1. Delmar Learning Copyright © 2003 Delmar Learning, a Thomson Learning company Nursing Leadership & Management Patricia Kelly-Heidenthal 0-7668-2508-6

2. Delmar Learning Copyright © 2003 Delmar Learning, a Thomson Learning company 2 Chapter 19 Managing Outcomes Utilizing an Organizational Performance Improvement Model

3. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company3 Objectives  Upon completion of this chapter, the reader should be able to: Articulate major principles of performance improvement (PI). –Customer identification –Need for participation at all levels –Focus on improving the process, not criticizing individual performance Describe how performance improvement affects the patient and the organization.

4. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company4 Objectives Identify how data is utilized for PI (i.e., time series data, Pareto charts). Describe the difference in risk management and PI. Describe how the principles of PI are operationalized in the organization.

5. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company5 History of Quality Assurance  Quality assurance (QA) emerged in health care in the 1950s as an inspection approach to ensure that minimum standards of care existed in health care institutions.  With its emphasis on “doing it right,” some thought that QA was very punitive and did little to sustain change or proactively identify problems before they occurred.

6. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company6 Total Quality Management  Total quality management (TQM) began in the manufacturing industry, when W. Edwards Deming and Joseph Juran consulted with Japanese corporations in the 1950s.  The end result of this method was to satisfy customers rather than just “doing it right.”  This approach became integrated in the health care industry in the 1980s.

7. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company7 General Principles of Performance Improvement  Recognize customers and their needs.  Involve all organization members in the process.  Make decisions supported by data.  Continually do things better.

8. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company8 Who Are the Customers in Health Care?  A customer is anyone who receives the output of your efforts.  Customers can be internal, within the organization.  Customers can be external, outside the organization.

9. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company9 Empowerment of Everyone in the Organization  Each person must feel that he or she participates.  Each takes responsibility for the success or failure of an organization.  Each takes an active part in developing new ways of doing business and securing new customers.  Each trusts that his or her efforts are valued.

10. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company10 Who Participates in the Improvement Process?  All staff members should be encouraged to participate.  All those involved with or affected by a goal or process should participate.  Staff can participate on individual, unit, or organizational levels.  Participants should include point-of-service staff, i.e., those workers on the front line who do the direct work involved in the process being changed.

11. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company11 Improvement of the Health Care Process  A process is a set of causes and conditions that repeatedly come together in a series of steps to transfer inputs into outcomes.  All processes have inputs, steps, and outputs.

12. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company12 Improvement of the System  A system is an interdependent group of items, people, or processes with a common purpose.  Outcomes in a system can be improved by examining not only processes, but also the relationships between processes.  Correct gathering and interpretation of data is an essential component of continuous improvement.  Shewart cycle: Shewart developed the concept that improvement is a cycle; it is continuous because it is linked to customer needs and judgments.

13. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company13 Implications for Client Care  Quality improvement for patient care can be measured by the overall value of care.  Value is determined by outcomes and cost.  Outcomes can be clinical/functional (did the patient live?) or related to patient satisfaction.  Cost can be direct or indirect.  Goal: increase quality outcomes, reduce cost.

14. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company14 Methodologies for Improvement  Plan-do-check-act (PDCA) cycle  FOCUS methodology

15. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company15 Storyboard: A Method for Sharing Work with Others  It takes the major steps in the improvement methodology and visually outlines the progression of each step.  It can be displayed on a chart in a high traffic area of the organization to inform other staff of the improvement efforts underway.

16. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company16 Problem Identification  A clear, identified mechanism by which front-line staff can suggest improvement opportunities they see in their day-to-day work should be established.

17. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company17 Improvement Strategies  Benchmarking: measuring organization performance with that of the best performers  Regulatory requirements: measuring organization performance against standards from regulatory/accrediting organizations  Sentinel event: an unexpected occurrence involving death or serious physical or psychological injury to a patient, requiring an investigation and possible change to the organization’s process

18. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company18 Balanced Scorecard  In order to assure value in care, measurement of progress has to be balanced.  Clinical value compass

19. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company19 Patient Satisfaction Data  Accumulated through questionnaires, focus groups, and postcare interviews  Helpful if data can be compared/benchmarked against data of similar organizations  Time series data Allows a quality improvement team to see change in quality over time Time series chart used to look for trends, shifts, and unusual data

20. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company20 Charts  Pareto  Histogram  Flow diagrams  Fishbone charts  Pie charts

21. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company21 Principles in Action in an Organization  Organizational Structure Encourage accountability. Maximize communication. Communicate and focus priorities at all levels.

22. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company22 Organizational Process  Process: the mechanisms used to accomplish the organization’s mission and goals  Evidence-based plans of care, such as clinical pathways, standardized protocols, and clinical guidelines  Benchmarking tools

23. Chapter 19Copyright © 2003 Delmar Learning, a Thomson Learning company23 Outcomes  Outcomes are a measurement of the patient response to structure and process.  Outcomes: Measure actual clinical progress Can be short-term or long-term  Outcome data can be helpful in identifying opportunities for improvement.