Applying Quality Management in Healthcare
T he quality landscape has changed dramatically since the first edition of Applying Quality Management in Healthcare: A Process for Improvement (2003). At that time, the Institute of Medicine reports To Err Is Human (1999) and Crossing the Quality Chasm (2001) were still relatively new and patient safety was in its early stages. The Premier Hospital Quality Incentive Demonstration, the precursor to today’s value-based purchasing initiatives, was just getting started. Transparency was in its infancy. Applying Quality Management in Healthcare
Fast-forward to today. The concept of systems is widely embraced in healthcare and has become a cornerstone for driving improvements toward achieving the Institute for Healthcare Improvement’s Triple Aim. Perverse financial incentives, which punished organizations for reducing utilization by improving care, are being challenged with a wide array of innovative payment models that reward improvements in quality, safety, and health promotion. The numerous and often disparate parts of the US healthcare system are working together to improve the health of populations, not just to care for sick individuals. The quality, safety, and systems concepts discussed in this book have become foundational, essential, and timeless. They may be applied to any type, size, level, or complexity of organizational forms. Applying Quality Management in Healthcare
I would like to thank the many students whom I have had the privilege to get to know, work with, and learn from as a result of writing and teaching with this text. I would also like to thank my mentor and friend, Dr. Arnold Kaluzny. I am delighted that Patrice Spath is collaborating on this fourth edition so that the book may continue to bring value to future students.
S everal years ago, I partnered with a physician, Dr. William Minogue, to respond to an article in a medical journal that bemoaned the lack of successful patient safety improvement initiatives. The article’s authors suggested a new model was needed for conducting patient safety investigations because the current way of doing things was not working. At the time, I was facilitating training workshops for the Maryland Patient Safety Center, where Dr. Minogue was the medical director. We both agreed that a new safety investigation model was not the answer. This belief resulted in our coauthoring an article on the subject for WebM&M, an online case-based forum on patient safety sponsored by the Agency for Healthcare Research and Quality.
Our article began by reminding readers of the insights of Louis Pasteur, who, throughout his career, “insisted that germs were the cause of disease, not the body.” Near the end of his life, Pasteur changed his opinion and “declined treatment for potentially curable pneumonia, reportedly saying, ‘It is the soil, not the seed.’ In other words, a germ (the seed) causes disease when our bodies (the soil) provide a hospitable environment” (Spath and Minogue 2008). Applying Quality Management in Healthcare
This lesson, discovered by Pasteur so many years ago, has application to all quality improvement activities and is reinforced by the topics covered in this book. The systems in health services organizations must be carefully nurtured to create a hospitable environment for the many tools and techniques of improvement to thrive. If the soil is not properly prepared, the seeds of improvement will not take root or be sustainable. Dr. Diane Kelly, author of the first three editions of this book, was insightful in taking a systems approach to quality improvement. Dr. Kelly understood that preparing the “soil” of the organization is just as important as learning how to use the various quality tools. I am honored to have the opportunity to build on Dr. Kelly’s contributions in this fourth edition.
This book is intended for managers—anyone who influences the design of healthcare systems for the purpose of improving quality. It is not necessary to hold the official title of manager in an organization to be instrumental in creating and supporting higher-quality services. Many frontline, nonmanagerial clinical and administrative staff members are directly or indirectly involved in Applying Quality Management in Healthcare
shaping patient care systems and in using improvement techniques to design more efficient, safer processes. Although the word manager is used liberally throughout this book, it is not intended to narrow the audience or the purpose. Anyone interested in making improvements in the quality and safety of health services will benefit from the learning in these pages.
Changes from the Third Edition
The emphasis on systems in the third edition is still evident in this fourth edition. What has changed is an expansion of information about quality tools, data analysis techniques, and patient safety. As with all editions of this book, concepts covered in the chapters are supported by real-life examples, illustrations, and thought-provoking end-of-chapter exercises. Some chapters have been added and others reordered. The book is now divided into three major sections instead of two. Applying Quality Management in Healthcare
Section 1 provides students with the foundational principles of healthcare quality and explains how systems affect an organization’s ability to accomplish quality goals. The chapter on the role of policy in advancing quality (chapter 8 in the third edition) was moved to this section so students can better appreciate how external forces affect system behavior and relationships as well as the quality methods used by health services organizations (covered in later chapters). Some of the material relevant to reliability and patient safety covered in this section in the third edition has been moved to a new chapter dedicated solely to the topic of patient safety.
Section 2 contains three chapters designed to illustrate what health services organizations must do to set the stage for success in quality management efforts. Because teamwork and collaboration are essential for advancing healthcare quality, the teamwork chapter at the end of the third edition has been expanded and moved to this section (chapter 8, “Fostering a Culture of Collaboration and Teamwork”). Much of the information from chapter 10 has been moved to chapter 9 (“Measuring Process and System Performance”), and some topics have been shifted to other related chapters. Applying Quality Management in Healthcare
The nuts and bolts of quality management are found in section 3. The chapters in this section are expansions of topics covered in the third edition. Instructors using the third edition in a quality course indicated the need for more detailed explanations of quality models and the tools and techniques of healthcare quality management. In addition, a new chapter has been added (chapter 10, “Using Data Analytics Techniques to Evaluate Performance”). This chapter covers basic concepts of healthcare data analytics, including how to use various statistical and graphical methods for reporting and evaluating
performance data. Some of these methods were covered briefly in the third edition, and some of the discussion is new to the fourth edition.
Materials on improvement models, project teams, and quality tools are greatly expanded from the third edition and now covered in two separate chapters (chapter 11, “Designing and Implementing Improvements,” and chapter 12, “Using Improvement Teams and Tools”). In the third edition, the various topics related to patient safety were dispersed among several different chapters. Now, most of the material concerning patient safety is in a new chapter (chapter 13, “Making Healthcare Safer for Patients”). This chapter is focused entirely on systems issues affecting patient safety and methods for reducing mistakes and preventing patient harm. Applying Quality Management in Healthcare
Health Administration Press now offers educators the opportunity to build custom textbooks comprising chapters from several different books. To accommodate this service, the chapters in the fourth edition of this book have been written to stand alone as much as possible. Within each chapter, references to material in other chapters have been minimized, or the concepts summarized and repeated when necessary. Where there are linkages between materials in various chapters, instructors are encouraged to point out these relationships because the connections are not as clearly stated as in the third edition.
Listed at the end of each chapter are companion readings and web resources. Instructors can expand students’ learning experience by assigning a companion reading or directing them to explore one or more of the online resources. These readings and websites are particularly useful in the chapter on data analysis techniques, if instructors want to cover more than just basic concepts. The web resources also provide instructors and students with sources of the most current information on relevant quality management and patient safety topics Applying Quality Management in Healthcare