Instructor’s Manual Chapter 1: Concepts of Quality Management

Healthcare Quality in the United States: A Snapshot In 2003, U.S. healthcare expenditures totaled $1.679 trillion and accounted for 15 percent of the gross domestic product (U.S. Census Bureau 2005; OECD 2005). In 2003, the United States spent more on healthcare, as measured by percentage of gross domestic product, than did any other country in the world; yet of 30 OECD countries, the United States ranked 22nd in male life expectancy at birth and 23rd in female life expectancy at birth, and 26th in infant mortality rate (OECD Health Data 2005). 55 percent of those surveyed are dissatisfied with the quality of healthcare in the United States and 40 percent responded that in the past five years quality of care has gotten worse (Kaiser Family Foundation et al. 2004). Adult Americans received 54.9 percent of recommended preventive care, acute care, and chronic care (McGlynn et al. 2003). Sources: See References in Chapter 1 of Applying Quality Management in Healthcare, 2nd Edition, by D. L. Kelly.

Healthcare Quality in the United States: A Snapshot Between 44,000 and 98,000 deaths per year in the United States have been attributed to preventable medical errors, making medical errors the eighth leading cause of death—causing more deaths than motor vehicle accidents, breast cancer, or AIDS (Kohn, Corrigan, and Donaldson 1999). Taking into account direct costs (e.g., healthcare costs) and indirect costs (e.g., lost income, lost productivity, and disability), preventable medical errors cost the United States between $17 billion and $29 billion a year (Kohn, Corrigan, and Donaldson 1999). In 2003, more than 45 million Americans, or 15.6 percent of the 290 million U.S. residents at the time, had no health insurance (U.S. Census Bureau 2005). In the United States, persons between the ages of 45 and 64 years with the lowest levels of education have 2.5 times the mortality rates of those with the highest levels of education, Poverty accounts for 6 percent of the nation’s mortality (McGinnis et al. 2002). Sources: See References in Chapter 1 of Applying Quality Management in Healthcare, 2nd Edition, by D. L. Kelly.

Quality Assurance threshold threshold better worse better worse Source: James, B. 1989. Quality Management for Healthcare Delivery, 37. Chicago: The Health Research and Educational Trust of the American Hospital Association. Reprinted with permission.

Quality Improvement better worse better worse Source: James, B. 1989. Quality Management for Healthcare Delivery, 37. Chicago: The Health Research and Educational Trust of the American Hospital Association. Reprinted with permission.

Instructor’s Manual Chapter 2: Three Principles of Total Quality

To find out about patient safety in the accreditation process, visit www.jointcommission.org

To find out about the specific safety practice endorsed by The Leapfrog Group, visit www.leapfroggroup.org

Instructor’s Manual Chapter 3: The Manager’s Toolbox

Shewhart Cycle Do Plan Check Act

To find out about the Picker Institute’s dimensions of care, visit http://nrcpicker.com/

Dimensions of Care Respect for patients’ values, preferences, and expressed needs Coordination and integration of care Information and education Physical comfort Emotional support and alleviation of fear and anxiety Involvement of family and friends Transition and continuity Access to care Source: http://nrcpicker.com.

Flowchart Symbols Begin/End Action step Decision

Simple Flowchart Example Start Alarm goes off Too tired? yes Hit snooze alarm no Get out of bed End Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Deployment Flowchart Example Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Workflow Diagram Example Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Lead Time Analysis Grid Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Fishbone Diagram: Four Ps Problem People Procedures Policies Plant Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Fishbone Diagram: Four Ms Manpower Materials Methods Machinery Problem Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Fishbone Diagram Example Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Simple Fishbone Diagram Example People Procedures Policies Plant Unpleasant side effects Inconsistent patient education Medication too expensive Pharmacy hours of operation Patient not taking hypertension medication

Simple Check Sheet Example Number of times Unpleasant side effects Inconsistent patient education Medication too expensive Pharmacy hours of operation

Simple Pareto Chart Example From our checksheet we see that patient education… While we may have been inclined to think something else was the major cause, the Pareto chart helps to focus our attention on designing an improvement intervention that will have the most leverage to improve results – that is “the most bang for the buck”

Check Sheet Example Make an appointment Name: Day of the week: M T W Th Fri Type of call 8:00-9:00 9:01-10:00 10:01-11:00 11:01-2:00 12:01-1:00 1:01-2:00 2:01-3:00 3:01-4:00 4:01-5:00 Make an appointment Call for nurse: patient Call for nurse: nonpatient Call for MD: patient Call for MD: nonpatient Personal calls Wrong number Asking for a phone number Other Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Pareto Chart Example Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Run Chart Example Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Run Chart Example Intervention Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Instructor’s Manual Chapter 4: A Systems Perspective of Quality Management

Systems thinking… “…is a discipline for seeing wholes. It is a framework for seeing interrelationships, rather than things, for seeing patterns of change rather than static ‘snapshots’.” --Peter Senge in The Fifth Discipline: The Art and Practice of the Learning Organization. 1990. New York: Doubleday Currency.

Characteristics of Dynamic Complexity Change Trade-offs History dependency Tight coupling Nonlinearity

Unintended Consequences

Instructor’s Manual Chapter 5: Systems Models for Healthcare Managers

Organizations as Systems

Simple System Inputs Conversion Process Outputs Like a recipe… 13

Healthcare Organizations as Systems Inputs Conversion Process Outputs Diagnostic Treatment Operations Business Management Support Patients Personnel Supplies Equipment Facilities Capital Clinical status Functional status Satisfaction Cost-effectiveness Culture 13

Open Feedback System Inputs Conversion Process Outputs Feedback 13

Quality Management as an Open Feedback System Inputs Conversion Process Outputs Feedback Improve 13

Quality Management in Healthcare Inputs Conversion Process Outputs Medical Personnel Licensure Continuing education Performance reviews Technology Clinical trials Governmental bodies Standards Facilities and Structures Inspections Standards and guidelines Health Technology Assessment Practice guidelines Process improvement Work simplification Policy (immunizations) Tracking and Monitoring Outcome Measures Individual, organizational, state, national Health status Business status This slide describes approaches used to improve the quality of inputs; approaches used to improve the quality of the conversion processes; and approaches used to improve the ability to measure and track the outputs to improve the quality of feedback in the system 13

Three Core Process Model Administrative Decision-Making Processes Outcomes Excellent clinical outcomes Value to patient Patient satisfaction Functional status Clinical/Medical Processes Patient Flow/Operational Processes Culture Administrative Decision-Making Processes Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Source: www.baldrige.gov.

Systems Model of Organizational Accidents

Socioecological Framework: Determinants, Interventions, Evaluation Source: Reprinted with permission by JoAnne Earp, Sc.D.; Peter Reed, M.P.H.; and the instructors of HBHE 131, Introduction to Social Behavior in Public Health, Department of Health Behavior and Health Education, University of North Carolina at Chapel Hill, School of Public Health, 2001.

Systems Models: Lessons for Managers Three Core Process Model Baldrige National Quality Program Systems Model of Organizational Accidents Socioecological Framework Encourages concurrent improvement of inter-dependent processes Aligns processes around patient needs Values all provider and employee groups Views administrative role as a process not a function Shows how the components of performance excellence are related Recognizes the context in which the organization operates Promotes alignment of all activities within the organization Promotes alignment of performance indicators Enhances communication around performance excellence Explains administrators and managers as sources of latent errors Describes frontline consequences of system errors Emphasizes importance of management competence Broadens and expands the manager’s view Addresses community and policy influences on health outcomes Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Instructor’s Manual Chapter 6: Expanding the Boundaries of the System: The Role of Policy

www.jointcommission.org To find out about the Joint Commission’s Shared Visions-New Pathways accreditation process, visit www.jointcommission.org

Source: © Joint Commission Resources: Tracer Methodology: Tips and Strategies for Continuous Systems Improvement. Oak Brook Terrace, IL. JCAHO, 2004, p. 5-6. Reprinted with permission.

Source: © Joint Commission Resources: Tracer Methodology: Tips and Strategies for Continuous Systems Improvement. Oak Brook Terrace, IL. JCAHO, 2004, p. 5-6. Reprinted with permission.

Source: © Joint Commission Resources: Tracer Methodology: Tips and Strategies for Continuous Systems Improvement. Oak Brook Terrace, IL. JCAHO, 2004, p. 5-6. Reprinted with permission.

Instructor’s Manual Chapter 7: Systemic Structure

The Iceberg Metaphor Source: Reprinted with permission from Innovations Associates, Inc. 1995. “Systems Thinking: A Language for Learning and Action.” Participant manual, version 95.4.1. Waltham, Massachusetts.

Comparison of Organizational Models Organizational Characteristic Rational Model Political Model Goals, preferences Power and control Decision process Information Cause-and-effect relationship Decisions Ideology Consistent across members Centralized Logical, orderly, sequential Extensive, systematic, accurate Predictable Based on outcome-maximizing choices Efficiency and effectiveness Inconsistent, pluralistic within the organization Diffuse, shifting coalitions and interest groups Disorderly, give and take of competing interests Ambiguous, selectively available, used as a power resource Uncertain Results from bargaining and interplay among interests Struggle, conflict, winners and losers Source: From Health Care Management: Organization Design and Behavior, 4th Edition, by S. M. Shortell and A. D. Kaluzny. © 2000. Reprinted with permission of Delmar Learning, a division of Thomson Learning: www.thomsonrights.com. Fax 800 730-2215.

Instructor’s Manual Chapter 10: Performance Measurement

Why measure performance?

Reacting to a Problem Approach Poorly defined strategic and operational goals Operations characterized by activities rather than processes Operations reactive to immediate needs and problems Reacting to a Problem Approach Continuum of development for organizations.. Childhood: react Adolescent: Improving Adult: aligned Source: Adapted from Baldrige National Quality Program Health Care Criteria for Performance Excellence. www.baldrige.gov.

Early Systemic Approach Strategic and quantitative goals are beginning to be defined Beginning stages of conducting operations by processes with repeatability, evaluation, and improvement Early coordination among operating units Early Systematic Approach Source: Adapted from Baldrige National Quality Program Health Care Criteria for Performance Excellence. www.baldrige.gov.

Aligned Approaches Processes address key strategies and goals of the organization Operations are characterized by processes that are repeatable and regularly evaluated for improvement Learning is shared and coordinated among organizational units Aligned Approach Source: Adapted from Baldrige National Quality Program Health Care Criteria for Performance Excellence. www.baldrige.gov.

Integrated Approach Integrated Approach Operations characterized repeatable processes Operational processes regularly evaluated for change and improvement in collaboration with other affected units Efficiencies across units are achieved through analysis, innovation, and sharing Processes and measures track progress on key strategic and operational goals A few minutes ago, we talked about the continuum of alignment for an organization. The most mature or developed approach on this continuum is an Integrated approach Integrated Approach Source: Adapted from Baldrige National Quality Program Health Care Criteria for Performance Excellence. www.baldrige.gov.

Integrating Internal and External Measures Internally used performance measures Externally required performance measures Performance measures used for multiple purposes Internal External Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Normal Distribution Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Statistical Process Control Chart Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Control Chart Example Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Control Chart Example A B Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Control Chart Example C Year 2 Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Control Chart Example ↓ Year 3 Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Control Chart Example Year 4 Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Instructor’s Manual Chapter 11: Organizational Traction

Why do we use snow tires, chains, and four-wheel drive?

…creative tension

Instructor’s Manual Chapter 12: Implementation Lessons

Incremental Versus Breakthrough Improvement Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Refining Vision/Context as Management Breakthroughs Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Incremental Implementation Breakthrough Vision, Incremental Implementation Ideal Vision Performance Measurement System History/ Mission Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Incremental Implementation Breakthrough Vision, Incremental Implementation Ideal Vision Intervention #3b #4 Intervention #2 #3a Performance Measurement System Intervention #1 History/ Mission Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Incremental Implementation: Surgical Services Example Breakthrough Vision, Incremental Implementation: Surgical Services Example Ideal Vision Pre-procedure/ Post-procedure processes Etc. Pre-Admission Process Pre-operative testing protocol First case start times Surgical Services Executive Committee Medical Executive Committee Shared Governance Performance Measurement System Administrative Team Mission Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.

Instructor’s Manual Chapter 13: Team Strategies

Anna Smith’s First Grade Daily Self-Evaluation Scroggs Elementary School, Chapel Hill, NC

Instructor’s Manual Epilog

Tools for Improving How We Do Our Work: Improving the Process Process Flowcharts Cause and Effect Category Frequency A B C lll llll ll llll Data Collection Data Analysis

Tools for Improving What We Do: Improving the Content Benchmarking Best Practices Driving Restraining Force Field Analysis Evidence-based Practice

Why are these new tools helpful? …the highest-leverage tools help us to improve how we think.

Leveraging Performance Improvement in Healthcare Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.