Carolyn BWeek 7 Discussion 1 Peer ReviewMy Abstract The lea.docx

Carolyn B
Week 7 Discussion 1 "Peer Review"
My Abstract: The leadership position has been in development
for centuries for the purpose of shaping and molding others in
hopes that they will perform through the examples that a leader
portrait. While the effective and ineffectiveness of leadership
has been researched there is not a specific time listed as to the
history of it, but it “has been going on for quite some time.”
There is no specific date as to when ineffective leadership
started, but the traits were characterized and based on the traits
that were different from an effective leadership.
Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.

The History OF HOSPITALS AND WARDS
Gormley, Tom
Healthcare Design; Mar 2010; 10, 3; ProQuest Central
pg. 50
Do No Harm: Adaptive reuse in healthcare construction
Oliver, Scot. The Idaho Business Review; Boise (Oct 17, 2016)
Buildings that are designed and built well can be valuable long
after their original intended use is over. More than just a
collection of wood, stone, steel and glass, a good building has
an intention of exceeding a basic utilitarian purpose. It aspires
to make a design statement, to be of service, to be an active
participant in the community. Good buildings exhibit a lot of
pride--in the developer's mission, or business, or himself. This
extends to the pride of design and craftsmanship that makes a
building valuable long after the source of the pride is gone.
Some of our favorite buildings have been adapted from other
uses.
The old Ada County Courthouse, once slated for demolition,
housed the state Legislature for a few years and now serves

magnificently as the Idaho Law Center. Railroad warehouses
became the cool, eclectic shops and offices in 8th Street
Marketplace, and attracted the BoDo development around it.
Old hotels got new life as office, residential and retail
uses in the Owyhee, Hoff and Idanha buildings. Downtown
department stores have been converted, like the Alaska Building
offices and Athlos Academy's headquarters. The office where I
write this was an opera house in the late 19th century; three
blocks away a warehouse from that era now houses the opera.
Even some older industrial buildings were built to last. Often,
these buildings don't survive redevelopment, but their high-
quality construction and design can lead to interesting reuse--
local examples from the early 1900s include the Biomark
office/manufacturing building, built as a coal-gasification plant;
the Linen Building and Powerhouse event centers; and the
Armory, undergoing rehabilitation for a new use.
Increasingly, however, commercial and industrial buildings are
victims of the national trend toward disposability and quick
profit. There's a sameness in design, and construction methods
and materials are quick and cheap. The owners expect a
relatively short business life in that location and build
accordingly. There's no motivation to think about the
neighborhood context and how the building will fit in it over
time. Owners of big-box stores or factories don't live in the
neighborhood and usually don't have the sense of pride or long-
term vision to create lasting buildings that enrich their context.
Health care is a rapidly growing industry that needs new
facilities as it grows. The single largest private
employer in Idaho is the St. Luke's Health System; three of
Idaho's 10 largest private employers are healthcare systems.
Nationally, healthcare workers are projected to be the largest
workforce by 2020.
Yet the way health care is delivered is constantly changing. Not
that long ago, healthcare delivery often meant doctors making
house calls. This was followed by a rapid increase in hospital
treatment, with a corresponding proliferation of large auto-

oriented factory-like hospitals. Trends are shifting again.
Patients, payers and the courts are deciding that too much
growth and consolidation in the healthcare industry is not
healthy. Today, U.S. hospitals have one million beds with an
average daily occupancy rate of 70 percent, a decline of nearly
39 percent since the 1980s. Inpatient use declined by 16.1
percent from 1999 to 2012. This is due in part to the push by
payers for evidence-based outcomes rather than more
procedures and hospitalization. Demand is changing, too, as
people look for care in ambulatory centers in their communities,
or opt for direct care in their homes. Home healthcare jobs are
the nation's fastest growing sector, expected to increase 70
percent between 2010 and 2020.
Facility design is changing as well. Patients and their families
are showing a preference for care in small, friendly, personal
spaces with access to daylight and the outdoors. This mirrors
their residential and business preferences: places that are
walkable and have a lively mix of uses. As patients develop a
more retail-oriented approach to healthcare choices, providers
are adaptively reusing retail and commercial spaces to be closer
to the market. There are many instances of large systems like
St. Luke's and Saint Alphonsus as well as smaller "docs-in-a-
box" taking advantage of this trend.
Kaiser Permanente, one of the nation's
largest healthcare systems, has been promoting green, smart-
growth healthcare facility design for years. Recently they held
the international Small Hospital, Big Ideas design competition
to encourage new thinking about hospitals that provide patient-
centered healing with a small environmental footprint and also
reduce costs and improve community health. The winning
concepts propose places that inspire human connection and
collaboration, blur the boundaries between the community and
the traditional hospital setting, provide direct access to daylight
and nature and go beyond carbon neutrality to restore
ecosystems and biodiversity.
We can't predict what's next in healthcare demand and delivery,

but we can expect the trend away from large centralized
facilities to continue. Healthcare providers will be challenged to
repurpose outdated buildings; if they fail the community
ultimately will be left with the task. If we're lucky, we'll have
good designs to work with. One excellent example is Fort Boise,
the first large development in the area. Fort Boise
started in 1863 as a U.S. Army cavalry fort and operated for
many years before it was adaptively repurposed as
a healthcare complex for the Veterans Administration. It's a
great example of how good design and construction can be a
lasting community asset.
Scot Oliver is executive director of Idaho Smart Growth, a
statewide nonprofit that promotes community choices in land
use, transportation and community development issues.
(c) 2016 Dolan Media Newswires. All Rights Reserved.
Credit: Scot Oliver
Word count: 917
(Copyright 2016 Dolan Media Newswires. All Rights Reserved)
Do No Harm: Adaptive reuse in healthcare
construction
Oliver, Scot
.
The Idaho Business Review
; Boise
(Oct 17, 2016)
after their original intended use
is
over. More than just a collection of wood, stone, steel and

glass, a good building has an intention
of exceeding a basic utilitarian purpose. It aspires to make a
design statement, to be of service, to
be an active participant
in
the community. Good bui
ldings exhibit a lot of pride
--
in
the
developer's mission, or business, or himself. This extends to the
pride of design and
craftsmanship that makes a building valuable long after the
source of the pride is gone.
Some of our favorite buildings have been ad
apted from other uses.
housed the state Legislature for a
few years and now serves magnificently as the Idaho Law
Center. Railroad warehouses became
the cool, eclectic shops and offices
in
8th Stre
et Marketplace, and attracted the BoDo
development around it. Old hotels got new life as office,
residential and retail uses
in

the
Owyhee, Hoff and Idanha buildings. Downtown department
stores have been converted, like the
Alaska Building offices and Athl
os Academy's headquarters. The office where I write this was
an opera house
in
the late 19th century; three blocks away a warehouse from that
era now houses
the opera.
these buildings don't su
rvive
redevelopment, but their high
-
quality
construction
and design can lead to interesting
reuse
--
local
examples from the early 1900s include the Biomark
office/manufacturing building, built as a
coal
-
gasification plant; the Linen Building and Powerhouse event
centers; and the Armory,
undergoing rehabilitation for a new use.
Increasingly, however, co

mmercial and industrial buildings are victims of the national
trend
toward disposability and quick profit. There's a sameness
in
design, and
construction
methods
relatively short business life
in
that
location and build accordingly. There's
no
motivation to think about the neighborhood context
and how the building will fit
in
it over time. Owners of big
-
box stores or factories don't
live
in
the neighborhood and usually don't have the sense of pride or l
ong
-

term vision to create
lasting buildings that enrich their context.
Do No Harm: Adaptive reuse in healthcare
construction
Oliver, Scot. The Idaho Business Review; Boise (Oct 17, 2016)
after their original intended use is
over. More than just a collection of wood, stone, steel and
glass, a good building has an intention
of exceeding a basic utilitarian purpose. It aspires to make a
design statement, to be of service, to
be an active participant in the community. Good buildings
exhibit a lot of pride--in the
developer's mission, or business, or himself. This extends to the
pride of design and
craftsmanship that makes a building valuable long after the
source of the pride is gone.
Some of our favorite buildings have been adapted from other
uses.
housed the state Legislature for a
few years and now serves magnificently as the Idaho Law
Center. Railroad warehouses became
the cool, eclectic shops and offices in 8th Street Marketplace,
and attracted the BoDo
development around it. Old hotels got new life as office,
residential and retail uses in the
Owyhee, Hoff and Idanha buildings. Downtown department
stores have been converted, like the
Alaska Building offices and Athlos Academy's headquarters.
The office where I write this was
an opera house in the late 19th century; three blocks away a
warehouse from that era now houses
the opera.

these buildings don't survive
redevelopment, but their high-quality construction and design
can lead to interesting reuse--local
examples from the early 1900s include the Biomark
office/manufacturing building, built as a
coal-gasification plant; the Linen Building and Powerhouse
event centers; and the Armory,
undergoing rehabilitation for a new use.
Increasingly, however, commercial and industrial buildings are
victims of the national trend
toward disposability and quick profit. There's a sameness in
design, and construction methods
relatively short business life in that
location and build accordingly. There's no motivation to think
about the neighborhood context
and how the building will fit in it over time. Owners of big-box
stores or factories don't
live in the neighborhood and usually don't have the sense of
pride or long-term vision to create
lasting buildings that enrich their context.
Chenee W
Abstract
Technology changed the way the industry professionals
approach healthcare. Despite the positivity that exists with
technology adoption in the healthcare industry, when a new
technology emerges, there are persons who adopt from the onset
and even earlier, while there are those who adopt in the late
majority and those that resist change. The reasons for the
different technology adoption rates among the professionals are
related to costs, mistrust in new technology and some prefers
the traditional way of doing things (Unknown 2018). With these
concerns comes challenges that need to be recognized and

avoided in order to facilitate quality and effective patient care
and treatment. Chapter 1 of this Capstone Project will analyze
the specific problems in technology adoption that needs to be
addressed, how the challenges may affect patient outcomes, the
problem’s history to include when it appeared, who it affects
and the current scope of the problem. The issue of the
Coronavirus pandemic and its role in redefining healthcare will
be briefly address. All information will be based on publicly
available healthcare data and other open data resources.
Reference
Unknown (2018). Technology in healthcare: Adoption,
challenges and progress. GHX. Retrieved
from https://www.ghx.com/the-healthcare-
hub/2018/technology-in-healthcare-adoption-challenges-and-
progress/
Healthcare Administration Capstone – Week #7 Lecture 1
Submission of Abstract and Revisions/Additions
Almost finished! In this week (no later than Thursday – Day 2),
you will submit the abstract you wrote last week to the Week 7
discussion forum for peer review and feedback. Before most
articles are published, they undergo a peer review similar to
what you will be doing. This step is completed because it is
easy to become so engaged in your project that you fail to see
the proverbial forest for the trees. As you read the abstracts of
your fellow students, ask yourself what holes may exist in the
plan. Odds are that they are more than likely addressed,
however, a fresh set of eyes can make a world of difference.
Another reason to read the work of others is that it provides a
great break from your own research project. Returning to your
own work may reveal some errors that were simply not caught
beforehand. As you reread your own material, be sure to review
it from a “says who?” perspective. As a reminder, anytime that

you move beyond what is referred to as “common knowledge”
you will need a citation.
What is “common knowledge”? For practical purposes, it is the
information and knowledge that one would expect the average
8th grader to have acquired. As an example, most everyone
knows that the sun is a star. However, not too many individuals
know that the sun is classified as a G2V star or yellow dwarf.
Such information would indeed require a citation. Additionally,
anytime that you use statistics you will need to support this
with a citation. As an example, if you mentioned that the sun is
93 million miles from the earth, you will need to provide your
source.
A word of caution is in order. Due to the number of healthcare
related courses that you have taken, you may find yourself very
comfortable with the healthcare related jargon. However,
remember that you are reading this from a “says who?”
perspective. The average 8th grader will more than likely not be
familiar with some of the terms and concepts; thus requiring
citations.
Your instructor and your peers will provide you with great
feedback. If you have any questions about any of the feedback
received, ask. Lastly, Microsoft Word provides excellent tools
to assist with editing and polishing your project. Be sure to use
the Spelling and Grammar tool frequently. Also, it is highly
recommended that you utilize the Readability Statistics.
Unfortunately, it is not normally enabled. To enable this
feature, while in Microsoft Word, follow these instructions:
· Click on the File tab
· Click on “Options”
· Click “Proofing”
· Under “When correcting spelling and grammar in Word”,
make sure the “Check grammar with spelling” check box is
selected.
· Select “Show readability statistics”
· Re-run the Spelling and Grammar tool
At the conclusion of the Spelling and Grammar tool, your

project’s “counts”, “averages”, and “readability” will be
displayed. A Master’s level Capstone Project should rate in the
“collegiate” level. The following table will help you decipher
readability:
Scores between 90 and 100 are easily understood by a 5th
grader. Scores between 60 and 70 are understood by an 8th
grader, and those scores below 30 are understood by a college
graduate. It is recommended that your score not exceed 55. The
following website can assist you in better understanding
the Flesch reading ease:
http://www.readabilityformulas.com/flesch-reading-ease-
readability-formula.php
As always, if you have any questions, please be sure to post
them in the “Project Questions” discussion forum.
The following resource is available to assist you in
proofreading:
https://owl.english.purdue.edu/owl/resource/561/01/
*Reminder: You will need to submit your Abstract to the
discussion forum no later than Day 2 (Thursday) to ensure that
your peers will have plenty of opportunity to review and reply.
CHAPTER 13
Improving Performance and Controlling the Critical Cycle
CHAPTER OBJECTIVES
• Define the management functions of quality improvement and
controlling.
• Introduce the concept of the search for excellence and
examine its relationship to the function of controlling.
• Relate controlling to directing in an essential cycle that
affords ongoing attention to follow-up and correction.
• Introduce the concept of benchmarking and describe its place
in the management process.
• Describe selected techniques for improving quality.
• Enumerate the essential characteristics of adequate controls,

and introduce some commonly used tools of control.
QUALITY, EXCELLENCE, AND CONTINUOUS
PERFORMANCE IMPROVEMENT
Headlines and key phrases that reflect a deeper organizational
commitment to quality include the following:
• Committed to Excellence
• Your Safety Comes First
• The 30-Minutes-or-Less ER Service Pledge
• Memorial Nursing Care Facility Granted 5-Star Rating
These are a sign of the continuing search for excellence and the
striving for perfection, creating a climate of continuous
improvement. Also, these phrases and similar ones reflect the
overall theme of performance improvement initiatives
associated with the management functions of quality
improvement and controlling. The search for excellence flows
from the healthcare organization’s fundamental vision and
purpose: the timely and thorough care of the patient. Its values
of stewardship and integrity further infuse the organization with
energy directed toward continuous quality improvement (CQI).
Effective managers engage in this pervasive process of
continuous performance improvement.
What other factors occasion the emphasis on quality? There are
several—some positive, some challenging. The fundamental
commitment to excellence includes full compliance with the
applicable laws, regulations, and standards. Thus, any area with
less-than-full compliance receives review and corrective action
to achieve that basic goal. The response to major legislation or
regulation (e.g., Health Insurance Portability and Accountability
Act [HIPAA], Affordable Care Act, electronic health record
[EHR] mandates, Recovery Audit Contractor [RAC] programs,
Program Effectiveness Review) brings renewed attention to the
systems and functions affected by these mandates. When
management chooses to make a major systems change (e.g.,
complete automation of information system, adoption of
advanced technology), new concerns arise; in these examples,
the related issues of identity theft, date security, and

antihacking measures become the focus of quality review.
During any major changeover in a system (e.g., migration from
hard copy to EHRs; a shift from one coding system to a newly
required one), the manager must attend to the issues associated
with phasing out legacy systems.
Topics relating to patient care studies reflect new concerns and
therefore special studies about these topics. By way of example,
note the increased attention paid to sports-related injuries (e.g.,
concussions, hand or knee injuries) in professional and high
school athletes. Another aspect of quality improvement studies
relating to patient care is reflected in the emphasis on outcomes
and predictive analysis. Or an external event (e.g., a
superstorm, a pandemic) might result in a review of the disaster
response findings: what went well; what needs upgrading?
Finally, negative publicity about a particular issue (e.g., rising
infection rate, a scandal arising from employee behavior, an
accident resulting in improper disposal of medical records) may
require the management team to prepare a proactive response,
including a renewed commitment to quality.
Just as there is negative publicity from time to time, there is
also the opportunity for sharing positive accomplishments with
the internal and external communities. For example, public
relations releases feature the achievement of a five-star rating,
the (n) number of days without accidents, excellence awards by
specialty groups for certain diagnostic categories (e.g., cancer,
stroke, neonatal care), peer-reviewed score for hospital safety,
and ranking in top 25 hospitals nationally in supply-chain
management. All of these issues reflect managers’ concerns
about maintaining quality in every aspect of organizational life.
This continuing search for excellence has a long and varied
history. A review of this history provides managers with a
framework within which to consider effective approaches to
CQI.
THE SEARCH FOR EXCELLENCE: A LONG AND VARIED
HISTORY
Emerging with a vengeance in the late 1980s, quality became

the most fashionable business term of the 1990s, just as the
term excellence had dominated much of the 1980s. The total
quality management (TQM) movement and the earlier
excellence movement had somewhat different origins, but so far
the results of the quality movement have been much the same as
the visible results of the excellence movement, although more
widespread. In each instance, a basically sound, well-
intentioned philosophy has been adopted, promoted, and
implemented with extremely mixed results.
Many of the organizations that attempted to adopt dedication to
excellence as a guiding philosophy ran into the same problem
that has stymied many otherwise effective organizations: how to
instill a philosophy in people so that it will cause them to
behave in the desired manner.
Between the philosophy, which may initially be accepted by a
few members of top management, and the actual practice, which
involves many employees living out the philosophy, lies a
matter of process. There has to be some process available to
successfully transfer the philosophy from the few to the many.
A great many people never see past the process and are thus
unable to truly adopt the philosophy. They simply go through
the motions, appearing to do what they perceive top
management wants them to do. Invariably, when a philosophy is
proceduralized—that is, when a process is superimposed on
something as ethereal as a concept, idea, or belief—something
essential is lost. Those who simply adopt the process as part of
the job without buying into the philosophy will not truly reflect
the philosophy in their behavior.
When a philosophy of management is overproceduralized,
overpromoted, overpublicized, and overpraised, it becomes a
fad. It becomes fashionable for its own sake. It was in this
manner that excellence essentially went down the same path
traveled years earlier by management by objectives. We have
reason to wonder, therefore, whether the quality movement will
prevail or devolve into just another fad, the current “flavor of
the month” destined to go the way of management by

objectives, quality circles, excellence, and others.
Quality Control, Quality Assurance, and Quality Management
For years, many of the manufacturing and service industries had
what was referred to as quality control. Quality control
ordinarily concentrated on finding defects, rejecting defective
products, and providing information with which to alter
processes so they would produce fewer defects.
Healthcare organizations had what they called quality
assurance. It consisted largely of record scrutiny during which
errors consisting of departures from some dictated standard
were counted, providing information that subsequently directed
which steps would be taken to reduce the frequency of
recurrence of the same kinds of errors.
In addition to correcting the processes that produced the errors,
both quality control and quality assurance were often
responsible for instituting more frequent quality checkpoints so
that errors might be caught earlier. The most important
similarity between quality control and quality assurance,
however, was that both focused primarily on finding errors after
the fact. Both were, and yet remain, retrospective processes.
During the 1980s, using philosophical grounding and methods
exported from the United States to Japan decades earlier and
later brought back as “new, revolutionary management
techniques,” the emphasis on quality began to shift from
catching errors before they went out the door to avoiding errors
in the first place. Thus we have the basis of the quality
movement embodied today in labels such as TQM, CQI,
and performance improvement initiatives.
Old Friends in New Clothes?
Many of the tools and techniques included under the
performance improvement umbrella should look familiar to
some people who have been in the workforce for a few years.
Many of the “current” tools and techniques have been around
for a considerable amount of time—some for decades. They
have been resurrected, revitalized (especially through computer
technology), and in some instances renamed. For example, a

number of TQM-implementation case histories mention the
acronym TOPS, standing for team-oriented problem solving. As
the name suggests, workers who have concerns with various
aspects of particular problems approach problem solving as a
team, with a common goal and purpose. These problem-solving
teams espoused under TQM look, sound, and function the same
as quality circles promoted during the brief popularity of
“Japanese management.”
Also essentially renaming quality circles are other TOPS look-
alikes such as self-directed work teams and team-oriented
process improvement. These particular labels are but two of
several similar designations that have emerged as representing a
significant part of the path to CQI.
Quality circles were themselves nothing new when they were so
named. In years past, many work organizations used what they
called work simplification project teams, in function and intent
essentially identical to quality circles and the problem-solving
teams of TQM. Written about in the 1950s and earlier, work
simplification teams found their way into hospital methods
improvement work as early as 1956.1
Even many of the specific tools used by today’s performance
improvement problem solvers go back 50, 60, or as far as 70
years. Industrial engineering techniques already existing for
decades scored a number of modest, if not long-lasting,
successes when implemented in hospitals from the second half
of the 1960s to the mid-1970s. Renamed management
engineering—probably because of a general aversion in health
care to anything perceived as “industrial”—they have
nevertheless fallen short of their potential value in health care.
Yet, there is a return to these practices (process flow, control
charts, and cause-and-effect diagrams, for instance) as part of
today’s performance improvement programs.
The Common Driving Force
Regardless of how many previously popular techniques are
returned to the spotlight or how many genuinely new features
are added, there remains one ingredient that is fully as essential

to performance improvement as it has been to any other
approach by any other name. That crucial ingredient is top
management commitment. Its importance should come as no
surprise. Top management commitment to new ideas and
approaches has been a prerequisite to complete success for as
long as organized enterprise has existed. Without sufficient top
management commitment, most organized endeavors are
destined to, at best, generate results that fall short of intentions,
or, at worst, fail altogether and cause harmful results or leave
residual damage.
One cannot imagine any rational top manager openly avowing
opposition to the principles of quality improvement. Ask any
top manager whose organization has espoused performance
improvement or TQM initiatives if he or she is truly committed
to it—or, for that matter, ask any top manager at all if quality,
period, is a personal commitment; surely each will state
unwavering commitment. We know that many such endeavors
fail because of insufficient top management commitment, but
because almost all managers will voice commitment there is but
one conclusion to be drawn: top management commitment is a
matter of degree, and the degree of commitment is critical.
None of today’s total quality programs will work as intended
unless top management is actually involved and actively
promoting the concept. Superficial commitment at the top
results in similarly weak commitment at lower organizational
levels. Beware of skyrocket commitment of the top manager
who gets all fired up over performance improvement initiatives;
distributes information to everyone; creates a steering
committee, advisory committee, or other body; and chairs the
first meeting or two or three—but then starts missing meetings
because of “pressing business” and soon transfers the guiding
role to subordinates.
A total quality program also will not work if managers,
especially first-line supervisors, will not let go and truly
delegate to employees. This means not simply giving employees
the responsibility for doing different tasks or determining more

efficient methods; it means also giving them the authority to
make the decisions to implement their own findings.
Furthermore, letting go means accepting what employees decide
and living with it.
Letting go as just described is difficult for the majority of
managers. A great many managers, far more than would be able
to see it in themselves, possess a recognizable streak of
authoritarianism. On reflection, the reasons for a fairly strong
presence of residual authoritarianism are understandable.
Modern management—true, open participative management—is
a phenomenon of the past two or three decades. Although the
spread of participative management has been steady, it has
also been gradual; there remain many areas of organized
activity in which employees have yet to experience any
management style other than straightforward “bossism.”
Managers learn about management mostly from other managers,
and especially from those organizational superiors who, for
good or ill, were by virtue of their positions role models for
those persons newer to management. At one time, virtually all
management everywhere was authoritarian; even now,
management that is at least partly authoritarian predominates.
Most management role models thus convey at least a modicum
of authoritarianism. Subtle proof of the existence of the
authoritarian streak can be experienced by the manager who
might ponder his or her reaction to being pushed abruptly into a
fully participative management situation. The manager may feel
that participative management exhibits weakness and that
delegating decision-making authority to subordinates is
somehow abrogating his or her responsibility.
Managers also have trouble letting go and adjusting to a truly
participative environment because, for the most part, TQM runs
contrary to classical organizational theory and old notions about
how a work group is to be managed. Classical theory stresses
structure, lines of authority, and the chain of command, and it
suggests that as far as each level is concerned, someone just
above it is in charge. In classical organizational theory, one

works for the manager; in contrast, in a truly participative
environment, one works with the manager.
It remains clear, however, that changes in management style and
approach may have to occur for a quality management program
to be successful. In most instances the manager will need to
shift from being the boss—from planning, telling, and
instructing—to being the leader of a team—to counseling,
teaching, coaching, and facilitating.
Management’s commitment, then, can be seen as a total
commitment not only to participative management and employee
empowerment but also to intradepartmental and
interdepartmental teamwork and improved communication
throughout the organization.
Will Total Quality Management Prevail?
The answer to this question is yes: the focus on quality is a
mandate flowing from the very purpose of the healthcare
organization. However, its forms and approaches will vary from
time to time. TQM has every chance of working where previous
and perhaps partial efforts undertaken under other names have
failed. There is a great deal going on with performance
improvement initiatives. Activity undertaken in the name of
quality improvement has become so widespread that the
impression that “everyone is doing it” places considerable
pressure on the supposed few who have yet to commit to true
quality improvement.
In the healthcare setting, quality improvement has become the
norm. It flows from the organization’s overall vision: quality
patient care, with emphasis on timely, effective care given in a
climate of safety. The Joint Commission as well as state and
federal regulatory bodies mandate performance monitoring and
improvement. Examples include the Centers for Medicare and
Medicaid Services (CMS) quality of care initiatives for
hospitals and other healthcare facilities; the American Recovery
and Reinvestment Act (ARRA)/Health Information Technology
for Economic and Clinical Health Act (HITECH), which gives
additional mandates concerning the protection of patients’

privacy; and the Federal Trade Commission and its regulations
concerning medical identity theft prevention. In addition,
Congress passed the Patient Safety and Quality Improvement
Act of 2005 (“Patient Safety Act”). The Joint Commission
reflects this mandate in its standards for patient safety. The
Institute for Healthcare Improvement launched the “100,000
Lives Campaign” concerning patient safety, which has since
been expanded to the “Five Million Lives” campaign. Quality,
excellence, and continuous improvement have become the
permanent underlying themes in the healthcare setting.
Performance Improvement Focus
Studies relating to performance improvement generally fall into
one of seven categories:
1. Mandates resulting from laws, regulations, and standards.
Within these laws and regulations there are specific target areas
requiring attention—for example, the payment-error review
requirements of the CMS, which includes a user’s guide
indicating the type of quality study needed to satisfy the review
of payments. Topics for study include same-day surgery
discharges, septicemia, simple pneumonia, and chronic
obstructive pulmonary disease. Also, any topic reflected in the
Plan of Correction for licensure or accreditation would receive
particular focus. Many of the mandates have been noted in
earlier discussions (see Chapters One, Two, and Five) and in the
opening discussions in this chapter. Recall the guidelines
provided in Chapter 6 under the consultant report that uses a
priority system of action.
2. CQI, focusing on maintaining the quality of standard
operations—for example, the quality of medical transcription,
detection of fraudulent line counting, completeness of
documentation, and spoliation of medical evidence in
documentation. These studies become routine and frequent (e.g.,
monthly).
3. Periodic studies, stemming from external requirements as
well as internal commitment to excellence—for example, an
accrediting agency’s quarterly reports or the state agency’s

annual licensure survey.
4. Adoption of a new process or approach, focusing on the
“debugging” of such undertakings and eventually moving it into
routine practice. Examples include “dry runs” using the tracer
methodology advocated by The Joint Commission, following the
course of care and services the patient received during the
course of hospitalization, with real-time review involving
several departments. Quality review protocols would be used in
a major project such as the overhaul of the master patient index,
culling out duplicate numbers, and consolidating the related
medical record documents. Once the solution has been found to
this problem, the topic becomes one of routine focus.
5. Critical areas of interest stemming from internal or external
concerns. From time to time, an issue demands intense review.
Examples include:
a. Patient safety. Although this has been an area of focus of risk
management for many years, fresh impetus has been given to
this topic, as noted earlier. The Patient Safety Act, The Joint
Commission standards, internal malpractice-related reviews,
infection control concerns—all of these have led to renewed
interest in studies such as those focusing on wrong-site surgery,
medication errors, “read back” requirements, and any of the
sentinel events emphasized by The Joint Commission in its
adverse patient occurrences topics. The ECRI Institute
(formerly the Emergency Care Research Institute) continues to
develop patient safety–quality improvement programs to support
risk management activities.
b. The revenue cycle. Efforts in improving both the timeliness
and the accuracy of billing, along with the prevention of fraud,
is a multidepartment effort including the physicians, the
admitting department, the emergency service, the finance office,
and health information management. Studies typically include
such topics as:
○ Tracking the time elapsed from the time of clinical events
through the final payment of a bill.
○ Analysis of billing rejections along with comprehensive error

rate testing as it relates to accuracy in payment.
○ Selection of high-priority coding and billing (e.g., a $200,000
inpatient bill versus a $500 clinic visit). All are important, but
priority effort devoted to rapid, high-revenue return is
sometimes indicated.
○ Comparison of present organizational practices to the planned
reviews announced by the Office of Inspector General and its
efforts at fraud control, with emphasis on the RAC program
requirements (e.g., specific attention to coding regarding
present-on-admission and hospital-acquired conditions).
c. Disaster and emergency preparedness. A major catastrophe
(e.g., hurricane, tornado, blizzard, fire) brings renewed
attention to this aspect of organizational plans. The after-action
reports, with lessons learned noted, provide the management
team with valuable focus points. In addition to overall
preparedness as reflected in the disaster/emergency plan, topics
of study could include:
○ Aspects of the business continuity plan for patient care and
financial records
○ Compliance with the HIPAA/Department of Health and
Human Services (DHHS) guidelines for release of information
about the aged and persons with disabilities during a disaster
event
○ The proper use of the condition modifiers in coding and
billing relating to catastrophic or disaster-related events
d. Patient privacy and medical identity theft. HIPAA, ARRA,
and HITECH legislation mandate a variety of security
compliance assessments, prevention of breach analysis studies,
and development of practices to prevent and mitigate
compromises of patient privacy. The increased use of smart
phones, laptop computers, and other devices that are often used
off site (such as by home care personnel) is an area needing
particular attention when these devices are lost or stolen. When
equipment is leased, or recycled, these items must be securely
“scrubbed” of confidential data. The Federal Trade Commission
has promulgated regulations (the “red flag” rules) focusing on

the detection, prevention, and mitigation of the effects of
medical identity theft. Regular auditing of workers’ access
rights and their history of access/attempted access to health
record information is another area of monitoring.
e. Patterns of care. Various federal and state government
initiatives include provisions concerning the reduction of rates
for preventable readmission. The frequency and causes of
readmission are aspects of this mandate. Related topics include
transition from acute to post-acute care and observation unit
utilization. Such initiatives also includes requirements to
monitor and report elder abuse, making this a topic ripe for
fresh scrutiny. Another area of focus deals with evidence-based
evaluation and treatment standards such as those promulgated
by the American College of Surgeons Commission on Cancer or
those included in the federal comparative effectiveness reviews.
6. Patient satisfaction studies. Questionnaires (using a mix of
anonymous and identifiable responses) provide feedback about
the effectiveness of quality initiatives as well as processes in
need of improvement. The incidents may describe seemingly
small concerns, but from the client’s perspective, these are the
tangible effects of practices. The care per se may have been
excellent, but the related processes might cause discomfort,
anger, or confusion. Examples include not being able to easily
access health record information because of HIPAA rules but
being asked over and over to state one’s date of birth within
earshot of other patients, giving an overseas 14-digit telephone
number of the next-of-kin/power-of-attorney (POA) holder to
registration personnel only to be told that phone number field is
limited to 10 digits, difficult-to-read/use computers for self–
check in, and no weekend or holiday campus transportation to
remote parking sites.
7. Employee satisfaction studies. As with patient satisfaction
studies, these questionnaires and interviews provide information
to assist managers in maintaining a culture of excellence.
Topics include general working conditions (noise levels,
temperature, proper equipment in good working order) and

related concerns such as safety, parking, lack of flexibility in
working hours, lack of adequate training and therefore
promotion opportunities, and lack of easy-to-contact “help
desk” for computer support. An analysis of grievance issues
provides another source of information about topics of concern.
There are many resources available to the manager for carrying
out performance improvement studies. Examples include
American Health Information Management Association
(AHIMA)’s Information Governance Principles for Healthcare,
National Hospice and Palliative Care performance outcomes and
measures, Medicare’s allowable/nonallowable cost compliance
checklist, and Healthcare Effectiveness Data and Information
Set performance measures and quality improvement core set for
cultural and linguistic services. See also the interpretive
guidelines of federal and state regulations.
Managers of each department develop and carry out such studies
within their immediate organizational jurisdiction; they also
partner with other units in the organization through committees,
teams, and special projects to achieve the goals relating to
organizational excellence. The management function
of controlling is the traditional term associated with these
detailed processes.
THE MANAGEMENT FUNCTION OF CONTROLLING
Controlling is the management function by which performance
is measured and corrective action is taken to ensure the
accomplishment of organizational goals. Performance
improvement, continuous quality efforts, TQM—all of these
initiatives make up the controlling function. It is an oversight
operation in management, although the manager seeks to create
a positive climate so that the process of control is accepted as
part of routine activity. Controlling is also a forward-looking
process in that the manager seeks to anticipate deviation and
prevent it. It is an overarching activity, involving all the
functions of management.
The manager initiates the control function during the planning
phase, when possible deviation is anticipated and policies are

developed to help ensure uniformity of practice. Goals and
objectives include quality measures. During the organizing
phase, a manager may consciously introduce the “deadly
parallel” arrangement as a control factor. Job descriptions
include reference to maintaining excellence through
performance of duties. Training and retraining programs are
provided in order to prevent poor performance. Motivation,
reduction of conflict, and the promotion of team effort support
quality initiatives. Two styles of leadership are necessarily
blended in this function:
• Close supervision and a tight leadership style reflect an aspect
of control. Through rewards and positive sanctions, the manager
seeks to motivate workers to conform, thereby limiting the
amount of control that must be imposed. Finally, the manager
develops specific control tools, such as inspections, visible
control charts, work counts, special reports, and audits.
• Participative management/leadership style, with wide
participation in the quality cycle, is the generally accepted
principle in performance improvement initiatives.
Does this comprehensive focus on quality consume all or most
of the manager’s time? No, not necessarily—studies and
oversight processes can be combined, efficiently scheduled, and
carried out by designated individuals, teams, and committees.
For example, when budget preparation is undertaken, a review
of just-in-time inventory practices could be an adjunct activity.
When a project to clean up and consolidate the master patient
index is implemented (including timely and accurate updates of
identifying information), a related study might focus on
registration processes regarding unconscious patients or trauma
and emergency admissions. A comprehensive study of clinic
appointments might include …
Chapter 13
IMPROVING PERFORMANCE AND CONTROLLING THE

CRITICAL CYCLE
Objectives (1 of 2)
Define the management functions of quality improvement and
controlling.
Introduce the concept of the search for excellence and examine
its relationship to the function of controlling.
Relate controlling to directing in an essential cycle that affords
ongoing attention to follow-up and correction.
Objectives (2 of 2)
Introduce the concept of benchmarking and describe its place in
the management process.
Describe selected techniques for improving quality.
Enumerate the essential characteristics of adequate controls and
introduce some commonly used tools of control.
The Continuing Search for Excellence
Terms associated with this search:
TQM: Total quality management
Quality control; quality assurance
Quality circles; performance improvement
CQI: Continuous quality improvement
Essential Top Management Commitment
An underlying philosophy
Participative management style
Active promotion of the concept
Truly delegate authority and responsibility
Employee empowerment

Intra- and interdepartmental teamwork
Performance Improvement Focus
Continuous quality improvement: focus on standard operations
Routine, periodic studies stemming from external mandates
(e.g., Joint Commission)
“Debug” new processes (e.g., Joint Commission tracer
methodology implementation)
Critical areas of interest (e.g., patient safety, revenue cycle,
disaster preparation)
When an Improvement Fails (1 of 2)
During the early stages of implementation, the manager must:
Remain attentive to feedback
Make necessary adjustments
Provide clients with assistance in adjusting to the change
When an Improvement Fails (2 of 2)
When the data and feedback indicate that the hoped-for
improvement has not occurred, the manager must be willing to
make the necessary change, including withdrawal of the new
process.
Definition of Control
The management function in which performance is measured
and corrective action is taken to ensure the accomplishment of
organizational goals

Participants in the Commitment to Excellence (1 of 2)
Governing board: Leadership role; adoption of philosophy of
excellence
Line managers: Continuous process improvement of routine
activities and periodic quality improvement initiatives
Quality improvement teams and committees: Interdepartmental
cooperation (e.g., patient safety studies)
Participants (2 of 2)
Employees: Peer group activities through quality circles and
teams
Clients: Response to invitation to give feedback (e.g., patient
satisfaction surveys)
The Basic Control Process
Establish standards
Measure performance
Correct deviations
Control Mechanisms Should Be:
Timely
Economical
Comprehensive
Specific and appropriate
Objective
Responsible
Understandable
Six Sigma Strategies
Based on statistical analysis of variations in performance

measures, Six Sigma is particularly suitable for studies such as:
Risk management reviews
Infection control monitoring
Clinical audit studies
Patient safety analysis
Coding error rates
Accounts receivable delays
The DMAIC Process
D: Define the project goal and customers/clients
M: Measure the process to determine current performance
A: Analyze and determine root cause(s) of the defect
I: Improve the process by eliminating the defect
C: Control future process performance
Benchmarking
Select a standard of practice against which performance will be
measured
Standards may be internal (e.g., a department’s best
performance)
Standards may be obtained from external sources (e.g., a
professional association, federal agencies, accrediting
organizations)
The GANTT Chart
Visible control chart
Scheduling and progress monitoring
Work-time relationships

Work accomplished compared to work planned
Interrelationship among the phases of the work
The Flowchart
To develop a procedure (think logically about task linkage)
To illustrate and emphasize key points in a written procedure
To compare present and planned workflow
To audit the workflow, especially about delay points
TQM Display Charts
Run chart: Trends
Histogram: Patterns; rates and frequency
Scattergram: Relationship of variables
Cause-effect: Problem identification
Pareto chart: Determining priorities
The Critical Cycle
The importance of follow-up: Make new decisions, or re-
enforce original decisions in light of the findings of the various
performance studies. Use the findings to adjust work processes
in light of current information.

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