Quality Management in Healthcare

Managing quality and patient safety through a combined proactive and reactive approach

When a medical institution aspires towards excellence and patient safety, quality management proves to be a key factor essential to the process.
It goes without saying that there are countless risks in the healthcare system and that it is always a priority to minimize these. There is nothing new about that. However, this article takes the innovative stance that the inevitable reactive approach to negative events is not the only method which can be used to reduce risks and therefore enhance quality. We will examine how a combined approach with an equal emphasis on preventative measures can be a highly effective management pattern which breaks down barriers and cuts through conventions.

So what exactly are we trying to achieve?

Patient safety is defined as a healthcare discipline primarily involving the reporting, analysis and prevention of medical or process errors which can lead to adverse healthcare events.

Quality in public health is understood to be the degree to which policies, programs, services and research for the population increase the desired healthcare outcome and conditions in which the population can be healthy.

Despite a general consensus that everyone wants to achieve the goal of optimum quality and patient safety, why is this target so difficult to reach?

Healthcare institutions invest enormous efforts and resources in order to improve quality and patient safety, but often fail to reach that aspired “ultra-safe” environment. The following factors have been identified as typical system barriers in striving towards this goal:

1. The error reporting processes are often timeconsuming and confusing. Errors are often misinterpreted as routine problems typical of a hectic and complex environment.
2. Furthermore, the general lack of confidentiality discourages staff, who are already battling to overcome a feeling of shame and arrogance, from having the courage to participate in the error reporting process. It is only human to find it difficult to admit one‘s mistakes and this is exasperated nowadays by the realistic fear of malpractice lawsuits, making it politically and financially intolerable to bear the burden of accidents.
3. As if this was not enough, there is a tendency in healthcare organizations to use the information collected from reported errors to just take punitive action instead of investing it wisely in system improvements (referred to as a “culture of blame”). This is hardly a motivating factor.
4. Given the interdisciplinary nature of healthcare and the need for cooperation among those who deliver it, teamwork is critical in order to ensure patient safety. Collaboration and communication are the name of the game. There is currently a very real lack of specific training and culture to encourage team work as a priority. When investigating the root cause of a problem, medical staff find it difficult to see the bigger picture and ignore the consequences that stem from processes across other departments or along the whole value chain (external suppliers, internal department).
5. Excessive professional rules and regulations are a negative side effect of excellence. Generated by the accumulation of layers that are intended to improve safety, we end up with an overly complex and burdensome system.The frequency of new rules and guidance materials are often high and is poorly aligned with internal system updates. Old rules and guidance materials are often not discarded or removed, consequently making it difficult to comply with the latest applicable regulations.

To summarize the above, an environment with technical and organizational complexity and process opaqueness obscures the route to excellence and makes it easy to overlook risks to patients.

The legislators in the U.S. are already “reacting” to this situation by taking a “proactive” approach to “encourage” participants to embrace change:

The “Patient Protection and Affordable Care Act” is a new healthcare regulation which, when it comes into force in the U.S.A, will intensify the need to overcome the aforementioned barriers.
Before we consider how healthcare companies can adjust to change, let us briefly examine the impact which this new legislation will have on the medical sector:

• Payment for services will be directly linked to quality – a value-based purchasing program for hospitals will link Medicare payments to quality performance on common, high-cost conditions such as cardiac, surgical and pneumonia care.
• Plans providing extra benefits to healthcare institutions must give priority to cost sharing reductions, wellness and preventative care prior to covering benefits not currently covered by Medicare.
• Incentives for physicians to report Medicare quality data – physicians will receive feedback reports beginning in 2012. Long-term care hospitals, inpatient rehabilitation facilities and hospice providers will participate in value-based purchasing with quality reporting starting in 2014, with penalties for non-participating providers.
• Support for prevention and public health innovation – A new CDC program will help state, local, and tribal public health agencies to improve surveillance for and responses to infectious diseases and other important conditions. An Institute of Medicine conference on pain care will evaluate the adequacy of pain assessment, treatment and management; identify and address barriers to appropriate pain care; increase awareness; and report to Congress on findings and recommendations.
• The government will make substantial investments to improve the quality and delivery of care and support research to inform consumers about patient outcomes resulting from different approaches to treatment and care delivery.

These new conditions have been a major incentive to Tefen to develop an innovative methodology which will assist healthcare organiziations to prepare for the above changes, while simultaneously helping them to achieve excellent quality and patient safety.

The benefits of a combined proactive and reactive approach in risk management

Based on the current, traditional approach, healthcare systems typically wait until an adverse event occurs during medical treatment and then react to this. The organization then conducts “Lessons Learned Exercises” based on the event that occurred – initiating action and “repairing” projects as a follow on to lessons learned from previous adverse events.
These actions and projects usually contain “local fixing” acts which address the safety issues that caused the event. Apart from this “reaction”, the organization usually continues its customary daily routine until the next unforeseen problem or chain of problems occurs.

“Now think about the things you‘ll do tomorrow if an adverse event occurs due to something involving your area of responsibility, then go back to your office and do it today”.

The less frequent and more difficult method to implement is the preventative approach. A proactive stance encourages an organization to take action now in order to prevent the next adverse event from happening. Revealing the risk factors before they cause an accident is not an easy task.

A combination of the two above mentioned approaches was found to be most suitable for the daily reality of healthcare systems. This combination offers more benefits than either approach on its own.

“P&R methodology – 4 steps to practical application of combined and reactive approach”

Step one – analyze current position on 2 axes diagram.

Initially, the organization should analyze its current position on the 2 axes diagram shown below.

The classic total quality management methodology (TQM) used for this article forms the foundation for the P&R methodology developed by Tefen in order to reach excellence in quality and patient safety and overcome key barriers by combining proactive and reactive approaches.

In order to perform this analysis, use TQM factors which are measured by TQM tools according to the following table:

Step two – How do we know what is going to cause the next accident…?
We need to identify and define inevitable/expected events, such as infections. In order to pinpoint risks which are hard to recognize, hospitals should analyze processes and the customer-supplier value chain etc. To allow this step to be repeated continuously, organizations should systematically collect data, regularly monitoring and integrating information from a variety of safety hazard sources. They can encourage staff to report errors by ensuring anonymity. This data should be used only for safety analysis and not for punitive action. By comparing aggregated data and benchmarks with national data sets, a point of reference can then be created. Most hospitals know they should identify events – they need a tool to do so – something such as the UHC-PSN tool.

Step three – means of actions and measurements
This is the time to define a proactive approach for prevention of the inevitable/expected events and to derive specific means of action. This should be backed up by designing a methodology to measure the efficiency of defined safety solutions to known problems. Possible TQM tools for this include audits, surveys, control charts, brainstorming and fishbone diagrams. This should be a continuous process aimed at eliminating potential problems.

Step four – a prioritizing policy
The policy should equally prioritize issues with quicker and more apparent outcomes as well as longer and less apparent processes. Classic TQM implementation usually requires long-term resource allocation at the expense of short-term, urgent resource requirements. Prioritizing both long and short term activities may help you explain the value of the long-term, less apparent benefits of a process to the staff, thus increasing their motivation and understanding of the final goals.

The innovative methodology described above has been designed by Tefen, and is relevant to any healthcare organization wishing to overcome barriers in order to thoroughly improve and manage quality and patient safety.

Expert opinion by Dr. Hoffmann regarding quality and patient safety in healthcare

Peter R. Hoffmann, M.D., M.Phil., is currently a Clinical Professor of Medicine at the University of Texas Southwestern Medical School and formerly the Chief Quality Officer and Senior Vice President for Quality of Care at Parkland Hospital, Dallas, Texas, where his activities included overseeing quality of medical care, patient safety and risk management, infection prevention activities and utilization management.

Quality and patient safety – a broader insight

Dr. Hoffmann uses the terms “quality of care” and “patient safety”, defined at the beginning of this article, in a broad sense. In his opinion, “patient safety” not only deals with medical errors which lead to adverse events, but also includes process problems which actually cause most of the harm to patients. For example, a patient may have received the wrong medication, but what were the steps involved in getting that medication to the patient? This means that, in order to detect the root cause of an adverse event, the organization must analyze the processes which led to that event and then address the factors which should and could have prevented harm from reaching the patient. In contrast, “quality of care” refers to improving health outcomes.

A common quality and patient safety definition released by the Institute of Medicine employs the acronym S.T.E.E.E.P:

• Safe care – avoiding injuries to patients caused by treatments intended to help them.
• Timely care – reducing wait times and harmful delays for patients.
• Effective care – making patients better.
• Efficient care – avoiding waste, in particular waste of equipment, supplies, ideas, energy, and resources in general.
• Equitable care – providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic
  location and socioeconomic status.
• Patient-centered care – providing care that is respectful of and responsive to individual patient needs, while ensuring that patient values guide all clinical decisions.

These categories lead to measurable parameters that can help an organization detect whether or not it is improving its quality and patient safety.

Additional barriers to achieving quality and safety excellence and the difficulty of identifying problems and achieving cultural change

Nowadays, most hospitals do not dedicate enough time and resources to tracking problems, analyzing the causes of adverse events or directly interviewing patients to find out “what is bothering them”.

Despite the efforts of many hospitals in the U.S.A to build internal quality departments, Dr. Hoffmann comes to the conclusion that “We still don‘t do as good a job in improving the quality of care as we should. Hospitals often don‘t identify significant problems, or don‘t identify them quickly enough, due to insufficient staffing, failures in the problem identification mechanisms, difficulties prioritizing the problems, an inability to examine the root causes of problems and most importantly, failure to implement change. Medical staff understandably find it challenging to perform problem analysis in addition to their primary role – taking care of patients”.

According to Dr. Hoffmann, the barriers in achieving excellence as specified in this article are of real and current relevance to the healthcare sector and he elaborates: “Not only do we have an inadequate error reporting system but we have difficulty in easily identifying errors”. For example, although it is simple to detect when the wrong medicine is administered, failures or near misses caused by process errors are more difficult to identify.

Another barrier to improving quality and patient safety as stated by Dr. Hoffmann, is the difficulty in achieving cultural change. Cultural change is needed when a problematic factor is identified and needs to be changed. Organizations find it particularly challenging to alter staff routines and habits and ultimately maintain these changes in the long term.

Which action can a healthcare organization take today?

According to Dr. Hoffmann, “Organizations should start assessing their own performance, and they should have done it yesterday”. If we use the example of the U.S., where change in legislation has resulted in a wake-up call, hospitals should begin preparing for quality audits in which failure or success will have real consequences on the organization, such as their Medicare billing.

Because of the difficulty in performing root cause analysis in addition to hectic daily routines, Dr. Hoffmann suggests hospitals use an external service provider to help build an internal quality assessment and improvement department.

Dr. Hoffmann explains that most healthcare organizations do not yet use a proactive approach. In order to implement change, companies must combine traditional reaction with preventative measures. In addition, Dr. Hoffmann believes that implementation and sustainment of the changes will pose a challenge as this requires skills more akin to a business environment than a healthcare center: project management, constant measurement, monitoring and great attention to feedback and communication.
On the other hand, we should never forget that, while we are demanding these skills, the primary function of a health care center is the care of patients, and staff must have the time, focus, and medical expertise required to do that.

The first step that hospitals need to undertake is to identify their problems and systematically assess their performance as detailed in the steps suggested in this article. In order to do so, Dr. Hoffmann recommends that organizations develop a suitable and sustainable reporting system for errors or near misses and start small, by focusing on the simple things that you can fix, improve or prevent in the foreseeable future, thereby showing your staff how implementation of change can be realized, monitored and sustained.

By Thomas Guglielmo, President, Tefen USA
Tamar Mass, Consultant, Tefen Israel

[Ref 1] Critical factors and performance measures of TQM, Jaideep Motwani |
[Ref 2] ASIAS: The Power of Data, Peggy Gilligan
[Ref 3] American Hospital Association | http://www.aha.org/advocacy-issues/quality/index.shtml 
[Ref 4] The Department of Health and Human Services is the United -HHS States government
https://www.hhs.gov/
[Ref 5] Exploring the causes of adverse events | http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1281594/?tool=pmcentrez
[Ref 6] Processes that caused adverse events a more urgent problem than human error (2011)
http://web.ebscohost.com/ehost/detail?vid=3&hid=21&sid=5778bae0-c164-4306-a26d-3bf063690ea
4%40sessionmgr15&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=cmedm&AN=21714399   
[Ref 7] Physicians Want To Learn from Medical Mistakes but Say Current Error-reporting Systems Are Inadequate
[Ref 8] System Barriers to Achieving Ultrasafe Health Care | http://annals.org/article.aspx?articleid=718374
[Ref 9] The Patient Protection and Affordable Care Act |
[Ref 10] Hospitals in pursuit of excellence |
[Ref 11] http://www.ynet.co.il/articles/0,7340,L-4202290,00.html