1. Quality Management & Change in Healthcare

2. Quality Management in Healthcare
The goal of an organization committed to quality care is a comprehensive, systematic approach that prevents errors or identifies errors so that adverse events are decreased and safety and quality outcomes are maximized
Nurses must focus on the six competencies identified by the Quality and Safety Education for Nurses (QSEN): patient-centered care, teamwork and collaboration, evidenced-based practice, quality improvement, safety and informatics (
Patient safety is a key component of quality improvement

3. Quality Management In Healthcare
Quality Management: a philosophy that defines a healthcare culture emphasizing customer satisfaction, innovation, and employee involvement
Quality improvement: the ongoing process used by organizations to adopt the quality management philosophy

4. Benefits of Quality Management
Greater efficiency and proactive planning may overcome resource constraints
Successful malpractice suits could be reduced with quality care
Job satisfaction can be enhanced because QM involves everyone on the improvement team and encourages everyone to contribute

5. Evolution of Quality Management
Non-healthcare QM strategies have been applied to health care organizations
Six Sigma – a data driven approach targeting a nearly error free environment. Five steps:
Define opportunities
Measure performance
Analyze opportunities
Improve performance
Control performance

6. Principles of Quality Management/Improvement
All employees should be involved in the process (administration to followers)-Top level leaders and managers retain responsibility
Healthcare workers should accept that QI is as an integral part of their role
Goal is to improve the system, not place blame
Customers define quality
Focus is on outcomes
Decisions must be based on data-use statistical tools to make objective decisions

7. Steps in the Quality Improvement Process
Identify needs most important to the consumer-should be concentrated on changes to patient care that will have the greatest effect
Assemble a multidisciplinary team to review the identified consumer needs and services
Collect data to measure the current status of these services
Establish measurable outcomes and quality indicators-use accepted standards of care and practice whenever possible
Select and implement a plan to meet the outcomes
Collect data to evaluate the implementation of the plan and the achievement of outcomes

8. Quality Assurance
Focuses on clinical aspects of the provider’s care, often in response to an identified problem.
Most focus on process standards (documentation, adherence to standards)
Use chart audits to determine problems
Focus of chart audits is to detect errors and determine the person responsible for them

9. Risk Management
Attempts to analyze problems and minimize losses after an adverse event occurs
JCAHO guidelines emphasize the importance of risk management (National Patient Safety Goals)

10. Functions of Risk Management Department
Identify situations that put the organization at financial risk
Determine how often these events occur
Intervene and investigate these events
Identify potential risks or opportunities to improve care

11. Key Points about Risk Management
Every nurse is a risk manager
Each nurse has the responsibility to identify and report unusual occurrences and potential risks
A barrier is fear of punishment
Adverse event reduction is key strategy to reducing healthcare mortality and morbidity
Adherence to best practice standards and assurance of quality standards for high risk/high volume practices can reduce adverse events

12. Sentinel Events
According to JCAHO, a sentinel event is “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.”
JCAHO calls for voluntary self-reporting of sentinel events
There are 10 events that are can be reviewed by JCAHO (see sentinel event policy)
After a sentinel event occurs, a root-cause analysis should be done to review the incident and to identify the sequence of events with the goal of identifying the root causes.
This leads to a plan involving specific risk reduction strategies which has to be reported to JCAHO

13. Advantages of Sentinel Event Reporting
Information is entered into JCAHO’s database so that all hospitals can share “lessons learned”
Can receive consultation from JCAHO during the Root Cause Analysis and Plan
Projects a good image to the public – hospital is doing everything to promote safe quality care

14. Incident Reports Internal reporting of risks or adverse events
Kept separate from patient records
Should serve as a means of communicating an incident that did cause or could have caused harm to patients, family members, visitors, or employees.
Should be used to improve quality of care and decrease future risks

15. Patient Safety
The Institute of Medicine’s (IOM) To Err is Human: Building a Safer Health System shed light on the need to focus on patient safety
Safety and subsequently quality, should drive such aspects of leading and managing as staffing and budgeting decisions, personnel policies and change and information technology and delegation

16. Three Major Driving Forces for the Emphasis on Quality
IOM reports
The Agency for Health Research and Quality (AHRQ)
The National Quality Forum

17. IOM Reports
Shed light on the number of patient deaths related to medical errors
Acknowledgement that errors commonly occurred because of system errors rather than practitioner errors
Keeping Patients Safe: Transforming the Work Environment of Nurses provided an impetus to change the work environment of nurses (shared governance)

18. Agency for Healthcare Research and Quality (AHRQ)
The primary federal agency devoted to improving quality, safety, efficiency and effectiveness of health care
Website has information for consumers and providers

19. National Quality Forum
Membership-based organization designed to develop and implement a national strategy for health quality measurement and reporting
Centers for Medicare and Medicaid developed their “no pay” policy based on the work of NQF on “never events” (Think hospital acquired infections)
Developed Nurse Sensitive Care Standards – See Box 2 – 4 pg. 30

20. Joint Commission
A not for profit organization that accredits health care organizations
Uses unannounced visits so that hospitals have to continuously meet JC standards

21. Institute for Healthcare Improvement (IHI)
Dedicated to rapidly improving care through a variety of rapid cycle change projects
Works in collaboration with the Robert Wood Johnson Foundation to create an innovative project called “Transforming Care at the Bedside”.

22. STAR Approach to Patient Safety
S – Stop to concentrate on the task
T – Think about the task
A – Act to accomplish the task
R – Review how well the task was accomplished

23. Change
A natural social process of individuals, groups, organizations, & society
Forces of change originate inside and outside of healthcare organizations
Is constant, inevitable, pervasive, and unpredictable and varies in rate & intensity
Nursing entities as open systems need to be able to respond to change with flexibility an creativity

24. Change Models
Planned change: change can occur in a sequential and directional fashion when guided by effective change agents
Useful in low-level, less complex change in stable environments
Theorists include Lewin, Lippitt, Watson, & Westley, & Havelock
Non-linear change: Chaos and Learning Organization Theories
Organizations are open systems – affected by and simultaneously affect the environment in which they exist
Have periods of stability followed by “bursts” of change
Small changes in the internal or external environment can result in significant consequences to the organizational work processes and outcomes
Learning Organization Theory: Place emphasis on flexibility and responsiveness
Can best respond and adapt when members of the organization complete their work using a learning approach

25. Planned Change Using Linear Approaches
Change can occur in a sequential and directional fashion when guided by effective change agents
Lewin’s Force Field Analysis: analysis of barriers and facilitators of change; three stages
Unfreezing: awareness of an opportunity, need or problem for which some action is necessary
Experiencing the change: incorporation of what is new or different into work and interpersonal processes
Refreezing: participants in the change situation accept and use the new attitude or behavior

26. Planned Change Using Linear Approaches
Havelock’s six stage model
Building a relationship
Diagnosing the problem
Acquiring relevant resources
Choosing the solution
Gaining acceptance
Stabilizing the innovation and generating self-renewal

27. Planned Change Using Linear Approaches
Lippitt, Watson, and Westley’s model
The client system becomes aware of the need for change
The relationship is developed between the client system and change agent
The change problem is defined
The change goals are set and options for achievement are explored
The plan for change is implemented
The change is accepted and stabilized
The change entities redefine their relationships

28. Non-linear Change Chaos theory:
Organizations are open systems operating in complex, fast changing environments
Similar to semi-permeable membranes allowing some exchanges between the internal and external environments
Organizations experience periods of stability followed by periods of intense transformation (spurts of change)

29. Non-linear Change Learning Organization Theory
Organizations that place emphasis on flexibility and responsiveness
Senge’s five disciplines of learning organizations:
Systems thinking
Personal mastery
Mental models
Shared vision
Team learning

30. Major Change Management Functions
May or may not used sequentially, may be applied simultaneously
Planning
Organizing
Implementing
Evaluating
Seeking feedback

31. Human Responses to Change
Innovators: thrive on change, which may be disruptive to the unit stability
Early adopters: Respected by their peers and are sought out for advice and information about innovations/changes
Early majority: prefer doing what has been done but will eventually accept new ideas
Late majority: openly negative and agree to the change only after most others have accepted the change
Laggards: prefer keeping traditions and openly express their resistance to change
Rejectors: oppose change actively, even use sabotage, which can interfere with the overall success of a change process

32. Strategies to Facilitate Change
Communication and Education: interchanges among the change agent, the change participants, and others for the purpose of integrating the elements of the change process
Participation and Involvement: incorporate all levels of staff as early as possible
Facilitation and support: reassure those who do not accept change because of anxiety and fear
Negotiation: change the terms of the process to accommodate the involved parties
Cooptation: get those are against change involved by appointing them to a task force
Manipulation: Appeals to the motivational needs of others and influences them to participate
Coercion: use of power to force others to make a change
Visioning: ongoing creation of goals and visions by the change participants
Information management: getting the right information to the right place at the right time
Relationships: putting the right person in the right position

33. Characteristics of Effective Change Agents
Display leadership
Excellent communication skills
Observation skills
Know how groups work
Perceptive about political issues
Are trusted by others
Establish positive relationships
Empower others
Are flexible
Manage conflict
Participate actively in change
Are respected & credible
Posses expert and legitimate power
Understand change process
Display appropriate timing