Healthcare Quality and Safety

Healthcare Quality and Safety

Question 1

Identify a patient safety issue.  You can use “Hospital Compare” on the CMS website or the “Why Not the Best website” for ideas.  Identify a structure, process or outcome measure that the facility should monitor to improve the problem.  These should be measurable so the common ways to describe the measures would be with a percentage, ratio or count.  Describe how you would measure them and the results you would expect to see.

Structure, Process and Outcome Measures

1. Structure measures are used to evaluate the environment in which the process is performed.
2. Process measures are used to determine if the right things are being done.
3. Outcome measures are used to judge the end results.

It is helpful to identify different types of measures when developing a quality improvement or performance improvement project.  Establishing measures will help determine whether the project was a success or failure and allow the team to identify next steps to consider.

Below are some examples of each type of measure:

Structure Measures	Process Measures	Outcome Measures
Ratio of Registered Nurses to Patients	Percent of patients assessed for fall risk at time of admission	Number of patient falls per 1000 patient days
Number of fire drills conducted annually	Percent of patients with stage II colon cancer who receive chemotherapy	Number of patients that develop a hospital-acquired pressure ulcer per 1000 discharges
Percent of employees who receive influenza vaccination	Percent of operative reports dictated immediately after surgery	Percent of patients with the principal diagnosis code of stroke that expire in the hospital
Hospital has norms for heparin administration using a nomogram	Percent of patient records containing patient demographic error	Percent of patients who report being “very satisfied” with the admission process
Number of nursing hours provided per patient per day	Percent of consent forms that are properly completed and signed	Average admitting times for inpatients, emergency, and outpatients
Number of surgical cases that are delayed beyond the scheduled start time	Percent of patient record number assignments that are correct	Mortality rate for patients admitted for treatment of a stroke
Hospital is using a cardiac registry to improve patient care	Average time between patient arrival at the emergency department and completion of CT/MRI scan	Percent of patients that develop a post-operative complication
Intensive care unit has a specialty physician available 24 hours a day	Percent of patients with high cholesterol who receive lipid-lowering therapy	Average operating room charges for patients undergoing coronary artery bypass surgery
Hospital has the capability for providers to prescribe electronically	Percent of patients who are discharged on antiplatelet therapy	Percent of home care patients who report being treated with courtesy and respect
	Percent of clinic records containing documentation of patient allergies	Percentage of surgery patients who develop pneumonia

References:

AHRQ (2016, July 15).  Selecting Structure Measures for Clinical Quality Assessment. Retrieved from https://www.qualitymeasures.ahrq.gov/help-and-about/quality-measure-tutorials/selecting-structure-measures on January 24, 2017.

Dimick, Chris. “Quality Check: An Overview of Quality Measures and Their Uses” Journal of AHIMA 81, no.9 (September 2010): 34-38.

Online Quality Reporting (CMS Hospital Compare, Why Not the Best)

There is a growing trend towards requiring healthcare facilities to report quality measures and publishing those measures for public view.   This information is helpful when patients are deciding which facility or provider they would like to see.  It may be especially helpful for those selecting long-term care facilities for a family member and allow them to narrow down the list of facilities they would like to visit and investigate further.

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Question 2

In the week 1 discussion, you selected a patient safety issue and identified measures to monitor to improve the problem.  Further analyze that issue and discuss how systems thinking can improve the process.  What departments and staff positions should be involved in planning and monitoring the improvements?  What are some strategies to help them work together to improve the interconnected processes?

Systems Thinking Concepts

Systems thinking is an important concept in performance or process improvement.  In healthcare, if a problem can be investigated and improved without placing blame, it is easier to gain cooperation and support of the staff involved.  The interconnections of different components affect each other.  Different levels of staff and departments involved in a service affect the “system”.  Looking at all the interconnections can help identify factors that would otherwise be missed.

An example may be a medication error.  A complete investigation of the process, using the systems approach, would include the full process that includes:

• The pharmacy ordering the medication.
• The hospital receiving area in materials management receiving the medication and delivering it to the pharmacy.
• The pharmacy staff intaking the medication, placing it in stock and recording the receipt in the system.
• The physician ordering the medication for a patient.
• The pharmacist checking the medication orders and authorizing delivery.
• The pharmacy tech checking inventory in the medication delivery system and delivery medications to the floor and restocking the electronic medication delivery system.
• The nurse removes the medication from the electronic medication delivery system and takes it to the patient room.
• The nurse scans the bar codes on the medication and the patient arm band.
• The computer verifies the scan with the orders on the patient record.
• The nurse gives the medication to the patient and scans the patient arm band again to record the medication as given in the computer system.

The systems thinking improvement process would require staff from all the areas who handle the medication process to be included in the team.  It also requires staff and different levels, such as the pharmacist and the pharmacy tech to part of the team.

This systems process looks for interconnections from the bigger picture, looking for patterns.  In the healthcare system there are many processes that depend on accurate patient information being entered at registration so that is one example of where there may be many interconnections.

There is more interdependence today of various roles in healthcare, than there has been historically, because of the increased specialization of the physicians and the increasing scope of practice in areas such as physical therapy and pharmacy.

Reference:

Shaw, P.L. & Carter, D. (2015).  Quality and Performance Improvement in Healthcare, Sixth Edition. Chicago: AHIMA Press.

Question 3

Find a report of a medical error in the news.  Find evidence-based medicine or clinical guidelines that should have been used when making the medical decisions in the case.  What policies and procedures should exist and be followed to prevent the error?  The best place to find local clinical guidelines currently may be on the medical specialty association websites.  Does this relate to the systems thinking process we discussed last week?

Week 3 Lesson: Understanding the Medical Decision-Making Process

When establishing performance targets in order to measure performance, these are some of the factors or documents that can be utilized:

• Clinical Practice Guidelines
• Practice Standards
• Therapeutic Guidelines
• Position Statements
• Standards of Practice

These standards and guidelines are ways to evaluate the medical decision-making process.

Patient Engagement in Medical Decision Making

There is a growing trend towards increased patient engagement in their medical treatment, with the expectation that this will increase their compliance with the medical treatment.

One area that can support patient engagement are the use of patient portals.  Healthcare providers can release records from the Electronic Health Record for viewing in the portal.  This gives patients quick access to their own records.  Patient portal usage is a meaningful use data element that is be tracked by CMS.

Evidence-Based Medicine

Evidence-based medicine became increasingly important in the 1990s.  This documents what the research shows to be the most effective treatment.  This research can help doctor’s diagnosis conditions, choose the best testing methods and the best treatments.

Some states may have laws that require state agencies that provide medical care to use evidence-based medicine when available.

Clinical Guidelines

Clinical practice guidelines are statements that help guide the physician’s decisions about the best healthcare treatments to provide.  The guidelines are developed by medical professional associations.  These are developed from medical research and the consensus of professionals with expertise in the field.  Due to federal budget cuts, clinical practice guidelines are no longer published on a federal government website.  The best place to get these clinical practice guidelines are on the websites of the medical specialty associations.

These guidelines may be very helpful to family practice physicians because they are able to easily access the recommendations of specialists.

Reference:

Spath, P.L. (2013).  Introduction to Healthcare Quality Management, Second Edition. Chicago: Health Administration Press.

Question 4

Locate the public health department or health authority for your state.  Determine whether there are quality measures that are reported to the state.  Are there additional requirements locally for accountable care organizations (ACO) or patient-centered medical homes (PCMH)?  How do these support medical decision-making?  Report on your findings.

*State is Hawaii

Week 4 Lesson:

Joint Commission Core Measures

The Joint Commission began development of performance measures with the inception of the Agenda for Change in 1987. Eventually these activities were subsumed into what is now called the ORYX initiative. The initial phase of the ORYX initiative offered health care organizations significant flexibility. Organizations could meet accreditation requirements by selecting from among literally hundreds of performance measurement systems and thousands of performance measures that best served their strategic measurement goals. The flexibility made available through the initial phases of the ORYX initiative also presented certain challenges. The biggest concern was the inability to compare health care organization data across systems and between disparate measures. However, the next phase of the ORYX initiative permitted more rigorous comparisons using standardized, evidence-based measures.

The Joint Commission solicited input from a variety of stakeholders including clinical professionals, hospitals, consumers, state hospital associations and medical societies about potential focus areas for the initial set of hospital core measures. Once focus areas were identified, advisory panels were convened to identify measures that, when viewed together, permitted an assessment of the care provided in a given focus area. The Attributes of Core Performance Measures and Associated Evaluation Criteria were used to evaluate candidate measures for potential use as core measures. Stakeholder engagement was actively sought by posting the potential core measures on the Joint Commission web site. A variety of stakeholders, including clinical professionals, health care provider organizations, health care consumers and performance measurement experts provided over 1,600 comments. These comments helped to shape the specifications for the initial core measure sets prior to pilot testing.

In 2001, the Joint Commission received feedback from the participating state hospital associations, measurement systems, and hospitals. This feedback, the analysis of on-site reliability data, and the Joint Commission’s ongoing discussions with CMS, directed toward alignment of similar measures, led to a number of improvements and modifications to the original core measures, prior to their release on November 21, 2001.

The four initial core measures were:

• Acute Myocardial Infarction (AMI) Core Measure Set
• Heart Failure (HF) Core Measure Set
• Community Acquired Pneumonia (CAP) Core Measure Set
• Pregnancy and Related Conditions (PR) Core Measure Set

In 2003 the Joint Commission and CMS began work to align their quality measures.  The current core measure categories are:

• Acute Myocardial infarction
• Children’s Asthma Care
• Emergency Department
• Hospital Outpatient Department
• Hospital-Based Inpatient Psychiatric Services
• Immunization
• Perinatal Care
• Stroke
• Substance Use
• Tobacco Treatment
• Venous Thromboembolism

Reference:

The Joint Commission (2019).  Measures.  Retrieved from https://www.jointcommission.org/core_measure_sets.aspx

CMS Quality Measures

The CMS quality measures are updated annually and healthcare facilities may choose the measures they wish to monitor from designated sets.  Currently these measures are part of the merit-based incentive payment system (MIPS).

Reference:

Quality Payment Program (2019).  Quality measures requirements.  Retrieved from https://qpp.cms.gov/mips/quality-measures?py=2019

State Quality Measures

States may have quality measure report reporting requirements as well.  Let’s use Oregon as an example.  Oregon implemented expanded Medicaid with the Affordable Care Act (ACA) and started coordinated care organizations (CCO), which are modeled after the accountable care organizations (ACO) in the ACA.  Oregon currently monitors 17 quality measures for the CCO’s.  Medical clinics who treat CCO patients, must report these metrics.  Oregon is also tracking 11 hospital incentive measures.

Reference:

Oregon Health Authority (n.d.).  Quality and Accountability.  Retrieved from https://www.oregon.gov/oha/hpa/analytics-mtx/pages/index.aspx

Current issues in Quality and Medical Assessment

Some specific areas that may require monitoring and reporting by healthcare facilities are opioid use, polypharmacy and Hep C screening and prevalence.  These may be required by grants, state agencies or accreditation agencies.  Polypharmacy is watched closely in long-term care centers because the elderly often has many prescriptions where sometimes a side effect of one medication is treated with an additional medication.  In the past, sometimes difficult to manage residents were given sedatives to lighten the staff workload and so this is monitored closely as well by agencies.

Question 5

Research facility and provider licensing in your state.  For facility licensing, determine whether a certificate of need is required to obtain approvals to build or expand a facility and identify the state survey requirements for opening the facility.  For healthcare provider licensing, locate the application requirements and the medical and nursing scope of practice laws.  Report your findings to the class.

Week 5 Lesson:

Facility Licensure

Healthcare facilities must be licensed before they can open and operate.  The precise process varies by state but most likely a state agency must survey and approve the facility before it can operate.  In some states, hospitals must complete a certificate of need process with the state before they can build a new hospital or increase the number of beds of an existing hospital.

Healthcare Professional Licensure

Many healthcare professionals must be licensed by the state before they can practice their profession.  The most well-known state licensure is for medical staff and nurses.  Each state has a medical scope of practice law that that physicians, physician assistants and other medical staff most practice under.  The states also have a nursing scope of practice law that defines the scope of practice that various levels of nurses are authorized for.  These include certified nursing assistants, licensed practice nurses, registered nurses and nurse practitioners.  There are other healthcare professions that may require state licenses, such as nursing home administrators.

Medical Staff

A hospital medical staff consists of:

1. Officers
2. Committees
3. Clinical Services/Departments
4. Medical Staff Members

There are several categories of medical staff membership to which a physician can be appointed.

The most common category of membership is ACTIVE, which means that physicians who are appointed to active membership are actively admitting patients. The active medical staff is responsible for the greatest amount of medical practice in the hospital. The Joint Commission requires hospitals to have an active category of membership. Physicians who are active members have voting rights and committee membership is mandatory. They can also hold office.

Physicians who are being considered for active membership are given ASSOCIATE or PROVISIONAL membership. This is a one-year initial appointment and physicians having this category of membership cannot vote or hold office; however, they can admit patients. They are not required to serve on committees.

COURTESY membership is given to physicians who treat patients occasionally. They do not frequently use the hospital but want privileges to admit an occasional patient. This category of membership cannot vote or hold office. They are not required to serve on committees.

CONSULTING membership is granted to physicians who will be asked to consult on patients. They do not have privileges to admit patients but can consult on a patient. A hospital usually has a standing list of consultants who all have consulting membership.

HONORARY membership is given to physicians who are recognized for noteworthy contributions to the hospital. For instance, they may have retired from practice, but want to be involved in the medical staff organization.

TEMPORARY membership is granted privileges for a specified period of time. It could be used when a physician is going to be gone and needs a physician to cover for him/her and that physician does not have active membership or courtesy membership at the hospital. Another example is when the President of the United States travels. If the President were hospitalized, his personal physician would need to treat him. The hospital would grant the physician temporary membership and the state would issue a temporary license.

Medical Staff Bylaws

The Medical Staff Bylaws are required for Medical Staff organization. They are the legal document that governs their activities.  There are specific requirements for these in the Joint Commission standards.

Besides the Bylaws, the medical staff also has rules and regulations. The rules and regulations are much more specific than the bylaws.

Medical Staff Committees

The hospital medical staff accomplishes many of its goals through a structure of committees. Typical hospital committees include:

• Executive Committee
• Credentials Committee (sub-committee of Executive Committee)
• Utilization Review Committee
• Quality Improvement Committee
• Joint Conference Committee
• Tissue/Surgical Review Committee
• Blood Usage Review Committee
• Pharmacy & Therapeutics Review Committee
• Medical Records Committee
• Safety Committee
• Risk Management Committee
• Ethics Committee
• Cancer Committee

The Joint Commission requires that certain medical staff reviews must be done. Most reviews are performed through the various committees or subcommittees of primary committees.

The medical staff reviews that Joint Commission requires are:

• Surgical Case Review
• Drug Usage Review
• Medical Record Review
• Blood Usage Review (Transfusions/Tissue)
• Pharmacy and Therapeutic Review

These committee are chaired by a member of the medical staff and have a coordinator supporting the committee, often from the Quality Improvement Department.

Medical Staff Credentialing Process

Physicians and mid-level providers (physician assistants and nurse practitioners) who provide independent licensed medical services, are credentialed and privileged by the facilities where they treat patients.  The credentialing process verifies their licensure and the privileging process determines the services they are permitted to provide at the facility.  This credentialing process of termed as an appointment to membership in the medical staff.

Current competence at the time of appointment to membership and initial granting of clinical privileges is verified in writing by peers knowledgeable about the applicant’s professional performance. The hospital obtains information directly from the primary source in the form of written documentation from authoritative sources, which contain informed opinions on each applicant’s scope and level of performance. The primary source verification may be obtained through a secure electronic communication or by phone contact with the primary source. Written documentation that describes the applicant’s actual clinical performance in general terms, the satisfactory discharge of his or her professional obligations as a medical staff member, and his or her ethical performance are acceptable. However, ideally the documentation also addresses at least the following two specific aspects of current competence:

1. For applicants in fields performing operative and other procedure(s), the types of operative procedures performed as the surgeon of record; the handling of complicated deliveries; or the skill demonstrated in performing invasive procedures, including information on appropriateness and outcomes. In the case of applicants in nonsurgical fields, the types and outcomes of medical conditions managed by the applicant as the responsible physician should be addressed.
2. The applicant’s clinical judgment and technical skills.

Typically, the medical staff are re-credentialed every two years.  The time period may vary by state.  During that time chart audits are completed on the documentation from the patients they treat and statistics are recorded.  These audits and statistics are overseen by a medical staff peer review committee.  The results of these audits are one component of the re-credentialing process.

Question 6

Locate a healthcare facility in your area and research their accreditation.  If possible, determine when the last accreditation survey occurred or when they expect surveyors to arrive again.  Discuss the process that will occur when the facility is preparing for accreditation.

*Hawaii

Week 6 Lesson:

Accreditation Organizations Overview

Accreditation at a healthcare facility is voluntary.  However, it is one way that an organization can achieve “deemed status” which allows them to accept payment from federal insurance, such as Medicare or Medicaid.  If a facility does not achieve deemed status, they will only be able to treat commercial or self-pay patients.  Because of that, it is rare that a healthcare facility does not pursue accreditation.  Most hospitals are accredited by either the Joint Commission (TJC) or DNV.

The Joint Commission (TJC)

You may hear people talking about JCAHO (“Jay-coe”).  This was the correct terminology when this accreditation organization was named Joint Commission for Accreditation of Healthcare Organizations (JCAHO).  The name was changed to The Joint Commission (TJC) in 2007.

In 2004 in response to the IOM reports JCAHO initiated a new survey process called tracer methodology which evaluates patient safety in all areas of the healthcare facility. National patient safety goals (NPSGs) are used to score facilities for compliance during surveys. Hospitals must now prove they are using methods to monitor patient safety. For instance, hospitals now use the method of marking surgical sites for verification and must confirm surgical site with the patient prior to surgery. Checklists and other documentation are used in the medical record to document compliance.

The Medicare Conditions of Participation require participating providers to have a written plan.  The Joint Commission standards do not require specify a written plan is needed, however, the standards imply a quality management plan is desirable.  In the organization, the leaders are responsible for establishing structures and processes that are focused on safety and quality.  A written plan helps demonstrate that leaders are compliant with the standards.  The NCQA health plan accreditation standards do require a written quality plan.  The plan may be a separate document or a set of policies and procedures.  Many organizations may have a combined Quality Management and Performance Improvement Plan (Spath, 2013).

The Performance Improvement Plan should define the responsibilities of the quality oversight groups, such as the Quality Council, the Medical Staff Executive Committee and the Hospital Trustees (Spath, 2013).

Reference:

Spath, P. (2013). Fundamentals of Health Care Quality Management, 4th Edition.

DNV GL – Healthcare

DNV GL received CMS Deeming Authority in 2008 and began accrediting hospitals at that time.  Many hospitals switched from TJC to DNV for accreditation because it was perceived to be more collaborative than TJC.  The main difference between the two is that DNV GL focuses on the Medicare Conditions of Participation and they do not have a publishing division and do not develop separate standards beyond those required by CMS.  They also integrate ISO 9001 into their survey process (DNV GL Healthcare, 2019).

Reference:

DNV GL Healthcare (2019).  Hospital Accreditation.  Retrieved from https://www.dnvglhealthcare.com/accreditations/hospital-accreditation

AAAHC

AAAHC (Accreditation Association for Ambulatory Health Care) was founded in 1979 and accredits many ambulatory healthcare centers.  These include ambulatory surgery centers, office-based surgery facilities, endoscopy centers, student health centers, medical and dental group practices, community health centers, employer-based health clinics, retail clinics, and Indian/Tribal health centers.

Reference:

AAAHC (2017).  About Us.  Retrieved from https://www.aaahc.org/about/

Question 7

Select a process improvement tool or technique of your choice.  Identify examples of situations where this tool or technique would be appropriate to use.

Week 7 Lesson:

Charts and Graphs

It can be challenging to select the type of chart or graph will best explain the data from your project.

A histogram is useful to display the frequency of events or categories of data.  An example is to show the length of time it takes to respond to a patient’s call light.  There may be a bar showing the number of call lights responded to within 30 seconds to 1 minute, the number of lights responded to between 1-2 minutes, etc.

A pie chart shows a snapshot in time.  Each portion of the pie shows a contribution to the whole.  This may be useful if the HIM department conducts a survey to determine levels of satisfaction with HIM services from hospital staff.

A line graph shows changes in performance over a time period.  An example of when this is used is in a behavioral health facility to show the number of seclusions over a month.

Statistical Process Control

Statistical Process Control was developed for manufacturing to help prevent defects, rather than to fix them.  Studies show that some variation always exists, even in a process that is repeated in exactly the same way.  SPC is useful in healthcare as well as manufacturing.  A control chart is a special type of line graph that is used to display this data.  It shows variations in performance in order to distinguish between common cause and special cause variations.

Common cause variation occurs in every process and falls within a predictable range unless something about the process changes.  Special cause variation is not predictable and is caused by something unexpected or unusual affecting the process.  We will not study SPC in detail within this course.  When time series data are plotted on a control chart and a data point falls above the upper control limit, the process is demonstrating special cause variation.  An example could be plotting the number of illness-related absences over a period of time.

PI Teams

Although everyone involved in some step of a process should be involved in a performance improvement project, it is important that the team not become too large. The optimum size of an improvement project team is six to ten people.

Improvement project teams work through some common stages.  These are Norming, Performing, Storming and Forming.

In the Forming stage, team members tend to be polite to each other while they determine how they fit into the group and how they will work together.

In the Storming stage, they may have dissension, irritation over lack of progress and general impatience.

In the Norming stage, the team members learn to appreciate their differences and work through conflict productively.

In the Performing stage, the team members have developed a trust and this is where they are the most creative.

Measuring Performance

One of the most widely used QI methods is the PDCA, which stands for Plan, Do, Check, and Act. As mentioned earlier in the term, this was originally developed in the 1920’s by Walter Shewhart and popularized in Japan by Deming (the Japanese subsequently called it the Deming cycle).

The PDCA method has the benefit of being conceptually simple, easily taught, and having few steps.

To generate ideas and data for monitoring one aspect of a process, TQM teams can use the PDCA tool, asking participants to plan, do, check, and act. By getting the team members involved and educated in using PDCA, managers can empower their team to create solutions to problems and then evaluate effectiveness.

• The Planning phase consists of data collection and analysis to propose a solution for an identified problem.
• The Do, or implementation phase, tests the proposed solution.
• Checking monitors the effectiveness of the solution over a period of time.
• The final phase, Act, formalizes the changes that have proved effective in the Do and Check stages.

The PDCA is a cyclic process so as one problem is resolved, another problem is investigated again with the planning stage and proceeding to action.

Some newer improved PDCA models also include FOCUS-PDCA model and the Langley, Nolan, and Nolan Model for Improvement. With these models they changed the “check” to “study” from the PDCA acronym to indicate a learning cycle as opposed to an inspection portion of the cycle. Therefore, you may see either PDCA or PDSA sometimes used interchangeably although they are slightly different. All of the models abide by the principle of having teams use continuous improvement.

The Lean Method

Some healthcare facilities have begun using lean or Six Sigma in recent years.  A lean project is one that involves analyzing a process to determine which steps add value and which steps do not add value.  Six Sigma is data-driven performance improvement that attempts to make a process defect-free.  The phases of a Six Sigma DMAIC Improvement Model are Define, Measure, Analyze, Improve, and Control.

If a Lean-Six Sigma project is conducted in an emergency registration department, the project would start by examining the process steps.  First activities that do not add value or those that include wasted steps would be streamlined or eliminated.  Then the new process would be examined to determine if there were defects, such as computer input errors, duplicate patient record numbers, or other items.  The source of these defects would be identified and the process would be modified to eliminate them.

Performance Improvement Tools

There are a variety of tools and techniques used to help with process or performance improvement.

The brainstorming technique was developed by an advertising executive who recognized the need for imagination and creative spirit for successful advertising campaigns. Brainstorming has since been widely used to solve thousands of problems in such diverse industries as banking, engineering and design, marketing, education, government, programming, as well as healthcare. It can be used in conjunction with other CQI tools and is a great way to get new CQI processes started or to revive stalled initiatives.

Another problem-solving tool is by using a decision matrix. Using this method, a PI team lists the criteria for a good outcome and then rates each possible alternative for the solution to the problem. Again, this can be used after some initial brain storming of possible solutions. Each alternative is identified, and each is rated on the extent to which it fulfills the desired outcome criteria. Finally, the criteria ratings are multiplied by the choice ratings and totaled. The alternative with the highest total is considered to provide the best combination of characteristics that meet the most important criteria.

A decision matrix is a good tool to use when there are several ideas for how a process can be changed.

Flowcharts are used to depict all levels of operations from whole systems that involve many departments and people.  Types of flowcharts may include a systems flowchart, a flowchart of the work of one person or procedure, and operations or procedure flowchart.

The systems flowchart depicts the flow of data through all or part of the system, the various operations that take place within the system, and the files that are used to produce various reports or documents.

The standard symbols are used to construct flowcharts. I have put the symbols in the table of contents for this week. When unique symbols are used, their meaning should be identified in a key or legend on the flowchart.

Use a flowchart any time you need to understand how an existing process affects the quality of the outcome that process is meant to generate. For example, if a HIM department has a problem with delinquent records, a flow chart might reveal unnecessary delays and redundant steps in the record completion process that contribute to delinquencies. Flow charts are frequently used not only in PI but in management, to identify problem areas within departments.

The cause and effect diagram is the brainchild of Kaoru Ishikawa, who pioneered quality management processes in the Kawasaki shipyards, and in the process became one of the founding fathers of modern management. The cause and effect diagram is used to explore all the potential or real causes (or inputs) that result in a single effect (or output). Causes are arranged according to their level of importance or detail, resulting in a depiction of relationships and hierarchy of events. This can help you search for root causes, identify areas where there may be problems, and compare the relative importance of different causes.

Causes in a cause & effect diagram are frequently arranged into four major categories. While these categories can be anything, you will often see:

• manpower, methods, materials, and machinery (recommended for manufacturing)
• equipment, policies, procedures, and people (recommended for administration and service)

This diagram is also known as the fishbone diagram because it was drawn to resemble the skeleton of a fish.

The affinity diagram is an improvement tool that is used to organize detailed information into more general categories.  It is a good improvement tool to use to sort solutions or problems into similar categories.

The affinity analysis helps an improvement team brainstorm and organize information based on natural relationships (or affinities).  The ideas determine the categories or groupings, rather than establishing pre-determined groups.  This method can be helpful when issues are large or complex, when consensus is desired, or when creative ideas are needed.

A workflow diagram is an improvement tool used to visually represent the movement of people, materials, paperwork or information within a process.  It is a tool that will help visualize the movement of activity within a process.

The workflow diagram is a visual representation of the sequential steps of a process.  It shows the movement of people, materials, paperwork or information within a process visually.  It allows a demonstration the general relationship of activities within the process.  This tool is useful for identifying waste in a process.

Another tool is process reliability.  When attempting to improve the reliability of a healthcare process, it is helpful to simplify the process, standardize process steps, reduce reliance on memory, and improve information access.

Question 8

Search the APUS library and find a journal article that discusses the process improvement tools and strategies as it relates to the quality, safety or value of healthcare services, or find a journal article that discusses an actual improvement project that was completed within a healthcare organization.  Discuss the tools and strategies used and identify any recommendations that will improve the process.

Week 8 Lesson:

Improving Patient Safety

Risk management is an important foundation towards improving patient safety.  Risk management is the reduction of unplanned or unexpected financial loss to an organization. It deals with avoiding injury during hospitalization. Risks can also occur to visitors and employees.

Risk management should prevent and control:

1. Patient injury
2. Malpractice claims
3. Malpractice issues
4. Employee injury and claims

When an injury occurs or error is made, an incident report must be completed.  An incident is any occurrence in a medical facility that is inconsistent with accepted standards of care. An incident can be an error in medication dosage given to a patient, or a patient slipping and falling on a wet floor. It can be a diabetic patient reporting they were fed a non-diabetic diet at the evening meal, or it can be a patient receiving the wrong blood type during a transfusion. The incidents of more severe consequences are called sentinel events.

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk of these occurring. Serious injury specifically includes loss of limb or function. These events are called “sentinel” because they signal the need for immediate investigation and response.

The main difference between incidents (or occurrences) and sentinel events is in the level of severity. Basically, a sentinel event is or has the capacity to be life threatening. You may hear incidents and sentinel events used interchangeably in some facilities but in stating that an incident is a sentinel event you are actually declaring the level of severity to require immediate action.

The Joint Commission requires organizations to conduct a root cause analysis after a sentinel event.  Examples of sentinel events are an unanticipated death, major permanent loss of function associated with a healthcare-associated infection, suicide within the facility, an abduction within the facility, rape of a patient or resident, surgery on the wrong patient or wrong body part or wrong procedure, and unintended retention of a foreign object after surgery.

A root cause analysis is conducted during a failure mode and effects analysis project to identify what would bring about a critical process failure.

The Joint Commission requires facilities to periodically conduct proactive risk assessments.  The Failure Mode and Effects Analysis (FMEA) is a tool to use for this.  The FMEA looks at processes with a high risk of failure and improves the process to reduce this risk.

When a sentinel event occurs, a facility must investigate, analyze, and determine improvements to be made to prevent the event in the future. Root cause analysis is the process used to identify the cause of the event. The focus for improvement should be on organizational and clinical systems and processes, not on the person or people involved in the sentinel event. Below is a suggested framework for conducting a root cause analysis:

The Quality Role in Value-Based Reimbursement

Value-based reimbursement is a fairly new strategy being used.  It is intended to encourage increased quality of care by creating payment incentives and penalties.  One of the earliest strategies were penalties for hospital-acquired conditions.  Healthcare facilities also need to focus on decreasing readmissions for the same condition within a specific time period, since there will be reimbursement penalties.  There are also efforts by CMS to link payment rates to quality measures that are reported.

Using Dashboards

A dashboard is a set of performance measures that are displayed in a format that is visually easy to understand, often on one screen using charts and graphs.  It is frequently used by administration to monitor important statistics.  It should be updated to the minute when displayed, though some may display data updated each 24 hours.  Besides patient care indicators, these are likely to show labor statistics as well, since that is a major portion of healthcare expenditures.  The dashboard can help balance patient care needs with staffing needs on a daily basis.