In the healthcare industry, various terminology is used to describe quality and performance. Sometimes various terms are used interchangeably (although incorrect to do so), so it is important to have an understanding of terms related to quality, quality management, total quality management, and performance improvement to appreciate their differences.
Within healthcare organizations, quality management is a shared responsibility among everyone. While a quality department is part of the organizational structure of healthcare organizations, the department does not work in a silo to assess, measure, and evaluate the quality of care provided to patients.
An effective quality management effort will include complementary focus on performance improvement. Without also focusing on performance improvement, understanding quality (or lack thereof) would be somewhat a moot point if identified deficiencies and opportunities for improvement were not followed up with actions to improve deficiencies.
Before clinicians scientifically understood the risks that infections posed to patients, clinical care – including surgical procedures – did not apply infection control techniques to reduce the risk of infections. Identifying that infections could be prevented was a big step forward in improving patient safety in healthcare. Three early patient safety pioneers were Joseph Lister, Ignaz Sammelweis, and Florence Nightingale.
Lister = 18th century physician; specialized in surgery. Implemented earliest examples of infection control processes into surgery such as placing anti-infective agents into surgical incisions/wounds and on dressings. Also identified the need to sterilize instruments.
Sammelweis = earliest to champion hand washing in clinical care settings
Nightingale = applied understanding of clinical practice and statistical analysis to identify that unsanitary conditions in healthcare facilities led to negative outcomes and increased mortality.
Prior to the Darling case, legal liability was not a concern for hospitals or other healthcare institutions when medical errors occurred and harmed patients. Prior to Darling, if a patient was harmed, only the physician could be liable; the Darling case set a new legal precedent in which hospitals as an organization could also be liable, along with physicians, when patients were harmed.
Patient broke leg playing football and went to the hospital. A series of errors during his hospitalization occurred, including poor communication among the care team, oversight of an infection that developed inside his cast, and providers directing medical care who weren’t qualified to do so. By the time the hospital realized the leg was infected, the damage to the leg was so extensive, the hospital was unable to treat the patient and had to transfer him to an academic medical center to provide specialized care. The academic medical center was unable to restore the leg and the leg required amputation. The patient sued hospital and even though it went through several levels of appeal, won a judgment against the hospital. From this point forward, hospitals could be held legally liable for medical errors occurring within their organization (and liability no longer resided solely with physicians or other health professionals).
Medicare covers those 65 and older, as well as select instances of disability and medical conditions; Medicaid provides insurance coverage to low income individuals/families.
Conditions for Coverage and Conditions of Participation are baseline health and safety standards that must be met by healthcare organizations that treat Medicare and Medicaid patients. CMS maintains the CfCs and CoPs online.
Patient advocacy groups began to emerge in the 1970s and the public had growing expectations for quality and safety in patient care. The American Hospital Association was also interested in seeing patients become more active advocates to understand their rights and responsibilities related to healthcare and drafted the Patient’s Bill of Rights in 1973; a newer iteration of this document is often provided to patient’s today known as the Patient Care Partnership. One of the earliest consumer-led patient safety advocacy organizations was Consumers for Medical Quality (established in 1983).
Managed care: HMO Act of 1973 provided federal funding to explore the use of HMOs as a mechanism to provide quality care in a cost-effective way. HMOs created from this legislation were required to focus their efforts extensively on quality; among the areas of emphasis within their quality programs were health outcomes and review of physicians and other professionals providing care.
In the 1990s – 2000s, patient safety became an industry focus and various reports were published about suboptimal environments in US healthcare. To Err is Human illustrated the toll of human lives lost as well as massive expense associated with unsafe care. Crossing the Quality Chasm called for a complete redesign of US healthcare.
The work of the IHI is largely based in applying the scientific method to study patient safety and healthcare quality. Their approach, the Triple Aim, is widely cited in the healthcare industry and has had influence on health policy.
The next slides will describe the role of accreditation standards, regulatory requirements, value-based payments, and consumer engagement
Examples of Accreditation Organizations
The Joint Commission
Accreditation Association for Ambulatory Healthcare
American College of Radiology
Commission on Accreditation of Rehabilitation Facilities
Federal regulations stem from federal law. A variety of federal laws influence healthcare. This slide shows a handful of examples of federal laws that address unique aspects of healthcare delivery, but all share a theme that quality is a focus within the laws.
EMTALA – addresses access to care in ERs; CLIA – address lab testing quality; Medicare Prescription Drug, Improvement, and Modernization Act – addresses access to prescription drugs and enhancements to Medicare; HITECH – addresses the need to expand EHR adoption, which has potential to improve quality and reduce costs; ACA – addresses access to health insurance
Reporting of quality indicators to stakeholders that subsequently makes the data available for public consumption has influenced a new era of transparency in healthcare. Critiques of this type of transparency argue that healthcare organizations that treat certain populations, such as the uninsured or poor, will have an unfair advantage because their data will look unfavorable. Another critique of this type of transparency is that the public has access to this information but may not be equipped to accurately appraise the information. Regardless, the movement toward transparency will likely only continue.
A wide variety of value-based payment methods are currently being used in US healthcare. Value-based payments are any method of healthcare reimbursement that either financially incentivizes providers for good quality and outcomes or those which penalize providers for inadequate quality and outcomes. For the purpose of this chapter, understand that value-based payments are a radical shift from the previous methods of reimbursement used in which reimbursement did not account for the quality of care provided. Reimbursement models in value-based care focus on quality not quantity.
Patients today, more so than ever before, can shop around before choosing a healthcare provider. As more and more data is transparently available on the Internet, it’s important that healthcare providers and organizations can establish themselves as first-class destinations for care that focus on quality and safety and engage the community they serve.
Organizations that commit to a culture of quality are more likely to achieve quality. The following slides describes the influence of mission and vision, leadership, organizational culture, interprofessional education and practice, and change management on quality.
If the organization does not embrace and implement the mission and vision in all it does, the mission and vision are not actualized. Mission and vision statements are succinct and state the mission and vision of an organization.
Managers cannot be the only source of leadership within an organization. Anyone can be given a job title of manager but that doesn’t mean they possess leadership skills. It is expected that managers provide leadership, however, the reality is that not all can or do. Some of the most effective leadership can come from within the ranks of an organization, particularly in healthcare where peers respond well to each other for insight, direction, and motivation. Regarding the ability for leadership to influence quality, quality is a shared responsibility and effective leadership on the topic from anywhere within the organization should be welcomed.
Organizational Culture Can be:
Positive or negative
Formative or punitive
Collaborative or silos
It’s important to recognize how organizational culture influences quality
If quality was easily achievable, the US healthcare system would not still struggle with quality. Therefore, change management comes into play in situations when staff must change practice habits, processes and procedures, roles, philosophies, culture, and more in order to improve performance related to quality.
Data collected during reviews is often submitted for various external reporting requirements; organizations often use the same data for various internal uses as well.
Internal benchmarking “identifies best practices within an organization, to compare best practices within an organization, and to compare current practice over time” (Hughes 2008). Example of internal benchmarking – comparing rates of healthcare associated infections acquired during hospitalization among nursing units of a hospital
External benchmarking “uses comparative data between organizations to judge performance and identify improvements that have proven to be successful in other organizations” (Hughes 2008). Example of external benchmarking—comparing measures on Nursing Home Compare website between one’s own skilled nursing facility and other skilled nursing facilities
Collecting the data is not just for reporting requirements—it is also to identify opportunities for needed improvement
PDCA is frequently used in healthcare organizations for quality and performance purposes. PDCA is continuous and cyclical in nature. W. Edwards Deming was a famous engineer, statistician, and management consultant.
Prior to the Healthcare Quality Improvement Act, a growing concern emerged that physicians could move freely around the country and re-establish their practice with little question after having been found liable for injury, death, or other harm experienced by patients under their care.
The National Practitioner Data Bank (NPDB) is “An information clearing house . . . to collect and release certain information related to the professional competence and conduct of physicians, dentists, and in some cases, other healthcare practitioners” (HHS 2015)
See chapter for examples of when a physician may be subject to peer review.
In addition to entities who can query the NPDB to find out information about physicians and other practitioners; healthcare practitioners, entities, providers, and suppliers are authorized to query on themselves for information reported to the NPDB
See textbook chapter for details on who, in addition to MD physicians, may be members of a medical staff per CMS.
Is replicated by healthcare organizations to monitor compliance with accreditation standards and identify potential areas of deficiency.
Findings from CER can inform not only the risks and benefits of treatment options, as examples, but can also illustrate the costs of such options. The textbook chapter described a 2013 peer reviewed study on the use of cesarean section delivery versus vaginal delivery of newborns to illustrate an example of CER.
CER is a better known concept today as a result of the Patient-Centered Outcomes Research Institute, funded by the Patient Protection and Affordable Care Act of 2010.
The AHRQ is a federal agency that aims to support health services research designed to improve the outcomes and quality of healthcare, reduce costs, address patient safety and medical errors, and broaden access to effective services.
Certain approaches, methods, protocols, and treatments have been proven to produce the best results for patients. Effective clinical care still requires clinical judgment and knowledge from clinicians. An early critique of evidence-based practice was that it thwarted the autonomy of physicians and their role in clinical decision-making. However, an increasing body of scientific evidence demonstrates the value of evidence-based practice when it’s applicable.
Clinical pathways do not exist for every single clinical scenario; however, when they do exist there are benefits to patients in using them. Clinical pathways expand the concept of a care plan because the pathway is established with the intent that the care plan accounts for the needs of the patient as well as promotes the interdependent nature of the health professions to achieve more cohesive patient care.
Case management is extremely valuable in the US because of the fragmented and complex nature of our healthcare system.
Without case management, patients are at risk for
Readmission
Medication mismanagement
Inadequate follow up care
Implementing health IT by itself does not improve quality; Instead, doing so in an effective way provides more opportunities for improvement
Many HIM professionals credentialed as RHIAs or RHITs work in quality management roles because their knowledge and background uniquely qualifies them for various roles in quality. HIM professionals working in quality management likely already possess on the previously mentioned quality-specific certifications, or plan to obtain them for career advancement.
EHRs emphasize the need for professionals who also understand data stewardship and information governance. Data stewardship and IG are two areas in which HIM professionals possess competency and can provide leadership in these areas. Risks to inaccurate and improper EHR documentation heightens the need for professionals understanding these areas to work in healthcare organizations. Compromised data and information quality in EHRs pose great risks to healthcare organizations and their patients, including risks that relate to quality.
When social media first came about, healthcare organizations did not jump on board. There were concerns about non-compliance with HIPAA on the mediums, depending on how they communicated with the public (who may be patients). The waters have been navigated in this regard and now healthcare organizations typically have a social media presence. Even if a healthcare organization is not on social media, their patients likely are –and the good and bad experiences, especially those perceived as bad by patients, will be shared with others. There are risks to the reputation and brand if a healthcare organization consistently has negative feedback and complaints
Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications. (Health Resources and Services Administration, n.d.), Quality must be considered and measured in telehealth settings. Questions to consider include:
How are appropriate physician partners established?
Are services offered beyond traditional medical care (PT, OT, others)?
How is documentation captured and managed?
Will patient satisfaction be measured?
How does telehealth affect care continuity?
This IOM report highlights that despite increasingly available information (also available in greater amounts than ever before), the US healthcare system has stalled in leveraging information as an asset to improve care. The concept of the learning health system relies in large part on smart and effective use of information to inform individual episodes of care as well as overarching efforts to improve health services delivery to large populations.
