innovation.cms .gov/initiatives.
———. 2015a. “Hospital-Acquired Conditions.” Last modified August 19. www.cms. gov/medicare/medicare-fee-for-service-payment/hospitalacqcond/hospital- acquired_conditions.html.
———. 2015b. “Partnership for Patients and Hospital Engagement Networks: Continuing Forward Momentum on Reducing Patient Harm.” Published September 25. www.cms.gov/Newsroom/MediaReleaseDatabase/Fact- sheets/2015-Fact-sheets-items/2015-09-25.html.
Cleves, M. A., and W. E. Golden. 1996. “Assessment of HCFA’s 1992 Medicare Hospital Information Report of Mortality Following Admission for Hip Arthroplasty.” Health Services Research 31 (1): 39–48.
Donabedian, A. 1980. Explorations in Quality Assessment and Monitoring. Vol. 1 in The Definition of Quality and Approaches to Its Assessment. Chicago: Health Administration Press.
Gold, J. 2015. “Accountable Care Organizations, Explained.” Kaiser Health News. Published September 14. http://khn.org/news/aco-accountable-care- organization-faq.
Iowa Hospital Association. 2014. “Iowa Initiative Reduces Medical Errors, Saves $51M.” Published February 25. http://blog.iowahospital.org/2014/02/25/ iowa-initiative-reduces-medical-errors-saves-51m/.
Jha, A. K. 2012. “Health Information Technology Comes of Age.” Archives of Internal Medicine 172 (9): 737–38.
Applying Qual i ty Management in Healthcare: A Systems Approach32
Joint Commission. 2016. “Sentinel Event Policy and Procedures.” Published January 6. www.jointcommission.org/sentinel_event_policy_and_procedures.
———. 2015. America’s Hospitals: Improving Quality and Safety: The Joint Commission’s Annual Report. Retrieved June 27. www.jointcommission.org/assets/1/18/ TJC_Annual_Report_2015_EMBARGOED_11_9_15.pdf.
Leavitt, M. O. 2006. Report to Congress: Improving the Medicare Quality Improvement Organization Program—Response to the Institute of Medicine Study. Retrieved June 25, 2016. www.cms.gov/QualityImprovementOrgs/downloads/QIO_ Improvement_RTC_fnl.pdf.
Longest, B. B. 2010. Health Policymaking in the United States, 5th ed. Chicago: Health Administration Press.
President’s Advisory Committee on Consumer Protection and Quality in the Health Care Industry. 1998. “Quality First: Better Health Care for All Americans.” US Department of Health and Human Services. Revised July 18. http://archive .ahrq.gov/hcqual/final.
Public Health Accreditation Board. 2016. “What Is Accreditation?” Accessed June 26. www.phaboard .org/accreditation-overview/what-is-accreditation.
Quality Improvement Organizations. 2016. “About QINs-QIOs.” Retrieved June 27. www.qioprogram.org/about/why-cms-has-qios.
Rooney, A. L., and P. R. van Ostenburg. 1999. Licensure, Accreditation, and Certification: Approaches to Health Service Quality. USAID Quality Assurance Project. Published April. www.usaidassist.org/sites/assist/files/accredmon.pdf.
Roper, W. L., W. Winkenwerder, G. M. Hackbarth, and H. Krakauer. 1988. “Effectiveness in Health Care: An Initiative to Evaluate and Improve Medical Practice.” New England Journal of Medicine 319 (18): 1197–202.
Smits, H., A. Supachutikul, and K. S. Mate. 2014. “Hospital Accreditation: Lessons from Low- and Middle-Income Countries.” Globalization and Health 10: 65.
Tang, N., J. M. Eisenberg, and G. S. Meyer. 2004. “The Roles of Government in Improving Health Care Quality and Safety.” Joint Commission Journal on Quality and Safety 30 (4): 47–55.
US Department of Health and Human Services (HHS). 2015. “Read the Law” HHS. gov. Reviewed August 28. www.hhs.gov/healthcare/about-the-law/read-the-law.
———. 2011. National Strategy for Quality Improvement in Health Care. Published March. www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.pdf.
Waters, T. M., M. J. Daniels, G. J. Bazzoli, E. Perencevich, N. Dunton, V. S. Staggs, C. Potter, N. Fareed, M. Liu, and R. I. Shorr. 2015. “Effect of Medicare’s Nonpayment for Hospital-Acquired Conditions: Lessons for Future Policy.” Journal of the American Medical Association: Internal Medicine 175 (3): 347–54.
Wetzel, S. 2014. Transparency: A Needed Step Towards Health Care Affordability. American Health Policy Institute. Published March. www.americanhealthpolicy. org/Content/documents/resources/Transparency%20Study%201%20-%20 The%20Need%20for%20Health%20Care%20Transparency.pdf.
CHAPTER
33
CHARACTERISTICS OF COMPLEX SYSTEMS
Learning Objectives
After completing this chapter, you should be able to
• discuss how a systems perspective can explain recurrent organizational problems,
• recognize different types of systems and the role of systems thinking, • describe system characteristics that contribute to dynamic complexity,
and • explain the influence of dynamic complexity on managerial decision
making.
A s people accumulate years of experience in the healthcare field, they begin to see recurring problems—sometimes in an individual organization and sometimes across the entire field. Problems thought to be solved by one manager may come back at a later time for a different manager. The vice president of nursing at a large hospital may centralize and cross-train nurse educator positions to meet necessary budget cuts for the year; three years later, the new vice president of nursing at the same hospital adds unit-based nurse educator positions to address the unmet clinical orientation needs of its new hires. Consider the following situation (Georgopoulos and Mann 1962, 549–51):
The hospital faces a number of problems concerning the nursing staff . . . one
major problem is . . . attracting and retaining a sufficient professional nursing staff,
especially non-supervisory nursing staff. . . . The problem lies in the fact that the
number of professional nurses being trained in nursing schools is much too low
to meet an ever increasing demand for professional nurses by hospitals and other
sources. . . . Being understaffed, hospitals often assign to the professional nurse
a rather heavy workload that is not seen as normal or reasonable by many nurses.
. . . Another important problem . . . involves the composition of the total nursing
staff, the question of optimum balance in the proportions of staff members who are
registered nurses, practical nurses, and aides.
3
Applying Qual i ty Management in Healthcare: A Systems Approach34
Although this situation may appear to address a manager’s current challenges with nursing shortages, the excerpt was taken from the book The Community General Hospital, which was published in 1962! During the more than 50 years since that book was written, health services organizations seem to have made little headway in issues related to workforce planning and management. Nursing shortages, for example, appeared and disappeared in waves in the 1960s, 1970s, 1980s, early 1990s, and again in the early decades of the twenty-first century. Worker shortages are not limited to nursing. In the 2013 AMN Clinical Workforce Survey, 78 percent of hospital executives report a physician shortage, 66 percent a shortage of nurses, 50 percent shortages of nurse practitioners and physician assistants, and 43 percent a shortage of allied healthcare professionals (AMN Healthcare 2013).
The projected supply of healthcare workers will not meet the demand associated with future population growth and aging (Anderson 2014). Compounding this problem, the Affordable Care Act of 2010 has flooded the already-strained healthcare delivery system with newly insured patients. Individuals are facing longer wait times to see physicians, difficulties accessing specialty care, reduced appointment duration, inadequate services, and overall frustration as a result of workforce shortages. Being short-staffed requires careful management of an organization’s healthcare resources. For example, the lack of experienced registered nurses is causing acute care facilities, such as the Rapid City Regional Hospital in South Dakota, to adjust the number of available beds every day on the basis of the number of nurses available for each shift (Grant 2016).
Regardless of how healthcare systems might change in the future, one constant remains. Organizations still need people on the front lines of healthcare delivery—physicians, nurses, advanced practitioners, and allied health professionals. As healthcare delivery systems become more complex, organizations without a sufficient number of skilled and dedicated workers will find it difficult to achieve quality goals.
Why do budget problems and workforce shortages remain nagging issues for health services managers? The reasons lie in the complex nature of healthcare, healthcare organizations, and the healthcare field. In healthcare, as in other sectors, “systems thinking is needed more than ever because we are being overwhelmed with complexity” (Senge 1990, 69). Today, one may rephrase Senge’s 1990 comment to read, “Systems thinking is imperative in health services organizations because they are much more complex than they were in 1990.”
In healthcare systems, the term complex refers to the presence of a large number of variables that interact with each other in countless and often unpredictable ways. Considering the multiple determinants of health and the vast number of components composing health services organizations,
complex having a large number of vari- ables that interact with each other in innumerable, and often unpredict- able, ways
Chapter 3: Character ist ics of Complex Systems 35
the possible interactions are mind-boggling. Health and health services organizations are also characterized by situations in which “cause and effect are subtle, and where the effects over time of interventions are not obvious” (Senge 2006, 71). This characteristic represents another type of complexity, known as dynamic complexity. In the presence of dynamic complexity, “the same action has dramatically different effects in the short run and the long run . . . an action has one set of consequences locally and a very different set of consequences in another part of the system . . . and obvious interventions produce nonobvious consequences” (Senge 2006, 71).
When faced with dynamic complexity, managers must select interventions that alter the fundamental behavior of the system that is causing the problem; otherwise, the solution is only temporary. As seen in the nursing shortage example, although interventions may offer temporary relief, the problems resurface again and again.
The starting point for altering fundamental system behavior is always a mystery. Every system improvement we now know as being successful started out as a puzzle in which the variables that mattered were unknown and the cause-and-effect relationships unclear (Martin 2013). Once relevant variables are understood, cause-and-effect relationships can be defined and managed. With study, the mysteries of the dynamic complexities in healthcare systems are becoming clearer. The relevant variables are still not entirely understood and subtleties of the cause-and-effect relationships have yet to be unraveled, but we are not at the mystery stage. This chapter introduces a systems perspective on quality management that is based on the concepts of systems thinking and dynamic complexity.
Systems Thinking
Just as there are a variety of perspectives surrounding the term quality, the term system brings with it numerous connotations and perceptions. While “system change” is often heard in the quality and safety discourse, “system” may be defined and perceived in a variety of ways. In this book, system refers to “a set of connected parts that fit together to achieve a purpose” (Langabeer and Helton 2016, 477).
A healthcare system contains a complex variety of interdependent organizations, as illustrated by the diagram of the public health system in exhibit 3.1. Such a megasystem of connected parts is necessary for the purpose of advancing the vision of healthy communities (Institute of Medicine 1996). The importance of understanding these megasystems as interrelated parts of a whole cannot be overstated.
dynamic complexity complexity in which “cause and effect are subtle, and where the effects over time of interventions are not obvious” (Senge 2006, 71)
system “a set of connected parts that fit together to achieve a purpose” (Langabeer and Helton 2016, 477)
megasystem a complex variety of interdependent organizations
Applying Qual i ty Management in Healthcare: A Systems Approach36
In the public health system are many macrosystems that provide input to the larger system. Macrosystems are the organizations providing health services, such as hospitals, nursing homes, community health clinics, and emergency medical services. These macrosystems are “connected via individuals and teams, regulations and rules, and technology” (Johnson, Miller, and Horowitz 2008, 3). The many health organization mergers, partnerships, and affiliations following passage of the 2010 Affordable Care Act have created a number of regional healthcare delivery systems comprising multiple macrosystems (PricewaterhouseCoopers 2016).
In each macrosystem are innumerable microsystems. Microsystems are made up of the “people, machines, and data at the level of direct patient care (the treatment team within the hospital or the physician office practice, for example)” (Schyve 2005, 2). Just like the parts of a macrosystem, the
macrosystems organizations providing health services, such as hospitals, nursing homes, community health clinics, and emergency medical services
microsystems “people, machines, and data at the level of direct patient care (the treatment team within the hospital or the physician office practice, for example)” (Schyve 2005, 2)
Transit
Employers
Tribal Health
Elected Officials
Community Centers
Schools
Emergency Medical Services
Doctors
Drug Treatment
Mental Health
Neighborhood Organizations
Laboratories
Faith Institutions
Home Health
Law Enforcement
Civic Groups
Public Health Agency
Community Health Clinics
Hospitals
Nursing Homes
Nonprofit Organizations
Corrections
Fire
Source: Data from Centers for Disease Control and Prevention (2014).
EXHIBIT 3.1 The Public
Health System
Chapter 3: Character ist ics of Complex Systems 37
parts of a microsystem interact with each other to form an interdependent whole. During research into the frontline clinical teams in various healthcare settings, Godfrey, Nelson, and Batalden (2004, 5) coined the phrase clinical microsystem to describe “a small group of people who work together on a regular basis to provide care to discrete subpopulations of patients.” These clinical microsystems are “the place where patients, families, and care teams meet. . . . They are living units that change over time and always have a patient (person with a health need) at their center” (Microsystem Academy 2016).
An example of a microsystem (or clinical microsystem, as some would call it) is the team of people working in the cardiac catheterization lab during a coronary angiography procedure. This team often consists of a cardiologist, one or more nurses monitoring the patient’s vital signs, a scrub nurse and a circulating nurse, an X-ray technician, and one or more nurses or cardiovascular invasive specialists assisting with recording and other duties. These people have different responsibilities, yet the angiography procedure cannot get done without each of them working interactively with other team members.
A system reflects the whole, and “systems thinking is a view of reality that emphasizes the relationships and interactions of each part of the system to all the other parts” (McLaughlin and Olson 2012, 39). Rather than considering each part of the system to be unique and separate, systems thinking acknowledges the infinite number of unique parts and the ways in which the parts interact, as well as the nature of the interactions. Recognizing how each part functions within the system as a whole and how an individual’s actions affect all other aspects of the system is vital to unlocking the power of systems thinking.
The importance of developing a clear understanding of the parts of a system and how they interact is illustrated by the ancient parable from India about the blind men and the elephant. There are many versions of this story; however, the common denominator is that each man feels a different part of the animal, and only that part, to learn what an elephant is. When the men compare their understandings of an elephant, they are in complete disagreement. This parable demonstrates what can happen when people have distinctly different perceptions about the same system. In these situations, identifying relationships between the elements and understanding how they are connected is more challenging.
Dynamic Complexity
Several system characteristics contribute to the presence of dynamic complexity (Sterman 2000). Five characteristics, predominant in healthcare and health
clinical microsystem a “small group of people who work together on a regular basis to provide care to discrete subpopulations of patients” (Godfrey, Nelson, and Batalden 2004, 5)
systems thinking “a view of reality that emphasizes the relationships and interactions of each part of the system to all the other parts” (McLaughlin and Olson 2012, 39)
Applying Qual i ty Management in Healthcare: A Systems Approach38
services organizations, are described in this section: change, trade-offs, history dependency, tight coupling, and nonlinearity (see exhibit 3.2).
Change Systems are dynamic—that is, constantly changing. Change occurs at different rates and scales within and among systems, especially in healthcare. Consider three levels of this characteristic of dynamic complexity in health services. First, the human body changes continuously. This fact means that key inputs (patients with a clinical problem) to and outputs (patients’ status after clinical intervention) of healthcare systems are moving targets. Second, the organizational contexts in which health services are carried out are dynamic in nature. Employees move in and out of organizations, research provides an ongoing stream of new evidence, and technological advances offer new clinical and management approaches. Third, the communities and political environments in which we live and in which healthcare organizations operate change—that is, the environment changes with economic cycles, political ideologies, and election cycles. Unlike other complex systems, such as aviation, the level of change and the degree of uncertainty that characterizes many of the problems faced by practitioners make healthcare a particularly hazardous complex system (Runciman, Merry, and Walton 2007).
Implications for Healthcare Managers From the day a person is born to the day she dies, she is in a constant state of change, growing and developing physiologically and emotionally. No two
Change Key inputs and outputs
are moving targets
Nonlinearity Effect is unrelated
to the cause
Tight coupling System parts have prompt
and major impact on one another
History dependency The past influences
the present
Trade-offs Compromises
must be made to achieve goals
EXHIBIT 3.2 System
Characteristics Contributing
to Dynamic Complexity
Chapter 3: Character ist ics of Complex Systems 39
human systems are alike or precisely predictable in their responses to a medical intervention. As a result, functions that may seem straightforward in other industries, such as product standardization, become more difficult for healthcare managers. For example, the practice of using a standardized list of drug names and brands (i.e., a hospital formulary) to reduce medication expenses is accepted practice. However, when the dynamic nature of patient physiology is introduced, the manager recognizes that in addition to the question, “What are the set of drug names and brands that will be most cost-effective?” he also needs to ask, “How should the approved drugs be selected, and what are the consequences to patients?”
To aid in grasping the subtle but important nuances involved in individualizing treatment plans, consider the process of trying on a pair of blue jeans. People have their own favorite brand of blue jeans that fit well, even though another brand may be advertised as having a similar size and style. The hospital formulary essentially dictates to doctors that the patient may buy only slim-cut size 10 jeans and not relaxed-fit size 10 jeans (Kelly and Pestotnik 1998). Studies on variations in genetic makeup and the nature of gene–environment interactions promise to shed light in yet unimaginable ways on why certain treatments or medications may work better for one person than another. The emerging field of pharmacogenomics may permit drug selection in the future to be based on an individual’s unique genetic makeup, altering the paradigm on which health services organizations manage pharmacotherapeutics (Medline Plus and Merriam-Webster 2016). Preemptive medicine—“removing the initial molecular event—precluding the possibility of that thing even happening” (Culliton 2006, W96)—will likely alter the fundamental role of healthcare delivery organizations in the future.
Trade-Offs The need to understand the nature of trade-offs may seem unnecessary for managers taught to weigh pros versus cons or opportunities versus risks as they consider organizational decision options. Trade-offs may be seen as an accepted attribute of management situations. However, an understanding of dynamic complexity fosters an appreciation for the system consequences of local management trade-off decisions. “Time delays in feedback channels mean the long-run response of a system to an intervention is often different from its short-run response. High leverage policies often cause worse-before-better behavior, while low leverage policies often generate transitory improvement before the problem grows worse” (Sterman 2000, 22).
Implications for Healthcare Managers Classic examples of low-leverage policies are found in the studies of attempts to reduce health system costs by reducing the length of hospital stays. One
pharmaco – geno mics “a biotechno- logical science that combines the techniques of med- icine, pharmacol- ogy, and genomics and is concerned with developing drug therapies to compensate for genetic differ- ences in patients which cause varied responses to a single therapeutic regimen” (Medline Plus and Merriam- Webster 2016)
pharmaco- therapeutics “the study of the therapeutic uses and effects of drugs” (Medline Plus and Merriam- Webster 2016)
Applying Qual i ty Management in Healthcare: A Systems Approach40
study reported that healthy newborns discharged from the hospital 48 hours or sooner after delivery, saving the costs of a longer stay, had a significantly higher risk for readmission, morbidity, and neonatal mortality (Farhat and Rajab 2011). Another analysis found that hospitals with shorter lengths of stay were more likely to discharge Medicare patients to nursing facilities and inpatient rehabilitation facilities, suggesting that some hospitals may be using post-acute care as a substitute for inpatient care (Sacks et al. 2016).
If a manager in these cases viewed the healthcare system as a microsystem (e.g., the hospital department where patients received care) or the hospital administrator viewed it as a macrosystem (e.g., this hospital), the interventions chosen to reduce system costs might have been viewed as successful. However, if one views the healthcare system as a megasystem that includes not only the acute phase of care (e.g., the department where patient care occurred, the hospital) but also the downstream providers (e.g., other hospitals, emergency services, clinic services, nursing and rehabilitation facilities) and takes into account how the relationships among all providers influence patient outcomes, the longer-term behavior of the system can be observed.
From a systems perspective, the acute care manager is responsible for the acute care unit or hospital and also for the effect those local decisions have on the rest of the system of which the manager’s component is a part. This perspective does not mean that the manager of a hospital department or the hospital administrator should not strive to reduce hospital costs. It does mean that managers, financial officers, CEOs, and policymakers should be aware of how decisions made and implemented in their domains of responsibility affect other parts of the healthcare system positively and negatively. When a negative impact on another part of the system is anticipated, the manager should be proactive in the short term to help minimize the negative effects and preserve positive patient outcomes. With the emergence of accountable care organizations, managers must learn how to optimize the macrosystems of healthcare delivery while improving the microsystems.
Other common trade-off challenges for healthcare managers surround the differences between expense and investment decisions within organizations and departments. The long-term effect of a manager’s short-term decision may not be felt by another component in the macrosystem, but perhaps it will surface in the future in the manager’s own department or organization. For example, does the manager sacrifice capital improvements to fund contract workers in the short term? Do managers reduce staff education expenditures to lower current expenses? Although choosing contract workers and reducing staff development activities may meet short-term financial priorities, these efforts fall into the category of low-leverage policies because the problems of facility aging, staff shortages, and the need for a competent workforce will surely be faced by the manager in the future. Without an appreciation of system
Chapter 3: Character ist ics of Complex Systems 41
consequences, one manager may be rewarded for short-term “success” with a promotion, while his successor inherits the longer-term problem.
In the formulary example, the organization may be willing to trade the rare adverse medication event for dollar savings realized from product standardization. However, this decision could compromise patient outcomes and unintentionally contribute to polarization and conflict between clinicians and managers.
History Dependency Systems are history dependent. In other words, what has happened in the past influences what is happening right now. “We have always done it this way” methods of healthcare delivery are often perpetuated, despite research- supported knowledge that points to more effective practices. Some of these dated practices include (Melnyk 2016)
• recording vital signs every four hours at night on stable patients, despite their need for undisrupted sleep for recovery;
• removing urinary catheters only on a physician’s orders, though the removal of catheters according to a nurse-driven protocol is more efficient and may prevent urinary tract infections; and
• continuing the practice of 12-hour nursing shifts, when findings from research indicate adverse outcomes for nurses and patients.
Some actions taken in the past are reversible, while some cannot be easily overturned. For example, a strategic decision by a hospital to convert some inpatient beds to skilled nursing beds could be difficult to reverse when more inpatient beds are needed.
Implications for Healthcare Managers History dependency may be seen in the patient and the organization. Because of advancements in the care of chronic illnesses, rather than succumb to complications of one illness, elderly adults are often under treatment for several chronic illnesses concurrently. Persons with cystic fibrosis or born with congenital heart defects now enjoy a life expectancy into adulthood; previously, these conditions usually were fatal in childhood. Unhealthy behaviors, such as excessive alcohol, drugs, or cigarettes, even when discontinued, may have long- lasting health consequences. Understanding a patient’s history is important not only for clinical providers but also for health services managers. For example, a patient’s health history influences resources required for his care. An obese patient being treated for asthma, hypertension, and diabetes requires more labor-intensive care when having his gallbladder removed than an otherwise
Applying Qual i ty Management in Healthcare: A Systems Approach42
healthy athlete undergoing the same surgery. In recognition of these differences, managers must be willing to make nurse staffing adjustments for patient acuity (Huston 2013).
The manager must realize not only how past events have shaped current events but also how past decision-making strategies and directions may influence her ability to successfully achieve current and future goals. Using the nursing staff issue example, if the organization has historically rewarded managers for staying within budgetary expectations, a significant increase in nurse salary costs associated with caring for sicker patients without corresponding increases in patient care revenue might be difficult to sell given the organization’s history of rewards and decision making.
Tight Coupling A system is characterized as tightly coupled when its “parts exhibit relatively time-dependent, invariant, and inflexible connections with little slack” (Scott 2003, 358). An example is an elegantly crafted configuration of dominoes that can be set in motion by a push to the first piece. In a tightly coupled system, it can be difficult for people to recognize and correct mistakes to prevent an undesirable outcome. Tight coupling is also present when “the actors in the system interact strongly with one another” (Sterman 2000, 22).
Implications for Healthcare Managers Organizations in industries outside of health services that are most commonly identified as tightly coupled include nuclear power plants and aircraft carriers (Dlugacz and Spath 2011). Healthcare organizations often demonstrate loosely coupled social structures such as departments, divisions, and professional groups, yet the tasks carried by the microsystems in the organizations are often tightly coupled. For example, cardiologists, nurses, and X-ray technicians belong to separate, distinct, loosely coupled professional groups and departments within the structure of the organization. Yet, when these people come together as a microsystem in the cardiac catheterization lab, the tasks they perform while conducting an angiogram procedure are tightly coupled. In this tightly coupled system, an undetected patient identity mistake or the administration of a wrong medication can quickly lead to disastrous consequences because the link between actions and outcomes is more direct.
Numerous interactions among and between people, processes, and departments in individual organizations and interactions among services along the continuum of care require managers to be attentive to the concept of coupling. Identifying, designing, and institutionalizing tools that promote task alignment, communication, collaboration, coordination, and strengthened relationships among players are required competencies for contemporary health services managers. Checklists that detail proper patient management practices,
tightly coupled relating to a system in which the parts “exhibit relatively time- dependent, invariant, and inflexible connections with little slack” (Scott 2003, 358)
Chapter 3: Character ist ics of Complex Systems 43
bar-coded patient identification mechanisms, and standardized handoffs between caregivers are just three of the many tools used to improve the quality of patient care in tightly coupled systems (Dlugacz and Spath 2011).
Nonlinearity The term nonlinear, as it refers to a system characteristic, means that the “effect is rarely proportional to the cause” (Sterman 2000, 22). Because the parts in nonlinear systems may interact in numerous ways, these interactions often follow “unexpected sequences that are not visible or not immediately comprehensible” (Scott 2003, 358). In a nonlinear system, small deviations may have huge, unpredictable, and irregular effects.
Implications for Healthcare Managers Here is an example of the nonlinear nature of healthcare systems. A respiratory therapist just starting the afternoon shift is the object of an outburst of anger from a patient’s family. The therapist relates the encounter to a colleague at the nurse’s station: “All I did was say, ‘Hello’!” This situation may bring to mind the old idiom “the straw that broke the camel’s back.” In fact, this cliché is an accurate description of the encounter.
The patient and her family had accumulated a sequence of unsatisfactory experiences during the hospital stay, so all it took was one more encounter to trigger their anger. Although this time was the first that the afternoon therapist had met the family, his was the last in a series of interactions between the patient and the healthcare system that caused this family grief. If the patient complains to the manager about this therapist, what should the manager do? Without an appreciation for the nonlinear nature of systems, the manager may be tempted to discipline the employee. However, if the manager does have such an appreciation, she may try to investigate the sequence of events that culminated in the family’s dissatisfaction. Although each event was relatively harmless when considered individually, when linked together with the family’s overall experiences, they contributed to an unacceptable encounter. From this investigation, the manager may identify areas that can be improved to enhance the patient’s overall experience with the care delivery process.
Another example of the nonlinear nature of systems may be seen in strategies used to reduce personnel expense in healthcare organizations. Because personnel expenses make up such a large percentage of operating budgets, changing the staff mix—that is, reducing the number of professional staff (e.g., registered nurses, medical technologists, pharmacists) and increasing the proportion of assistive personnel (e.g., nurse aides, laboratory assistants, pharmacy technicians)—is a common cost-cutting intervention. When this intervention is studied from a systems perspective, however, the resulting sequences of activities and their interrelationships are more readily seen. The
nonlinear relating to a system in which the “effect is rarely proportional to the cause” (Sterman 2000, 22)
Applying Qual i ty Management in Healthcare: A Systems Approach44
unplanned consequences of this cost-cutting strategy in one organization included an increase in the overall employee turnover rate because of the frequency with which entry-level, assistive personnel left their jobs. Because this cost-cutting strategy was used by managers across different types of professions and departments, the stress and cost of continuously recruiting, hiring, and training new employees more than offset the savings hoped for from lowering the average hourly wage. When viewed from one department’s point of view, the cost-reduction strategy may appear to be reasonable; however, when the compounding effect of this cost-cutting strategy is viewed across the entire organization, the strategy designed to reduce costs actually undermines the organization’s ability to do so (Kelly 1999).
Summary
Like “quality,” “system” can carry a variety of connotations. In this text, a system refers to a set of connected parts that fit together to achieve a purpose. The connected parts may be a health system that contains many organizations (a megasystem), an organization (a macrosystem), or a small unit or clinical team in an organization (a microsystem).
Systems thinking, a management discipline, acknowledges the large number of parts in a system, the infinite number of ways in which the parts interact, and the nature of the interactions. The healthcare system, whether the term refers to a single patient care unit, a facility, or all providers in a state or throughout the nation, is dynamically complex. The five system characteristics contributing to the presence of dynamic complexity are change, trade-offs, history dependency, tight coupling, and nonlinearity.
Exercise 3.1 Objective: To practice identifying dynamic complexity.
Instructions: Describe how the following example illustrates one or more of the system characteristics that contribute to dynamic complexity.
Example: Medical Associates is a for-profit medical group of 40 physicians that operates two facilities and offers services in several medical specialties, including cardiology; ear, nose, and throat; family medicine; gastroenterology; general surgery; pediatrics; and obstetrics and gynecology. Medical Associates is open six days a week in each location from 8:00 am until 6:00 pm. Plans are being developed to extend its hours to 9:00 pm two days a week. For several years, Medical Associates discounted its listed fees by 3 percent to 5 percent for its
Chapter 3: Character ist ics of Complex Systems 45
managed care contracts, but a few years ago, it had to accept larger discounts to remain in the networks of health plans. Lower reimbursements led
Medical Associates to change its staffing from relying solely on registered nurses
(RNs) to hiring medical assistants (MAs) as well. Currently, all physicians assigned to
primary care service are assigned one RN or MA to assist with patient care. Physicians
assigned to surgery are assigned one RN for every two physicians. As RNs retire or
reassign, they have been replaced with MAs. On five recent occasions, when an RN
assigned to a senior physician resigned, the senior physician demanded that the
RN assigned to a junior physician be reassigned to him and that a new MA be hired
to fill the vacancy with the junior physician. This ad hoc system of job switching has
caused internal turmoil between the senior and junior physicians and has led to the
subsequent resignation of two RNs who did not want to be reassigned. . . . Confusion
exists around staff reporting relationships and who has the authority to change job
assignments. (Seidel and Lewis 2014, 215)
Companion Readings
Anderson, A. 2014. “The Impact of the Affordable Care Act on the Health Care Workforce.” The Heritage Foundation. Published March 18. www.heritage.org/ research/reports/2014/03/the-impact-of-the-affordable-care-act-on-the- health-care-workforce.
Coutou, D. L. 2003. “Sense and Reliability: A Conversation with Celebrated Psychologist Karl E. Weick.” Harvard Business Review 81 (4): 84–90.
Lipsitz, L. A. 2012. “Understanding Health Care as a Complex System: The Foundation for Unintended Consequences.” Journal of the American Medical Association 308 (3): 243–44.
Nelson, E. C., M. Godfrey, P. B. Batalden, S. A. Berry, A. E. Bothe, K. E. McKinley, C. N. Melin, S. E. Muething, G. Moore, J. H. Wasson, and T. W. Nolan. 2008. “Clinical Microsystems, Part 1: The Building Blocks of Health Systems.” The Joint Commission Journal on Quality and Patient Safety. Published July. http:// clinicalmicrosystem.org/wp-content/uploads/2014/05/jc_quality_safety_01. pdf.
New England Complex System Institute. 2016. “About Complex Systems.” Accessed November 8. www.necsi.edu/guide.
Peters, D. H. 2014. “The Application of Systems Thinking in Health: Why Use Systems Thinking?” Health Research Policy and Systems. Published August. https:// health-policy-systems.biomedcentral.com/articles/10.1186/1478-4505-12-51.
Senge, P. M. 1990. “The Leader’s New Work: Building Learning Organizations.” Sloan Management Review (Fall): 149–65.
Applying Qual i ty Management in Healthcare: A Systems Approach46
Web Resources
Applied Systems Thinking: http://appliedsystemsthinking.com Dartmouth Institute Microsystem Academy: https://clinicalmicro
system.org Society of Organizational Learning: www.solonline.org System Dynamics Society: www.systemdynamics.org
References
AMN Healthcare. 2013. Clinical Workforce Survey. Retrieved June 30, 2016. www .amnhealthcare.com/uploadedFiles/MainSite/Content/Healthcare_Industry_ Insights/Industry_Research/executivesurvey13.pdf.
Anderson, A. 2014. “The Impact of the Affordable Care Act on the Health Care Workforce.” The Heritage Foundation. Published March 18. www.heritage .org/research/reports/2014/03/the-impact-of-the-affordable-care-act- on-the-health-care-workforce.
Centers for Disease Control and Prevention. 2014. “The Public Health System and the 10 Essential Public Health Services.” Updated May 29. www.cdc.gov/ nphpsp/essentialservices.html.
Culliton, B. J. 2006. “Extracting Knowledge from Science: A Conversation with Elias Zerhouni.” Health Affairs 25 (3): W94–W103.
Dlugacz, Y. D., and P. L. Spath. 2011. “High Reliability and Patient Safety.” In Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, edited by P. L. Spath, 35–56. San Francisco: Jossey-Bass.
Farhat, R., and M. Rajab. 2011. “Length of Postnatal Hospital Stay in Healthy Newborns and Re-hospitalization Following Early Discharge.” North American Journal of Medical Sciences 3 (3): 146–51.
Georgopoulos, B. S., and F. C. Mann. 1962. The Community General Hospital. New York: MacMillan Company.
Godfrey, M. M., E. C. Nelson, and P. Batalden. 2004. Clinical Microsystem Action Guide: Improving Healthcare by Improving Your Microsystem. Dartmouth College. Revised September 2. http://clinicalmicrosystem.org/wp-content/ uploads/2014/07/CMAG040104.pdf.
Grant, R. 2016. “The U.S. Is Running Out of Nurses.” The Atlantic. Published February 3. www.theatlantic.com/health/archive/2016/02/nursing-shortage/459741.
Huston, C. J. 2013. Professional Issues in Nursing: Challenges and Opportunities. New York: Lippincott Williams & Wilkins.
Chapter 3: Character ist ics of Complex Systems 47
Institute of Medicine. 1996. Healthy Communities: New Partnerships for the Future of Public Health. Washington, DC: National Academies Press.
Johnson, J. K., S. H. Miller, and S. D. Horowitz. 2008. “Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work.” In Advances in Patient Safety: New Directions and Alternative Approaches, vol. 2: Culture and Redesign, edited by K. Henriksen, J. B. Battles, M. A. Keyes, and M. L. Grady. Agency for Healthcare Research and Quality. Published August. www.ncbi.nlm.nih. gov/books/NBK43731/pdf/Bookshelf_NBK43731.pdf.
Kelly, D. L. 1999. “Systems Thinking: A Tool for Organizational Diagnosis in Healthcare.” In Making It Happen: Stories from Inside the New Workplace, no editor, 89–98. Waltham, MA: Pegasus Communications.
Kelly, D. L., and S. L. Pestotnik. 1998. “Using Causal Loop Diagrams to Facilitate Double Loop Learning in the Healthcare Delivery Setting.” Unpublished manuscript.
Langabeer, J. R., and J. Helton. 2016. Healthcare Operations Management: A Systems Perspective, 2nd ed. Burlington, MA: Jones & Bartlett Learning.
Martin, R. L. 2013. “Our Self-Inflicted Complexity.” Harvard Business Review. Published September 6. https://hbr.org/2013/09/our-self-inflicted-complexity.
McLaughlin, D. B., and J. R. Olson. 2012. Healthcare Operations Management, 2nd ed. Chicago: Health Administration Press.
Medline Plus and Merriam-Webster. 2016. Medical Dictionary. Retrieved June 30. www.merriam-webster.com/medlineplus/pharmacotherapeutics.
Melnyk, B. 2016. “Evidence-Based Practice vs. Doing It the Way We’ve Always Done It.” Medscape Nurses. Retrieved June 30. www.medscape.com/viewarticle/860627.
Microsystem Academy. 2016. “Transforming Microsystems in Healthcare.” Dartmouth Institute for Health Policy and Clinical Practice. Retrieved June 26. https:// clinicalmicrosystem.org.
PricewaterhouseCoopers. 2016. US Health Services Deals Insights: Analysis and Trends in US Health Services Activity: 2015 and 2016 Outlook. Published February. www.pwc.com/us/en/healthcare/publications/assets/pwc-health-services- deals-insights-q4-2015.pdf.
Runciman, B., A. Merry, and M. Walton. 2007. Safety and Ethics in Health Care: A Guide to Getting It Right. Burlington, VT: Ashgate.
Sacks, G., E. Lawson, A. Dawes, R. Weiss, M. Russell, R. Brook, D. Zingmond, and C. Ko. 2016. “Variation in Hospital Use of Postacute Care After Surgery and the Association with Care Quality.” Medical Care 54 (2): 172–79.
Schyve, P. 2005. “Prologue: Systems Thinking and Patient Safety.” In Advances in Patient Safety: From Research to Implementation, vol. 2: Concepts and Methodology, edited by K. Henriksen, J. B. Battles, E. S. Marks, and D. I. Lewin. Agency for Healthcare Research and Quality. Published February. www.ncbi.nlm.nih .gov/books/NBK20523.
Applying Qual i ty Management in Healthcare: A Systems Approach48
Scott, R. A. 2003. Organizations: Rational, Natural, and Open Systems, 5th ed. Upper Saddle River, NJ: Prentice Hall.
Seidel, L. F., and J. B. Lewis. 2014. The Middleboro Casebook: Healthcare Strategy and Operations. Chicago: Health Administration Press.
Senge, P. M. 2006. The Fifth Discipline: The Art and Practice of the Learning Organization, 2nd ed. New York: Doubleday Currency.
———. 1990. The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Doubleday Currency.
Sterman, J. D. 2000. Business Dynamics: Systems Thinking and Modeling for a Complex World. Boston: Irwin McGraw-Hill.
CHAPTER
49
UNDERSTANDING SYSTEM BEHAVIOR
Learning Objectives
After completing this chapter, you should be able to
• explain systemic structure from the perspective of the iceberg metaphor; • describe how an understanding of systemic structure guides managerial
questions about performance problems; • identify the influence of mental models on managerial behaviors,
decisions, and effectiveness; and • apply learning strategies to better understand how systemic structures
affect performance.
O n Thursday, respiratory therapist (RT) Ahmed volunteers to work a double shift in the internsive care unit (ICU). The next day, he misses his regularly scheduled shift when he calls in sick. The following month, RT Martinez, who works in the same ICU, volunteers to work a double shift. Two days later, she misses her regularly scheduled shift when she calls in sick. When the RT manager mentions this “coincidence” to two nurse manager colleagues, they also describe similar situations with their staff members. As the RT manager gathers more information about employee staffing practices, he realizes that although the work schedule policies help staffing in the short term, the same policies inadvertently contribute to increased sick calls and more overtime in the long run. The manager discovers that well-intended efforts such as the carefully written staffing policies and procedures for his department may not yield the expected results. Likewise, well-intended change or improvement interventions often yield disappointing results. This chapter explores how better understanding the dynamics of system behavior can help managers plan and execute improvement interventions in their organizations.
A Systems Metaphor for Organizations
Metaphors provide a concrete picture of a theoretical concept. Thinking of an organization as an iceberg is one metaphor that illustrates the subtle but
4
Applying Qual i ty Management in Healthcare: A Systems Approach50
powerful systems principles at work in organizations (Innovation Associates 1995). Those forces that cause an organization to function the way it does and the people in the organization to behave the way they do are like the nine- tenths of an iceberg hidden underwater. The essence of an organization is not visible to most observers; what is below the organizational “waterline” can undermine well-intended change initiatives, improvement efforts, and clinical interventions, just as the part of the iceberg beneath the water’s surface can sink a passing ship.
The triangular shape in exhibit 4.1 represents the iceberg, and the wavy, thick line represents the waterline. The tip of the iceberg (the top layer of the triangle) represents the events that occur daily in the organization. The middle layer of the iceberg represents a deeper understanding of the organization as a system that links events into patterns of behavior. The bottom level of the iceberg, which is underwater, represents the deepest understanding of the behavior of the organization as a system. This level represents relationships among system variables that cause the events and patterns to occur.
In the staffing example at the beginning of this chapter, the managers saw the RTs and nurses working double shifts and calling in sick as unique events in each of their areas. However, while comparing notes, they identified a pattern of similar behavior across different patient care services. Although the act of identifying patterns is above the organizational waterline, it is the first step toward systems thinking. The RT manager began to go below the
Events
Patterns
System Structures
Source: Reprinted with permission from Innovation Associates (1995).
EXHIBIT 4.1 The Iceberg
Metaphor
Chapter 4: Understanding System Behavior 51
waterline when he started linking his observations into patterns. By telling a “story” of his discoveries, the relationships and underlying causes of the problems began to emerge:
The hospital policies were supposed to promote adequate staffing and discourage
sick calls; however, the day shifts were often overstaffed and the evening and nights
shifts were understaffed.
Employees were paid overtime and often an additional “premium” for working
a double shift. When professional staff volunteered for a double shift, they were
positively perceived as “helpful” and “team players.” The employees helped out with
a shift that was short-staffed and did not cause staffing difficulties on their next shift.
By working a double shift and calling in sick later in the week, the employees
were able to work the same amount of hours but get paid more than if they had
worked their regular scheduled shifts.
The RT manager began to identify the key system variables at work: scheduling policies, individual employee incentives and compensation, informal rewards, policy on calling in sick, individual unit operations, and float-pool operations. Although individually the policies and operations seemed reasonable, their interactions contributed to the underlying systemic structure. The perceived benefit to professional staff (i.e., the opportunity to help out peers and patients and earn more money while working the same hours) and the frequency of these staff members volunteering for a double shift and calling in sick later in the week were related in a way that reinforced the behavior; that is, as the number of employees who perceived this benefit increased, the number of times the behavior occurred increased. Note that the staff members had no malicious intent in this case; they were simply following the policies as they were crafted. As this reinforcing relationship occurred across several nursing and clinical support departments, an overall increase in salary expense became the unintended consequence to the hospital.
When the RT manager understood each of the policies in the context of how they made up the human resources system, he and the other managers were able to redesign the system to achieve the intended result of staffing the hospital in a dependable and cost-effective manner. Some of the changes this organization made to break the reinforcing cycle included reviewing the distribution of nurses and other clinical staff during the day, evening, and night shifts to better balance staffing across the 24-hour period; improving coordination between the RT and nursing schedules and the float-pool schedules; and changing the overtime criteria (consistent with legal labor requirements) from hours worked in excess of 8 hours per day to hours worked in excess of 40 hours per week.
Applying Qual i ty Management in Healthcare: A Systems Approach52
Lessons for Healthcare Managers
In the iceberg metaphor for organizations, above-the-waterline activities are daily events and the patterns that make up these events. The term systemic structure refers to what is found below the waterline. The systemic structure involves the interrelationships among key elements in the system and the influence of these interrelationships on the system’s behavior over time (Senge 2006). Systemic structure refers to interrelationships among elements, components, and variables that make up the system, not to interpersonal relationships among people (Senge 2006). Systemic structure should also be differentiated from organizational structure, which refers to how responsibility and authority are distributed throughout an organization (Shortell and Kaluzny 2006), although organizational structure may act as a systemic structure.
Understanding systemic structure helps a manager to better understand the organization. Based on this understanding, the manager may choose high- leverage interventions to improve the organization’s performance. Valuable insights about one’s organization may be gained by understanding the concept of systemic structure. This section offers four lessons for healthcare managers:
1. Systemic structure influences behavior. 2. Systemic structure is not readily visible. 3. Information is essential to identifying systemic structure. 4. Successful change requires going below the waterline.
Lesson 1: Systemic Structure Influences Behavior Consider the following story from an anonymous author:
A college student spent an entire summer going to the football field every day wearing
a black-and-white striped shirt, walking up and down the field for 10 or 15 minutes,
throwing birdseed all over the field, blowing a whistle, and then walking off the field.
At the end of the summer, it came time for the first home football game. The referee
walked onto the field and blew the whistle. The game had to be delayed for a half
hour to wait for the birds to get off the field.
Everyone laughs at this story. However, if one were sitting in the stadium stands without a clue about the events of the summer, one would probably be annoyed and blame those darn birds. The birds were not right or wrong. They were doing what they were supposed to be doing based on the underlying systemic structures: the relationships between feeding time and the football field, the striped shirt and the birdseed, the whistle and their hunger.
“Every organization is perfectly designed to get the results that it gets. To get different results you need to improve the design of the organization”
systemic structure the interrelation- ships among key elements in the system and the influence of these interrelationships on the system’s behavior over time (Senge 2006)
organizational structure the manner in which responsibil- ity and authority are distributed throughout an organization (Shortell and Kaluzny 2006)
Chapter 4: Understanding System Behavior 53
(Hanna 1988, 36). This expression has almost become a cliché in quality improvement presentations and articles. However, what is not commonly heard or read is that improvements must be targeted at issues below the waterline, not simply above the waterline. An understanding of the iceberg metaphor prompts improvement questions to be asked from all levels of the iceberg to reveal the underlying structures that cause the patterns and events to occur.
Consider how the improvement interventions change depending on the level from which the improvement questions are asked. An events- level improvement question might focus on what the individual needs to do differently and usually results in the desire to blame an individual in response to unsatisfactory performance or a medical error. A patterns-level question moves from the individual to the group and focuses on what we need to do differently. Interventions at this level may target the collective actions of a team, a department, or an organization and may include implementing clinical guidelines, streamlining office scheduling systems, or installing new computers. The below-the-waterline question focuses on how we can best understand why we are getting the results we are getting (see exhibit 4.2).
The iceberg metaphor adds insight to issues on the sector level and the organizational level. For example, after passage of the Affordable Care Act in 2010, traditional roles, responsibilities, and authority of various healthcare stakeholders were altered. One notable change has been increased costs for consumers covered by high-deductible health plans, including spending more on medications. Many consumers now exhibit cost-conscious behaviors such as asking for generic drugs instead of brand names, checking the price of a service before getting care, and requesting more information about treatment
Events
What does an individual do differently?
What does an organization do differently?
How can we better understand the results we are getting?
Patterns
System Structures
EXHIBIT 4.2 Improvement Questions
Applying Qual i ty Management in Healthcare: A Systems Approach54
options and costs (Santilli and Vogenberg 2015). Healthcare organizations are discovering that patient satisfaction is linked to how well it understands and is prepared to address the changing cost-conscious behaviors of its consumers.
Lesson 2: Systemic Structure Is Not Readily Visible Systemic structure is not readily visible unless a conscious effort is made to find it. Just because managers do not see what is below the organizational waterline does not mean that a systemic structure is not present in the organization. For example, a newly hired manager at an academic medical center was assigned to facilitate an improvement project for a patient care unit. If the project proved successful, the intent was to expand the intervention organization-wide. Despite positive results—as measured by improved efficiencies and increased patient and staff satisfaction—the project was not implemented beyond the original pilot site. When the manager began to explore possible reasons the project was not replicated on other units, he discovered that over the years numerous project teams had designed and implemented successful pilot projects aimed at improving specific problems. However, few of these projects had actually been integrated into the ongoing activities of the organization (i.e., institutionalized).
On further investigation, he uncovered the following systemic structures operating in this organization. First, all improvements in the organization were called “pilots.” The expectation was that a trial would be conducted for a specified period, results would be presented to the administrative team, and the administrative team would then authorize the project to continue or not. The problem was that this process occurred independently from the budgeting process. When the “special pools” of dollars to fund pilot initiatives were gone, no mechanisms were in place to reallocate funds either in or among departments to support institutionalizing successful improvements or innovations.
The label of “pilot” also brought with it other short-term perceptions related to support, staffing, and budgets. Because of these hidden, but real, relationships among the variables required to support change, this academic medical center demonstrated a constant stream of successful improvement pilot efforts, yet sustained improvement in the overall organizational performance never occurred.
Lesson 3: Information Is Essential to Identifying Systemic Structure A pattern is defined as “something that happens in a regular and repeated way” (Merriam-Webster 2016). This definition implies that identifying or recognizing a pattern requires more than one observation. In the staffing example, the discussion among the RT manager and nurse manager colleagues about issues in their respective areas provided an opportunity to observe the behavior of
Chapter 4: Understanding System Behavior 55
many employees across multiple units. Only when these observations were combined did the organizational pattern become evident.
The need for multiple observations or data points has implications for how managers determine reporting relationships, how they interact and communicate, and how they present performance data. The traditional vertical organizational structure, which compartmentalizes groups in rigid reporting lines, reduces the opportunity to interact across departments and disciplines and minimizes managers’ ability to identify organizational patterns.
Communication methods based on “telling” rather than “sharing” information also reduces opportunities to identify organizational patterns by limiting two-way communication and the “fresh eyes” often needed to interpret and link events. Reporting data by single periods only (e.g., monthly departmental financial reports) reduces managers’ ability to identify patterns over time in their own departments. In addition, reporting aggregated organizational data reduces managers’ opportunity to identify patterns across smaller units of analysis in the organization.
Strategies that can promote pattern identification and prompt investigation into underlying structures include
• organizational structures and cultures that encourage interaction among levels and units,
• open and free flow of information, and • performance data displayed graphically and plotted over time to make
data trends more visible.
Lesson 4: Successful Change Requires Going Below the Waterline To implement successful and lasting change efforts, managers must go below the organizational waterline. The iceberg metaphor explains why the potential of many change or improvement efforts is not fully realized. If changes are targeted at the event or pattern levels (i.e., what we do) rather than at the systemic structure level (i.e., what causes the system to behave the way it does), the effect will be only temporary. Because structure influences behavior, the only way to truly change behavior in the system is to identify, target, and change the underlying structures.
Many ideas have been proposed on how to improve organizational systems; however, a common challenge for managers and care providers alike is how to actually implement these ideas. Organizational culture may be thought of as an underlying systemic structure. The influence of the healthcare organization’s culture on the ability to convert continuous quality improvement concepts into effective implementation has been described in the healthcare research literature (Glickman et al. 2007). Health services researchers have found that cultural characteristics such as effective governance and management
Applying Qual i ty Management in Healthcare: A Systems Approach56
of human capital and supportive dynamics are essential structural elements of quality improvement in healthcare organizations (Jiang et al. 2009; Mannion, Davies, and Marshall 2005; Tsai et al. 2015). These types of studies have helped inform policy changes that target underlying structures at the national level.
Going Below the Waterline
The captain of a ship sailing in the North Atlantic uses radar, sonar, and a bow watch (a sailor posted at the front of the ship to look out for danger) to alert him to underwater ice. Likewise, managers may also use strategies that alert them to underlying systemic structures. Following are three strategies managers may use:
1. Understanding history 2. Being aware of mental models 3. Integrating double-loop learning into management philosophy and
approach
Understanding History History is a powerful underlying structure. A healthcare manager’s current work may be influenced by her department’s history, the organization’s history, a professional group’s history, the community’s history, or the sector’s history. For example, in one organization, the sudden death of a well-respected department manager had a long-lasting impact on the department staff. The new incumbent manager was faced not only with getting settled in a new role and a new department but also with addressing the staff ’s grief. For new employees, the lack of shared history with the deceased manager was a source of polarization between the “before” and “after” staff and interfered with the entire staff ’s ability to achieve a high level of teamwork.
As another example, a physical therapist at a rehabilitation center that had recently been purchased by a for-profit organization carefully explained the organization’s history to a patient’s family. The previous owners and managers of the center were proud of their heritage of religious service and quality. The family members inquired whether their loved one would still get what she needed at this for-profit facility, and the physical therapist informed the family that though the organization’s ownership had changed, the staff still identified with the center’s historical values.
In the book The Social Transformation of American Medicine, Paul Starr (1982) describes the evolution of the US medical profession and physicians’ roles from the eighteenth through the twentieth centuries. Although one may agree or disagree with Starr’s conclusions, this book explains how the history of physicians,
Chapter 4: Understanding System Behavior 57
hospitals, and insurance companies shaped the healthcare field of today, and as such the book provides an explanation of the current state of the US healthcare system. Understanding the circumstances surrounding the Flexner Report, which was published in 1910 and describes the state of medical education at the time, can provide insights into why medical schools are structured the way they are and into the role of academic medical centers in US healthcare (Starr 1982).
The simplest strategies that managers may use to understand history are to ask, listen, and read. In addition, large-group “visioning” meetings have incorporated structured discussions about history (Weisbord and Janoff 2010). Managers, especially those assuming a new role, may gain valuable insights by facilitating similar discussions with staff in their own departments. The following guidelines may help:
• Ask the group to identify significant events during defined periods. Events in the department, organization, community, clinical specialty or profession, or industry may be identified.
• List the events by periods of time (e.g., in five- or ten-year increments, depending on the group).
• Look for patterns in the listed events.
For example, one group of nurses in the postpartum area identified this event in its history discussion: At 5:00 am every day, the charge nurse would announce over the unit’s intercom system, “Patients who have not had a bowel movement yet, please put on your nurse call light.” The group burst into laughter, and one nurse observed, “Glad those ‘good old days’ are gone!” This simple observation helped the group let go of its resistance to a proposed change on the unit as it realized that it had experienced numerous changes over the years, most of which had direct benefit to the patients.
A manager in a laboratory was intrigued about the type of events identified during a history discussion with staff. Most of the identified events focused on current events from the news, and few events focused on laboratory technology or the department, as he had anticipated. The manager realized that because the demographic composition of his department had been changing over the years (the technologists were aged 50 years or older, the technical assistants and phlebotomists were aged 30 years or younger), the two distinct demographics had little in common but current events. This realization helped to explain why previous team-building sessions had been only moderately successful and prompted the manager to establish common ground for his employees through a shared vision for the department. This manager also became more attentive to age diversity; succession planning; and the needs of differing demographic groups, particularly in his approaches to recruitment and hiring (Kelly 1999).
Applying Qual i ty Management in Healthcare: A Systems Approach58
Being Aware of Mental Models The field of cognitive psychology is the branch of psychology “concerned with mental processes (as perception, thinking, learning, and memory) especially with respect to the internal events occurring between sensory stimulation and the overt expression of behavior” (Merriam-Webster 2016). In the field, the term schema refers to a “mental codification of experience that includes a particular organized way of perceiving cognitively and responding to a complex situation or set of stimuli” (Merriam-Webster 2016). In the management domain, the related term mental model is often used interchangeably with “paradigm” and “assumption.” Although these terms are technically slightly different, they all refer to a deeply ingrained way of thinking that influences how a person sees and understands the world and how that person acts. When someone declares an unquestionable status or condition, a mental model is usually being expressed; words such as “always” and “never” are clues that mental models are being expressed. Mental models may be so strong they override the facts at hand. For example, at a quality manager workshop, one hospital manager stated her mental model as follows: “Physicians would never spend time at a workshop like this.” However, sitting beside her for the duration of the workshop were two pediatricians and a family practitioner!
What this manager did not realize was that her own mental model was interfering with her ability to design appropriate strategies to engage physicians in improvement efforts in her organization. As a result of her mental model, she found numerous reasons physicians would not participate, and she was blinded to strategies to encourage physician participation. To promote learning and improvement in organizations, managers, care providers, and other employees in the organization must “look inward . . . to reflect critically on their own behavior, identify ways they often inadvertently contribute to the organization’s problems, and then change how they act” (Argyris 1991). Without an understanding of our own mental models, we run the risk of unknowingly undermining our attempts to progress along the quality continuum.
For example, the mental model of “clinical guidelines are used to control physician behavior” encourages organizations to adopt top-down mandates for “cookbook medicine.” Alternatively, the mental model “using evidence- based clinical guidelines to standardize steps of care can actually save physician time on routine interventions so that more time can be spent on the unique needs of the patient” encourages organizations to support and foster clinician involvement in evaluating, selecting, adapting, and implementing clinical guidelines. The mental model of “data are necessary to name, blame, and shame” encourages managers to use data to justify punitive actions directed at employees. The mental model of “knowledge is power” encourages managers to guard data tightly and to distribute them only on a “need-to-know” basis. Alternatively, the mental model of “data are the foundation of performance
cognitive psychology the branch of psychology “con- cerned with mental processes (as perception, think- ing, learning, and memory) espe- cially with respect to the internal events occurring between sensory stimulation and the overt expres- sion of behavior” (Merriam-Webster 2016)
schema a “mental codifica- tion of experience that includes a particular orga- nized way of per- ceiving cognitively and responding to a complex situation or set of stimuli” (Merriam- Webster 2016)
mental model a deeply ingrained way of thinking that influences how a person sees and understands the world as well as how that person acts
Chapter 4: Understanding System Behavior 59
improvement” encourages organizations to put in place data collection, analysis, and dissemination systems that make information easily accessible. Once mental models and their subsequent actions are understood, managers may purposely choose to operate from mental models that help rather than hinder in achieving desired performance results.
Differing mental models may also be a source of conflict in an organization. A manager’s view or perspective on organizations themselves will shape her management strategies, actions, and style. Two contrasting views of organizations are the rational model and the political model (Shortell 2000). A manager who views the organization through a rational model expects decision making to be logical, orderly, and focused on maximizing outcomes. Such a manager can be extremely frustrated when an administrative team, operating from a political perspective, encourages decision making that involves lots of give and take among competing interests. From the manager’s point of view, the decision-making processes in this politically driven organization serve the interest of the players involved but do not result in optimal patient outcomes or cost-effective approaches. On the other hand, the members of the administrative team perceive this manager’s emphasis on outcomes as interfering with the delicate political alliances they had worked hard to establish. The lack of understanding of each other’s mental models creates ongoing conflict between the manager and the administrative team: The manager thought the team did not care about results, and the team thought the manager was compromising relationships with important stakeholders. Without an awareness of each other’s mental models, the conflict between the manager and the administrators continued to grow until the manager finally left the organization.
Had both parties made their mental models explicit—through discussion, definition of organizational operating principles, or orientation of new managers to the culture of decision making—their conflict may have been avoided, or at least some common understanding may have been established. Instead, the results were conflict, tension, and, eventually, manager turnover.
Integrating Double-Loop Learning A technique used to bring attention to mental models is double-loop learning. Exhibit 4.3 illustrates the difference between single-loop and double-loop learning. In single-loop learning, if one is not satisfied with the results or consequences of the actions, the actions are changed; however, the new actions are still driven by the same assumptions. In double-loop learning, if one is not satisfied with the results or consequences, underlying assumptions are examined, clarified, communicated, or reframed. Only then is subsequent action, based on lessons revealed, taken (Argyris 1991; Tagg 2007).
double-loop learning a type of learning in which, if one is not satisfied with the results or con- sequences, before taking further action, underly- ing assumptions are examined, clarified, communi- cated, or reframed based on what the assumptions reveal. Only then is subsequent action, on the basis of lessons revealed, taken (Argyris 1991; Tagg 2007).
Applying Qual i ty Management in Healthcare: A Systems Approach60
In one large hospital, a nursing supervisor complained to the manager of environmental services that when asked, the housekeeper refused to move a piece of equipment to prepare a room for a patient admission. The supervisor accused the housekeeper of being uncooperative and an obstacle to patient care. The supervisor operated from a professional mind-set and believed the housekeeper should be able to determine when touching medical equipment is allowable. However, because of language, cultural, and educational differences among staff in entry-level positions, the environmental services staff were trained to strictly adhere to the department’s standard policies and procedures, which stipulated that medical equipment must never be disturbed. The housekeeper was operating from one set of assumptions (i.e., following the rules), while the nursing supervisor was operating from a conflicting set of assumptions (i.e., doing whatever needs to be done to care for a patient). Although both parties were trying to do their jobs the best way they knew, their opposing assumptions led to conflict and antagonism.
This situation of “accidental adversaries” may be unintentionally created when underlying assumptions are not known. The numerous roles, backgrounds, personalities, levels of education, and other diverse characteristics of the healthcare workforce necessitate managerial use of double-loop learning to promote teamwork and quality in a given scope of responsibility. In the workplace, however, managers often spend more time trying to mend adversarial relationships than preventing them. Managers may minimize accidentally adversarial interactions by
Assumptions Mental Models
Operating Values Actions ConsequencesResults
Single-Loop Learning
Loop #1
Assumptions Mental Models
Operating Values Actions ConsequencesResults
Double-Loop Learning
Loop #1
Loop #2
Source: Adapted from Tagg (2007).
EXHIBIT 4.3 Single-Loop and
Double-Loop Learning
Chapter 4: Understanding System Behavior 61
• clarifying operating principles, • helping staff members understand and communicate their own
assumptions, • helping staff ask for clarification and explanations of others’ behavior,
and • explicitly describing their (the managers’) own expectations for
individual employees and for teams.
Double-loop learning is not appropriate for all situations in a health services organization. For example, an emergency resuscitation is not the time to question why a cardiac arrest code is carried out in a certain manner. Double-loop learning is a technique that should be part of initiatives requiring innovative solutions or improved levels of performance. Managers and care teams should be comfortable asking questions such as, “Why do we do things the way we do? Is there a better way to get the job done? Are my own mental models helping or hurting me and our group’s effectiveness?”
For an improvement team, double-loop learning may take the form of discussions that question “whether operating norms are appropriate—then inventing new norms as needed” (Pierce 2000, 15). Double-loop learning has resulted in several innovative solutions, such as rapid response teams for emergency situations (Barwise et al. 2016) and the Broselow pediatric emergency tape used to predict a child’s actual body weight to determine acceptable doses of emergency medications (Meguerdichian and Clapper 2012). Managers may consider assigning a team member to be the devil’s advocate and present an opposing view to ensure that assumptions are tested and challenged; otherwise, the challenger may be viewed as a barrier to the team process.
Summary
Organizations may be compared to an iceberg, where events and patterns in the organization are above the waterline and system structures are below the waterline. Systemic structure refers to interrelationships among elements, components, and variables that make up the system and not to interpersonal relationships among people. Understanding systemic structure and how to identify it assists managers with solving problems by altering system behavior. Otherwise, managers risk treating symptoms of a problem and seeing the problem return over time.
Exercise 4.1 Objective: To explore “below the waterline” factors that can impede quality improvements in healthcare organizations. Managers must recognize whether
Applying Qual i ty Management in Healthcare: A Systems Approach62
these factors exist in their work setting and determine how best to overcome these barriers when initiating operational improvements.
Instructions: Read the following article:
Berwick, D. 2003. “Improvement, Trust, and the Healthcare Workforce.” Quality & Safety in Health Care 12 (supplement 1): i2–i6. www.ncbi.nlm.nih .gov/pmc/articles/PMC1765768/pdf/v012p000i2.pdf.
In this article, Dr. Berwick describes several historical and present-day “below the waterline” factors that inhibit healthcare quality improvement. For example, he observes that improvement is limited when the workforce is not encouraged to actively participate in reinventing the system.
• Identify three factors described by Dr. Berwick that are the most difficult for healthcare organizations to overcome and explain why.
• For the three factors you select, describe actions that managers can take to eliminate or minimize the factor so it no longer inhibits operations improvement.
Companion Readings
Hovlid, E., O. Buke, K. Haug, A. B. Aslaksen, and C. von Plessen. 2012. “Sustainability of Healthcare Improvement: What Can We Learn from Learning Theory?” BMC Health Services Research 12: 235. Published August 3. www.biomedcentral .com/1472-6963/12/235.
Lencioni, P. 2006. Silos, Politics and Turf Wars: A Leadership Fable About Destroying the Barriers That Turn Colleagues into Competitors. San Francisco: Jossey-Bass.
McComb, S., and V. Simpson. 2014. “The Concept of Shared Mental Models in Healthcare Collaboration.” Journal of Advanced Nursing 70 (7): 1479–88.
Trbovich, P. 2014. “Five Ways to Incorporate Systems Thinking into Healthcare Organizations.” Biomedical Instrumentation & Technology: Connecting the Dots 48 (s2): 31–36.
Web Resources
The Institute for Systemic Leadership: www.systemicleadershipinstitute.org Pegasus Communications: https://thesystemsthinker.com
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References
Argyris, C. 1991. “Teaching Smart People How to Learn.” Harvard Business Review 69 (3): 99–110.
Barwise, A., C. Thongprayoon, O. Gajic, J. Jensen, V. Herasevich, and B. W. Pickering. 2016. “Delayed Rapid Response Team Activation Is Associated with Increased Hospital Mortality, Morbidity, and Length of Stay in a Tertiary Care Institution.” Critical Care Medicine 44 (1): 54–63.
Glickman, S. W., K. A. Baggett, C. G. Krubert, E. D. Peterson, and K. A. Schulman. 2007. “Promoting Quality: The Health-Care Organization from a Management Perspective.” International Journal of Quality Health Care 19 (6): 341–48.
Hanna, D. P. 1988. Designing Organizations for High Performance. Reading, MA: Addison Wesley Publishing Company.
Innovation Associates. 1995. Systems Thinking: A Language for Learning and Action. Participant manual, version 95.4.1. Waltham, MA: Innovation Associates.
Jiang, H. J., C. Lockee, K. Bass, and I. Fraser. 2009. “Board Oversight of Quality: Any Differences in Process of Care and Mortality?” Journal of Healthcare Management 54 (1): 15–29.
Kelly, D. L. 1999. “Systems Thinking: A Tool for Organizational Diagnosis in Healthcare.” In Making It Happen: Stories from Inside the New Workplace, no editor, 89–98. Waltham, MA: Pegasus Communications.
Mannion, R., H. T. Davies, and M. N. Marshall. 2005. “Cultural Characteristics of ‘High’ and ‘Low’ Performing Hospitals.” Journal of Health Organization and Management 19 (6): 431–39.
Meguerdichian, M. J., and T. C. Clapper. 2012. “The Broselow Tape as an Effective Medication Dosing Instrument: A Review of the Literature.” Journal of Pediatric Nursing 27 (4): 416–20.
Merriam-Webster. 2016. Online Dictionary. Retrieved June 17. www.merriam-webster .com/dictionary.
Pierce, J. C. 2000. “The Paradox of Physicians and Administrators in Healthcare Organizations.” Healthcare Management Review 25 (1): 7–28.
Santilli, J., and F. R. Vogenberg. 2015. “Key Strategic Trends That Impact Healthcare Decision-Making and Stakeholder Roles in the New Marketplace.” American Health & Drug Benefits 8 (1): 15–20.
Senge, P. M. 2006. The Fifth Discipline: The Art and Practice of the Learning Organization, 2nd ed. New York: Doubleday Currency.
Shortell, S. M. 2000. Healthcare Management, 4th ed. Clifton Park, NY: Delmar Learning.
Shortell, S. M., and A. D. Kaluzny. 2006. Health Care Management: Organization Design and Behavior, 5th ed. Albany, NY: Delmar Thomson Learning.
Applying Qual i ty Management in Healthcare: A Systems Approach64
Starr, P. 1982. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. Reading, MA: Perseus Books Group.
Tagg, J. 2007. “Double-Loop Learning in Higher Education.” Change 9 (4): 36–41. Tsai, T. C., A. K. Jha, A. A. Gawande, R. S. Huckman, N. Bloom, and R. Sadun. 2015.
“Hospital Board and Management Practices Are Strongly Related to Hospital Performance on Clinical Quality Metrics.” Health Affairs 34 (8): 1304–11.
Weisbord, M. R., and S. Janoff. 2010. Future Search: Getting the Whole System in the Room for Vision, Commitment and Action, 3rd ed. San Francisco: Berret- Koehler Publishers.
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5VISUALIZING SYSTEM RELATIONSHIPS Learning Objectives
After completing this chapter, you should be able to
• recognize the benefit of viewing system components when managing quality,
• explain how parts of the health services delivery system are interconnected,
• contrast four different models for illustrating system relationships, and • describe the management implications of different system relationship
models.
J ust as a road map provides a picture of how places are connected in a geographic area, models can provide a picture for managers of how elements may be connected in and between systems. These models are valuable managerial tools for revealing and providing insight about systemic structure. Similar to one’s preference for an electronic map over a paper map, managers may prefer one model over another depending on their work settings, backgrounds, and individual preferences. Numerous models provide healthcare managers with a picture of the organizational system in which they work to help them recognize, understand, and anticipate how the parts of the systems are related and interact to form the whole.
The most basic system may be characterized by three elements: input(s), a conversion process, and output(s). These elements are demonstrated visually in this simple diagram:
Input(s) → Conversion process → Output(s)
In a health services organization, examples of inputs are patients, personnel, supplies, equipment, facilities, and capital. Examples of conversion processes are diagnostic processes, clinical treatments, operational activities, and business management functions. Examples of outputs are a patient’s health status and an organization’s business performance.
Applying Qual i ty Management in Healthcare: A Systems Approach66
Often, quality efforts focus on managing the inputs and conversion process that make up the system. The healthcare field regulates the quality of personnel inputs by various means, including licensure requirements, continuing education, and performance appraisals. Clinical trials and US Food and Drug Administration approval are two examples of ways to control the quality of technology inputs such as drug therapies. Clinical guidelines, process improvement, and standardization help maintain high standards for conversion processes. Controlling the quality of the inputs and conversion processes is intended to improve the quality of the outputs, such as patient clinical and functional status, satisfaction with services, cost-effectiveness, employee behaviors, and organizational culture.
Adding a feedback loop creates a more dynamic process—one that leads to a more mature quality management approach. Feedback about the quality of the outputs guides efforts to improve the quality of the inputs and the conversion processes (see exhibit 5.1). Continuous feedback promotes continuous improvement. The Donabedian (1980) categories of medical quality measures and their relationship (structure → process → outcomes) support this continuous improvement model.
In chapter 3, systems thinking is defined as “a view of reality that emphasizes the relationships and interactions of each part of the system to all the other parts” (McLaughlin and Olson 2012, 39). A systems thinking approach to quality management involves improving the quality of the parts and understanding and improving the quality of the relationships between the parts. This systems thinking approach requires managers to view health services organizations in a systems context. Four models are presented in this chapter to help managers better understand system relationships: the interconnected systems model, the three core process model, the Baldrige Performance Excellence Program framework, and the socioecological framework.
Feedback
Improve Conversion ProcessesImprove Inputs Outputs
Source: Adapted from Tagg (2007).
EXHIBIT 5.1 Quality
Management System
Chapter 5: Visual iz ing System Relat ionships 67
Interconnected Systems Model
Ferlie and Shortell (2001) offer a systems view of healthcare that illustrates the interconnected clinical delivery system: the environment, the organization, the microsystem, and the patient (exhibit 5.2). The environment (e.g., government regulations, accreditation policies) has a significant impact on the delivery system. The organization’s infrastructure influences how patient care is delivered. The infrastructure is shaped in part by external stakeholders, such as the federal government’s push for adoption of electronic health records (EHRs). Ensuring the workforce has the right equipment and skills to properly care for patients are important elements of the infrastructure. The patient care microsystem, in this model, is “the level of healthcare delivery that includes providers, technology, and treatment processes” (McLaughlin and Olson 2012, 9).
Lessons for Healthcare Managers The interconnected systems model is the only approach that clearly shows the patient at the center of the health system. The manner in which each layer of the system interacts with the others has a direct impact on the patient. Improving the effectiveness of clinical care requires process changes at the patient care microsystem level and in the infrastructure. For example, implementation of evidence-based treatment guidelines can help ensure patients receive appropriate treatments at the correct time. Making this goal a reality often requires changes in the organizational infrastructure. Tools such as computerized physician order
patient care microsystem “the level of healthcare deliv- ery that includes providers, technol- ogy, and treat- ment processes” (McLaughlin and Olson 2012, 9)
Organization Level C
Microsystem Level B
Patient Level A
Environment Level D
Source: Reprinted from Ransom, Joshi, and Nash (2005). Based on Ferlie and Shortell (2001).
EXHIBIT 5.2 Interconnected Systems View of Healthcare
Applying Qual i ty Management in Healthcare: A Systems Approach68
entry and treatment plans, together with electronic prompts or alerts built into the EHR, help remind providers of the guidelines at the point of care.
The subsystems in the interconnected systems often have feedback mechanisms that reinforce or balance system performance. Exhibit 5.3 illustrates how a change in the environment level ripples throughout the other three levels of the system.
Three Core Process Model
The three core process model shown in exhibit 5.4 represents a “horizontal” view of a health services delivery organization. All processes in the organization (represented by the arrows) should operate in an aligned fashion toward improving performance. The model starts on the right of the exhibit by defining desired results using a balanced set of outcomes: the patient’s clinical outcomes, functional status, satisfaction, and cost of services.
In the three core process model, the many processes that take place in a health services organization are grouped into three core categories: (1) clinical, medical, and technical processes; (2) operational or patient-flow processes; and (3) administrative processes.
Clinical, medical, and technical processes are the fundamental reasons individuals seek the assistance of a health services organization—that is, to take care of some need that involves diagnosis, treatment, prevention, or palliative care. Physicians and nonphysicians provide these services. The processes may be medical, such as surgery; mental health related, such as counseling or therapy; connected to daily care, such as nursing care after a stroke; or required by special treatments, such as obtaining oxygen or other durable medical equipment for the home.
Payers want to reduce costs for chemotherapy
Clinical Microsystem
Environment PatientOrganization
New payment method for
chemotherapy is created
Chemotherapy treatment needs
to be more efficient to meet payment levels
Changes are made in care
processes and support systems
to maintain quality while
reducing costs
Source: Reprinted from McLaughlin and Olson (2012, 12). Used with permission.
EXHIBIT 5.3 Linkages in the Interconnected
Clinical Delivery System:
Chemotherapy
Chapter 5: Visual iz ing System Relat ionships 69
Operational or patient-flow processes enable an individual to access the clinical, medical, and technical processes. This category includes processes such as registering patients, scheduling activities, and coordinating services. Administrative decision-making processes occupy two positions in the exhibit, above and below the other two core processes. In this way, the model illustrates how administrative processes influence the overall organization. These processes include decision making, communication, resource allocation, and performance evaluation. The arrows linking the three core processes reflect the interdependence of the processes.
Lessons for Healthcare Managers The three core process model teaches managers several lessons. First, the interdependent relationships between the three core processes suggest that improvement in any one of these processes has the potential to increase the value of the service provided. However, the concurrent targeting of these core processes provides a synergy that can accelerate the achievement of improved outcomes. “An efficient clinical process supported by an inefficient operational process, or vice versa, is still an inefficient process. . . . In addition, if . . . changes are made independent of clinician involvement, the likelihood of implementation is reduced. It is therefore necessary to have decision-making processes that actively engage clinicians in change efforts” (Kelly et al. 1997, 127–28).
Desired results: • Clinical outcomes • Functional status • Satisfaction • Cost
Operational/Patient & Client Flow Processes
Clinical/Medical/Technical Processes
Administrative Decision-Making Processes
Administrative Decision-Making Processes
EXHIBIT 5.4 Three Core Process Model
Applying Qual i ty Management in Healthcare: A Systems Approach70
For example, in one ambulatory surgery unit, the patient postoperative length of stay—the time the patient leaves the operating room to the time the patient is discharged—was found to be longer than in other, similar ambulatory surgery units. An improvement effort aimed at ameliorating the discharge process was undertaken in hopes of reducing the length of stay. As the improvement effort progressed, the team realized that anesthesia practices were affecting its ability to achieve better results. If patients were being heavily sedated in the operating room and were slow to wake up as a result, the gains from improving the discharge process could not be fully realized. Likewise, if the physicians implemented a new clinical protocol for anesthesia and pain management but patients still had to wait for the nurses to discharge them, gains from improving the anesthesia process could not be fully realized. Recognizing the interdependence of these two processes and targeting the discharge process and the anesthesia protocol for improvement allowed the benefits of both improvement efforts to be achieved. Furthermore, if the administrative processes did not permit employees to be scheduled away from clinical duties so they could be involved in the quality efforts, neither of the improvements could take place.
Second, the three core process model helps promote a patient-focused orientation by recognizing the need for aligning processes and improvement efforts toward the needs of the patient. The conceptual view of operations and administration observes how the patient (or client) moves through the entire system to access a clinical process. For example, a seemingly simple supervisory decision such as scheduling lunch breaks took on new meaning for one emergency department (ED) when the decision was viewed with patient flow in mind. Although scheduling staff lunch breaks at noon seemed reasonable, this practice created unnecessary patient delays and bottlenecks in the patient care processes because patient visits typically increased during the hours of 11:00 am to 1:00 pm. After ED management observed the situation from the patient-flow perspective, the break policy was revised so staff breaks occurred before and after—rather than during—busy patient times.
Third, the model reinforces the different yet necessary and interdependent contributions each core process and each provider (or implementer) of those processes provide to patient care and organizational outcomes. This way, collaboration among the entire care team can be promoted.
Fourth, when the administrative role is viewed as a process rather than a function or a structure, the tools used to improve other types of processes may also be applied to administrative processes. If one of the desired outcomes is patient satisfaction, the administrative decision-making processes must include mechanisms to regularly collect, analyze, report, and evaluate patient satisfaction data and to communicate these results throughout the organization.
Chapter 5: Visual iz ing System Relat ionships 71
Baldrige Performance Excellence Program Framework
The healthcare criteria of the Baldrige Performance Excellence Program (BPEP) provide a well-established systems approach for improving organizational effectiveness. Charleston (WV) Area Medical Center Health System found the criteria provided “an overarching framework for the system. . . . CEO Dave Ramsey reported that . . . ‘Baldrige added ways to achieve quality in our support of the community, our working relationship with vendors, our relationship with the medical staff, medical researchers and the workforce, pretty much everything’” (Asplund 2016). For readers who desire a more in-depth explanation, information about these criteria and examples of how health services organizations address the criteria can be found on the program’s website (www.nist.gov/baldrige).
Exhibit 5.5 illustrates the essential elements in the Baldrige framework and the links between these elements. The following passage explains how to read and interpret the exhibit (BPEP 2015, 1):
The Organizational Profile sets the context for your organization. It serves as the
background for all you do. The performance system consists of the six categories in
the center of the exhibit. These categories define your processes and the results you
Core Values and Concepts
Integration
Workforce
RESULTS
Operations
Measurement, Analysis, and Knowledge Management
Organizational Profile
Leadership
Strategy
Customers
Source: Reprinted from Baldrige Performance Excellence Program (BPEP) (2015).
EXHIBIT 5.5 Organizational Profile: Baldrige Performance Excellence Program Framework for Health Care
Applying Qual i ty Management in Healthcare: A Systems Approach72
achieve. Performance excellence requires strong Leadership and is demonstrated
through outstanding Results. Those categories are highlighted in the exhibit. The word
“integration” at the center shows that all the elements of the system are interrelated.
The leadership triad (Leadership, Strategy, and Customers) emphasizes
the importance of a leadership focus on strategy and customers. The results triad
(Workforce, Operations, and Results) includes your workforce-focused processes, your
key operational processes, and the performance results they yield. All actions lead
to results—a composite of health care and process, customer-focused, workforce-
focused, leadership, and governance, and financial and market results.
The system foundation (Measurement, Analysis, and Knowledge Management)
is critical to effective management and to a fact-based, knowledge-driven, agile
system for improving performance and competitiveness. The basis of the Health Care
Criteria is a set of Core Values and Concepts that are embedded in high-performance
organizations.
The center horizontal arrowheads show the critical linkage between the
leadership triad and the results triad and the central relationship between the
Leadership and Results categories. The center vertical arrowheads point to and
from the system foundation, which provides information on and feedback to key
processes and the organizational environment.
Lessons for Healthcare Managers Managers may take several lessons from the Baldrige systems model. First, the model describes the essential elements of organizational effectiveness (represented by the seven boxes in the model) and how they are related. The model recognizes the unique circumstances in which different organizations operate and encourages managers to base decisions, strategies, and interventions on their unique organizational profiles. The overarching nature of the organizational profile promotes ongoing consideration of external influences, such as environmental, regulatory, or market demands.
When viewed in light of the Baldrige model, one can see that the traditional principles of total quality (customer focus, continuous improvement, teamwork), described in chapter 1, touch on some, but not all, of the required elements (customer focus, operations focus, and workforce focus). The Baldrige model visually illustrates that a systems approach to quality management in a healthcare organization requires managers to focus on more than just the three principles of total quality. Achieving organizational effectiveness also requires a focus on the external environment, leadership, strategic planning, measurement, analysis and knowledge management, and on how the workforce members contribute individually and collectively to achieving the desired organizational performance results.
Chapter 5: Visual iz ing System Relat ionships 73
Managers who use this model understand the importance of alignment in the organization. This alignment means that the activities in each box in the model are directed toward achieving the same results and that organizational and management choices are consistent with the organization’s mission, vision, values, strategic direction, and patient and stakeholder requirements. Without alignment, improvement efforts can be less effective. For example, one health services organization offers comprehensive quality improvement training for its managers. Each manager is expected to design and carry out an improvement effort as a requirement of the training, so each selects a topic on which to focus his improvement project. Although each manager demonstrates improvement in the chosen area, the collective improvements of all the training participants may not contribute to the overall organizational objectives. This observation is illustrated by one manager who devoted much time and effort to improving a service area that was eliminated by the organization the following year. Another healthcare organization offering a similar type of training engaged senior leaders to help select improvement topics that would not only provide benefit within the managers’ scope of responsibility but also contribute to the overall organizational strategy.
The Baldrige model also illustrates the link between management and human resource needs. Before implementing a process improvement, managers ask themselves, “What needs to happen to ensure the staff will succeed at implementing the new process?” As a result, when a new process is initially implemented, managers support employees as they learn the new process or their new roles. Adapting to something new takes time, and by anticipating slight disruptions during the transition period, the manager is better prepared to accommodate whatever short-term budget or productivity variances might occur. An understanding of the framework that helps managers realize their role in process improvement also includes ensuring that employees have the information, training, and tools they need to successfully implement improvements in the work setting.
Finally, the Baldrige model illustrates essential linkages in the system. For every key leadership, management, and daily work process of the organization, the Baldrige criteria ask four questions (BPEP 2015):
1. Do you have a systematic approach, tools, and tactics? 2. Is your approach deployed to the people who need to use it? 3. Do you evaluate and improve the approach periodically? 4. Does this particular approach integrate into and align with other
organizational approaches in other areas?
Applying Qual i ty Management in Healthcare: A Systems Approach74
Integration of the leadership and results elements, represented by the arrows, is a vital component of an effective organizational system. For example, one health services manager realized the connection between the leadership triad and the results triad was one-way only. Communication flowed in one direction only with little opportunity for the managers and other staff to provide feedback for consideration in decision making at the organizational level. This realization helped to explain her perceived disconnect between organization- wide initiatives and her department’s local circumstances and needs.
Socioecological Framework
The socioecological framework represents a transdisciplinary systems perspective on promoting health and wellness that uses and reflects theory from multiple fields, including medicine, public health, and behavioral and social sciences. Social ecology scholar Daniel Stokols (2000, 27) further describes the underpinnings of the framework:
The healthfulness of a situation and the well-being of its participants are assumed to
be influenced by multiple facets of both the physical environment (e.g., geography,
architecture, and technology) and the social environment (e.g., culture, economics,
and politics). Moreover, the health status of individuals and groups is influenced not
only by environmental factors but also by a variety of personal attributes, including
genetic heritage, psychological dispositions, and behavioral patterns. Thus, efforts
to promote human well-being should be based on an understanding of the interplay
among the diverse environmental, biological, or behavioral factors.
Key to this framework is the recognition of “the complexity of human environments” and the emphasis on multilevel, interrelated influences and multilevel, interrelated interventions influencing health and wellness (Stokols 2000). These multiple levels may be thought of as nested systems within systems, starting with the individual and expanding to include “interpersonal, organization, community, society, supranational” (Kok et al. 2008, 438). Peter Reed illustrates the multiple and interrelated levels of influences (determinants) and interventions in exhibit 5.6. Reading the exhibit top to bottom illustrates the four levels of determinants of health behavior: individual, organization, community, and population (Reed 2001). Reading the exhibit left to right illustrates that for each of these levels of determinants, specific interventions may be implemented and their effects evaluated. For example, the model may be used to better understand smoking behavior.
Chapter 5: Visual iz ing System Relat ionships 75
Individual determinants of smoking behavior include a person’s knowledge of associated health risks and the smoking behavior of family and friends. Individual interventions to reduce smoking behaviors may include smoking cessation classes and pharmacotherapy (e.g., nicotine patches). The impact is measured by whether the person stops smoking or does not start in the first place.
Organizational determinants of smoking behavior include policies regarding smoking in the workplace and the availability of smoking cessation classes as an employee health benefit. Prohibiting smoking, offering limited access to on-site smoking areas, and reimbursing employees for smoking cessation classes are interventions targeted at the organizational level. The proportion of employees who smoke and the “quit rate” are common organizational evaluation measures.
Community determinants of smoking behavior include social norms and beliefs. For example, smoking may be linked to social status and acceptance. Because of the history of tobacco farming in the southeastern United States, smoking has also been associated with the community’s economic livelihood and therefore viewed more favorably. Redefining social norms and recruiting nontobacco economic opportunities would be considered community-level interventions. Impact may be measured in terms of community smoking rates.
Determinant Intervention Evaluation (impact)
Evaluation (outcome)
Individual
Organization
Community
Population
Health and Health
Behaviors
Source: This illustration reprinted with permission by Peter Reed, MPH, JoAnne Earp, ScD, and the instructors of HBHE 131, Introduction to Social Behavior in Public Health, Department of Health Behav- ior and Health Education, University of North Carolina at Chapel Hill, School of Public Health, 2001.
EXHIBIT 5.6 Socioecological Framework
Applying Qual i ty Management in Healthcare: A Systems Approach76
Population determinants of smoking behavior include regulations regarding smoking in public places. No-smoking airline flights, no-smoking buildings, or a “sin tax” on cigarettes are examples of population-level interventions. The effect may be measured by compliance with regulations and population smoking rates.
In exhibit 5.6, the arrows between the levels indicate the interconnectedness of the determinants, interventions, and impact at all levels. While a level-specific intervention may be effective, recognizing the relationships between the levels creates a synergy to enhance desired outcomes. Using the example on smoking, one can understand the limited impact of enrolling a person in a smoking cessation class when he is surrounded by smokers in the family, in the workplace, and in public venues.
Lessons for Healthcare Managers The major lesson from this framework for healthcare managers is that it provides a more expansive view of the nature of health and wellness in general and of health services specifically. In doing so, the model offers a larger context in which to understand interventions designed to improve the quality and safety of services provided by health services organizations and, in turn, to understand complementary and competing interventions within and between levels. This knowledge is particularly important to partners in accountable care organizations that share medical and financial responsibilities for providing coordinated care to a population of patients (Gold 2015).
In 2001, the Institute of Medicine recommended that “the changes needed to realize a substantial improvement in health care involve the health care system as a whole” (20). This recommendation implies understanding not only how organizations work as systems but also how the multiple players and layers involved in the health services sector are interrelated.
Summary
Systemic structures may not be readily visible. System models are valuable managerial tools to help managers identify the elements and connections between those elements in their organizations and the environments in which they operate. Exhibit 5.7 summarizes lessons from the four system models discussed in this chapter. Managers are encouraged to identify, integrate, and continuously apply lessons from each of these models to further develop their skills in understanding systemic structures.
Chapter 5: Visual iz ing System Relat ionships 77
Exercise 5.1 Objective: To practice identifying activities that represent essential elements in the Baldrige Performance Excellence Program (BPEP) framework.
Instructions: Think about your healthcare services work area or area of interest. Identify two activities a manager in this area does to advance organizational excellence in each of the following Baldrige framework categories:
• Strategy • Customers • Workforce • Operations
Examples of what healthcare recipients of the Baldrige National Quality Award have done in these areas can be found online at www.nist.gov/baldrige.
Interconnected Systems Model
Three Core Process Model
Baldrige Performance
Excellence Program Framework
Socioecological Framework
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