Quality & Continuous Improvement in Healthcare

This is the first in a series of articles exploring the issues and opportunities in the realm of performance excellence or, more specifically, for quality and continuous improvement. It focuses on healthcare organizations and their patients or clients in both the private and public sectors.

Healthcare is defined here as “Any industry, field, company or individual which treats, restores, maintains and/or improves the physical and/or mental health and well-being of one or more patients or clients.”

Quality, in general, is defined as “Conformance with requirements” or “Fitness for use.” Healthcare quality is defined here as “the degree to which supportive services for individuals and populations increase the likelihood of desired health and well-being outcomes and are consistent with current professional knowledge.”

Continuous improvement, in general, is defined as: “an ongoing effort to enhance the measurable performance of a product, service or process.” Healthcare continuous improvement is defined here as “systematic, data-guided activities designed to bring about the measurable enhancement of the delivery of supportive services in healthcare settings.”

Healthcare can include both for-profit and nonprofit hospitals, medical centers, health systems, nursing homes, volunteer medical initiatives, assisted living facilities, organ/tissue procurement organizations and clinics of various sizes operating as an institution as well as physicians, chiropractors, physical therapists, psychotherapists, wellness counselors, nutritionists, dieticians, sleep specialists, social workers and other practitioners operating individually or in small practices. Healthcare can also include companies of various sizes in pharmaceuticals, biotechnology and medical devices. Finally, it can include the departments of health and mental health at the municipal, county, state and federal government levels.

Quality and continuous improvement in healthcare has always been a high-profile topic, but it has been receiving even more careful scrutiny since 1999 with the release of the Institute of Medicine’s report entitled ”To Err Is Human: Building a Safer Health System.” In fact, the definition of healthcare quality above was based on that report which asserted the following:

“The necessity for quality and safety improvement permeates health care (since) the majority of medical errors result from faulty systems and processes, not individuals. Processes that are inefficient and variable, changing case mix of patients, health insurance, differences in provider education and experience and numerous other factors contribute to the complexity of health care.”

That landmark IOM report made it clear that patient safety was a major component of healthcare quality and continuous improvement and that’s something to which EVERYONE can relate—healthcare practitioners AND the general public. A 1997 article in the American Journal of Health-System Pharmacy asserted that:

“…because errors are caused by system or process failures it is important to adopt various process-improvement techniques to identify inefficiencies, ineffective care and preventable errors to, then, influence changes associated with systems. Each of these techniques involves assessing performance and using findings to inform change —including such strategies and tools for quality improvement as Failure Modes and Effects Analysis, Plan-Do-Study-Act, Six Sigma, Lean and Root-Cause Analysis—that have been used to improve the quality and safety of health care.”

No article on healthcare quality, patient safety and continuous improvement would be complete without mentioning “The Joint Commission” (JC), an independent, not-for-profit organization, based in Chicago, which accredits and certifies nearly 21,000 healthcare organizations and programs in the United States. JC accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. Its mission is to continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. Its vision is that “All people always experience the safest, highest quality, best-value healthcare across all settings.” (For more on the JC, go to: www.jointcommission.org.)

A strategic emphasis on healthcare quality, patient safety and continuous improvement has emerged in the past 17 years that is based on W. Edwards Deming’s “Total Quality Management” (TQM) approach first described in his 1986 classic “Out of the Crisis.” It promoted concepts such as “constancy of purpose” and the “systematic analysis and measurement of process steps in relation to capacity or outcomes.”

TQM is an enterprise-wide approach that must be initiated by the senior leadership team (SLT) employing teamwork, defined processes and systems thinking and transforming the organization to create a culture of improvement that permeates the organization.

In 2004, the Agency for Healthcare Research and Quality (AHRQ) noted that quality improvement methods had “generally emphasize[d] the importance of identifying a process with less-than-ideal outcomes, measuring the key performance attributes, using careful analysis to devise a new approach, integrating the redesigned approach with the process and reassessing performance to determine if the change in process (was) successful.”

In addition to TQM, other quality improvement strategies have come forth, including the Baldridge Excellence Framework, the International Organization for Standardization (ISO 9000) series of standards, Zero Defects and the Toyota Production System (TPS) with its lean thinking approach.

Most of these methods, frameworks or standards were originally invented in or refined for manufacturing environments. They have been adapted and customized to apply to healthcare environments where service (to patients) and transactions (with patients and their families) drive most of the work being performed.

The original “Baldridge Excellence Framework” was first released in 1987 with its primary focus being manufacturing. It was named in honor of former Secretary of Commerce Malcolm “Mac” Baldrige Jr., who had just died unexpectedly as the result of a tragic accident in July of that year. Since he had taken a personal interest before he died in early drafts of federal legislation that became the Quality Improvement Act of 1987 (Public Law 100-107), Congress named the law and an annual award after him (the “Malcolm Baldrige National Quality Improvement Act of 1987” and the “Malcolm Baldrige National Quality Award”).
Then, in 1998, the “Baldridge Excellence Framework” was adapted for healthcare. This resulted in the first National Baldrige Award recipient for healthcare in 2002: SSM Health Care (St. Louis, Missouri). That was followed by Baptist Hospital, Inc. (Pensacola, Florida) and Saint Luke’s Hospital (Kansas City, Kansas) in 2003, and Hamilton, New Jersey-based Robert Wood Johnson University Hospital in 2004. Since then, there have been 16 more National Award recipients in the healthcare sector, including a second New Jersey-based healthcare organization, AtlantiCare (Egg Harbor Twp, New Jersey) in 2009. (See http://www.nist.gov/baldrige/ and http://www.nist.gov/baldrige/enter/health_care.cfm.)

The 2015-16 version of the Baldrige Healthcare Criteria for Performance Excellence has seven categories, comprised of six that are focused on “process” (each of which has two items)—leadership, strategy, patients (customers), measurement, analysis and knowledge management, workforce and operations—and one that is focused on “results” (with five items).
Before closing, I want to return to the subject of “patient safety” as a key component of tracking healthcare quality and continuous improvement. Earlier this year, a Johns Hopkins University School of Medicine research team declared in a controversial May 4th article in BMJ that “Medical errors now third leading cause of death in the U.S.” (See http://www.bmj.com/company/wp-content/uploads/2016/05/medical-errors.pdf)

While alarming, this headline was considered somewhat misleading by many U.S. healthcare professionals. The reason? “Because death certificates in the U.S. have no facility for acknowledging medical errors,” asserted the two lead researchers. These researchers called for “better reporting to help understand the scale of the problem and how to tackle it.”

Currently, death certification in the U.S. relies on assigning an International Classification of Disease (ICD) code to the cause of death, so causes of death not associated with an ICD code, such as human and system factors, are not captured.

In the next article in this series on quality, continuous performance improvement and operational excellence, we will explore the patient safety challenges and issues facing our own Meadowlands area healthcare organizations.

William S. Ruggles is a member of the MRC and its ambassador and technology committees. He is the COO and managing partner of the Ruggles2 Center for Organizational Performance Improvement (COPI), a virtual training center and management consulting firm specializing in quality, continuous performance improvement and operational excellence with both for-profit and nonprofit organizations.

Ruggles is a 2016 Baldrige National Examiner currently assigned to assess a healthcare application. He has a master’s from Columbia University and certifications in Project Management, Quality Management, Six Sigma, Lean and Agile/Scrum. Previously, he was a New Jersey State Baldrige Examiner, a program manager for the WTC Medical Monitoring & Treatment Grant Program at the Mount Sinai Medical Center in New York City, an adjunct professor at Stevens Institute of Technology in Hoboken and a PMO program manager and deputy chief technology officer for workforce enhancement for the State of New Jersey OIT in Trenton. He can be reached at bill.ruggles@ruggles2llc.com.

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