HCS/588 Version 5 / 1
Weekly Overview
Week One
Overview
Quality in the health care industry is based on the same concepts in other industries. However, quality in health care is defined not only by the direct consumer, but also by the clinician, regulator, payer, and organization. All these stakeholders demand high quality of care, and reimbursement for services provided is now based on meeting or exceeding quality measures. The key indicators for quality are established by the organization’s mission and vision as well as by meeting state, federal, and other regulatory requirements. The assessment of an organization’s improved performance is based on the measurement of these indicators through both manual and computerized methods. System thinking and understanding the dynamic complexity of the organization with respect to day-to-day operations with a focus on patient safety and quality outcomes are also considered elements of successful performance enhancement.
What you will cover
1. Organizational quality
a. Analyze the purpose of quality management in the health care industry.
1) Quality services provided to the recipient of the care or service has various perspectives and understandings from the various stakeholder groups
a) Patients' definitions, perspectives, and expectations of quality of care
(1) Based on service received, the patient determines whether he or she would recommend that provider's service to others
(2) Patient’s rating of service
(3) Depends on whether medical concerns have been positively resolved
(4) Whether they were involved in the decision-making process regarding their care
b) Family members' definitions, perspectives, and expectations of quality of care
(1) The service received by family members and the perception of that service determines whether they recommend that service to others
(2) Family members rate service received while visiting the facility or provider (hospital, clinic, outpatient center, physician's office, and so on)
(3) Based on perception of care provided, family members determine whether they would use the provider
(4) Based on ratings on external websites such as Healthgrades, family members decide if they will use that provider in the future
c) Clinicians’ definitions, perspectives, and expectations of quality of care
(1) Based on the patient’s admitting diagnosis, and if the medical problem was resolved
d) Payers’ definitions, perspectives, and expectations of quality of care
(1) The patient’s quality outcome met expectations and established guidelines per the insurance policy and achieved these goals with appropriate utilization of resources (no under or over utilization)
e) Accrediting and regulatory organizations' definitions, perspectives, and expectations of quality of care
(1) Provider meets established compliance requirements to ensure safety expectations are met
(2) Provider routinely submits reportable metrics, as required
2) Quality management
a) Organizational strategic and operational focus on patient care, safety, and clinical outcomes expectations
b) Organization's quality improvement plan
(1) Strategic and operational objectives
(2) Those responsible to develop and maintain the plan
(3) Key stakeholders who must actively participate
(4) Quality improvement committee
(5) Flow of information and metrics to and from quality improvement committee
c) Quality leadership and respective support staff's role in managing and supporting improved quality outcomes
(1) Establish required quality outcome measures reportable by patient care services
(2) Establish guidelines to collect, analyze, and report required metrics
d) Organizational Improvement (Lean) leadership's role in supporting quality management
(1) Establish specific metrics for monitoring outcome measures based on improvement opportunities
e) Organizational executive leadership's role in supporting quality management
(1) Establish the organization's goals and objectives, based on its strategic plans, for measuring, analyzing, and reporting quality outcome metrics
(2) Develop specific leadership accountability plans to ensure that quality of care focuses on patient safety
(3) Develop specific plans to ensure regulatory and accrediting organization's requirements are met as mandated
f) Organizational leadership’s role in supporting quality management
(1) Develop specific plans to ensure that respective areas of responsibility support and align with the organization’s quality improvement plans
3) Quality improvement
a) Measurement-related concepts
(1) Structure: focuses on individuals who provide care and the settings where care is delivered
(2) Process: refers to what takes place during the delivery of care
(3) Outcome: measures the outcome to determine whether health care goals were achieved
b) Criteria and standards
(1) Specific attributes to assess quality: clearly defined data elements
(2) Sources: revolves around the strength and validity of scientific evidence
c) Quality tools
(1) FOCUS PDCA
(a) F = Find a process to improve
(b) O = Organize a team that knows the process
(c) C = Clarify current knowledge of the existing or redesigned process
(d) U = Understand the variables and causes of process variation in the process
(e) S = Select the process improvement and identify the potential action
(f) P = Plan to carry out the project
(g) D = Do the plan
(h) C = Check whether the plan is working
(i) A = Act on what you learned or carry out additional improvement cycles
(2) Failure mode and effects analysis
(a) Examines potential problems and their causes and predicts undesired results
(3) Control charts
(4) Fishbone diagram
(5) Pareto chart
(6) Benchmarking
d) Implication of quality outcomes
(1) Mortality rate
(2) Complication rate
(3) Medication errors
(4) Patient falls
e) Knowledge transfer and spread techniques
(1) Rapid-cycle testing
(2) Institute for Health Care Improvement Breakthrough Series Model
(a) Health care organizations working together through collaboratives to improve clinical and operational areas
b. Evaluate strategies for meeting regulatory and accreditation standards within health care organizations.
1) Regulation and accreditation
a) Organizational certification for providing selected services
(1) The Joint Commission: http://www.jointcommission.org/
(2) Comprehensive Accreditation Manual for Long Term Care: http://www.pohly.com/books/comprehensiveaccreditationlong.html
(3) Residential Care and Assisted Living Compendium- 2007: http://aspe.hhs.gov/daltcp/reports/2007/07alcom1.htm
(4) National Committee for Quality Assurance (NCQA): http://www.ncqa.org/
b) Governmental licensure for providing selected services
(1) State and local departments of health
(2) U.S. Department of Health and Human Services: http://www.hhs.gov/
2) Process and content of accreditation
a) Observation
b) Interviews
c) Audits and tracers
d) Review of written documents
e) Surveys
f) Derived information
3) Scope and use of accreditation
a) Hospitals
(1) Standards set by Centers for Medicare & Medicaid Services (CMS)
(2) Compliance monitored by Joint Commission (JC) or state's Departments of Health if institution is not JC accredited
(3) Core measures used to monitor the process related to issues on quality of care
b) Insurers
(1) Standards set by CMS
(2) Compliance monitored by NCQA
(3) Performance monitored through use of health effectiveness data and information set measurements
c) Nursing home
(1) Standards set by CMS
(2) Long-term care evaluation and accreditation program
d) Ambulatory care
(1) Outpatient surgical services
(2) Various medical clinics
(3) Outpatient rehabilitation services
4) Strategies to meet regulatory and accreditation standards in health care organizations
a) Strategy one
(1) Management commitment
(a) The role of the health care quality coordinator
(b) The role of the quality council
(c) Mission and vision
(2) Allocating resources
(a) Quality training
(b) Monitor compliance with standards
(c) Identify opportunities for improvement
(d) Initiate and coordinate improvement projects
(e) Disseminate the concept of quality
(3) Organizational structure
(a) Initiate planning for quality initiatives
(b) Set organizational standards for quality
(c) Communicate standards to the organization's employees
(d) Monitor compliance with standards
(e) Facilitate performance and productivity measurements
(f) Coordinate all committees related to quality
(g) Develop the organization's quality program document and annual plan
(h) Coordinate an effective system for credentialing and recredentialing the organization's practitioners
b) Strategy two
(1) Communicating a vision and strategy
(2) Empowering employees to act on the vision and strategy
(3) Generating short-term wins
(4) Consolidating gains and producing more change
c) Strategy three
(1) Initiate continuous monitoring of regulatory and accrediting agencies
(a) Focus on regulatory strategies to promote and improve patient safety and quality outcomes
(b) Legislative mandatory compliance with standards
(c) Enhancing incentives to comply
(d) Use of outcome-based standards
(e) Incorporating a continuous improvement requirement
(f) Determining compliance with standards
(g) Combining compliance and continuous improvement objectives
(2) Monitor the stakeholder perspective on regulatory approaches.
(a) Evaluation of accreditation processes
(b) Views on regulatory approaches
(c) Regulatory compliance and enforcement
c. Analyze how performance and quality measures are aligned to the organization’s mission, vision, and strategic plan.
1) Review and evaluate the organizational goals and the strategic plan
2) Identify and evaluate external benchmarks beneficial to setting organizational goals
a) CMS' Hospital Compare website
b) The Joint Commission
c) National Database of Nursing Quality Indicators (NDNQI)
d) Healthgrades
e) The Commonwealth Fund
f) Commercial vendors such as Truven Health Analytics, Premier, VHA, etc.
g) Medical Group Management Association (MGMA)
h) Ambulatory Surgery Center Association (ASCA) Benchmarking
3) Determine what quality measures are to be monitored
a) Regulatory required monitoring (local, state, and federal)
b) Other monitors: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), value based purchasing, etc.
c) Processes that are problem-prone for the organization
4) Ensure that quality and performance measures monitor processes align with the goals of the facility
a) Review monitors with senior leadership to ensure alignment with the mission and strategic plan
(1) Adjust and amend as necessary
5) Develop tools to measure and monitor progress towards goals
a) Surveys
b) Checklists
c) Microsoft® Excel® spreadsheets
6) Develop reporting structure within the organization to disseminate progress and results.
a) Committee reports
b) Data sent to outside organizations
c) Celebrate successes within the organization
d. Identify criteria and tasks for developing quality improvement plans.
1) Define quality improvement plan
a) It is an organizational work plan for a health care organization's clinical and service quality improvement activities
b) Developed by executive and clinical leadership
c) Approved by the organizations governing body
d) Generally outlines the specific clinical focus areas
e) Developed as an outgrowth of the evaluation of the previous year's QI activities, organizational priorities and organizational program requirements.
2) Determine elements of an Effective QI Plan
a) Describes the organizational mission, program goals, and objectives
b) Defines key quality terms/concepts
c) Reports how QI projects are selected, managed, and monitored
d) Delineates training and support requirements for staff
e) Describes quality methodologies and tools/techniques to be utilized
f) Summarizes communication plans for QI activities and processes
g) Outlines measurement and analysis
h) Describes evaluation/quality assurance activities that will be utilized to determine the effectiveness of the QI plan’s implementation
3) Identify areas for improvement
a) List and prioritize QI projects aligned with the organization's strategic and operational plans
b) Define key program goals and objectives for the current year
c) Determine quantifiable goals and objectives
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