Transcript Quality Improvement - Healthcare Leadership Network

Quality and Performance
Improvement
HLNDV Study Group Summary
May 1, 2013
Quality and Performance Improvement
(19 of 200 questions)
1.
2.
3.
4.
5.
6.
7.
Quality Benchmarking
Medical staff peer review and disciplinary processes
Risk management principles and programs (e.g.,
insurance, education, safety, injury management,
patient complaint)
Performance and process improvement (e.g., CQI,
TQM, QA/QI)
Customer satisfaction principles and tools
Clinical pathways and disease management
Utilization review and management regulations
Source: Reference Manual Page 72 to 82
(http://www.ache.org/mbership/credentialing/EXAM/BOG_exam_reference_manual.pdf)
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Part 1: Benchmarking
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Performance refers to output results
obtained from processes and services that
permit evaluation and comparison relative to
goals, standards, past results, and other
organizations
Benchmarking- comparative process used
by organizations to collect and measure
internal or external data that may be used for
the purpose of developing, implementing, and
sustaining quality improvements
Benchmarking Techniques
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Hospitals are under increasing pressure to
reduce costs
Hospital leaders have been intensifying efforts to
identify the steps the organization needs to take
to make a difference
Can use publicly reported (Medicare) data for
benchmarking
The benchmarking analysis should seek to
identify any unexpected differences related to
similar or “like” hospitals
It is important to select a peer group carefully
i.e. teaching hospital to teaching hospital
Sources of Comparative
Measures
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Patient Satisfaction –CMS HCAHPS
Practice Patterns – Dartmouth Health Atlas
Health Plans – NCQA (HEDIS)
Clinical Indicators – CMS Quality Indicators
Population Measures- State Health
Departments, AHRQ (National Healthcare
Quality Report)
Common sources for
Benchmarking
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U.S. Agency for Healthcare Research and Quality (AHRQ) State Snapshots
 A government tool created to help States improve healthcare quality
 Can see how the State performed overall on more than 100 quality
measures
 Helps organizations develop programs, etc…
 http://statesnapshots.ahrq.gov/snaps10/
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Hospital Compare
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http://www.hospitalcompare.hhs.gov/
The Joint Commission Oryx data
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http://www.jointcommission.org/core_measure_sets.aspx
What are the Core Measures ?
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Core measures are disease specific best
practice measures.
The measures are part of the performance
measurement system developed by the
JCAHO.
The measures are publicly reported on the
internet and are also utilized by Medicare to
judge clinical quality.
Where do the Core Measures
come from ?
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The measures are developed based on best
practice literature, medical association clinical
recommendations, as well as the National
Quality Forum, who is the recognized final
pathway for the review and approval of
performance measures.
The measures are developed in a collaborative
manner, tested and then subsequently approved
for performance measurement.
What Measures are utilized for
Performance Measurement ?
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Congestive Heart Failure
Pneumonia
Acute Myocardial Infarction
Pregnancy and Related Conditions
Surgical Care Improvement Project
Congestive Heat Failure
Core Measure
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Discharge instructions specially prepared for
CHF patients
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Including: activity, diet, weight monitoring,
mediations, follow-up appointments, what do do if
symptoms worsen
Left Ventricular Assessment
Ace Inhibitor / ARB at discharge for patients with
LVEF <40%
Smoking cessation counseling
A balanced scorecard is a set of performance
measurements used to:
a. Assess patient satisfaction
b.
Ensure the organization does not exceed one
performance metric at the expense
of another
c. Provide a scorecard for annual performance
monitoring
d. Gather and monitor financial data
1. ____ Which is not a source of comparative data?
a) Clinical Indicators
b) Practice Patterns
c) Local Newspaper
d) Health Plans
Answer: C.
1. ____ Which of the following is not a source of comparative measures for quality and
performance improvement?
a) Patient satisfaction
b) Budget variance report
c) Health Plans
d) Clinical Indicators
Answer: B.
1. ____ Which of the following most closely relates to the term Benchmarking?
a) Care for which expected health benefits exceed negative consequences
b) Maximization of the quality of a comparable unit of healthcare delivered for a given
unit of resources uses
c) A comparison of actual performance to the best known performance
d) The value of the output as defined by the consumer
Answer: C. Griffith and White pp 188.
One method for evaluating relative value of
different jobs is:
a. Broad banding
b. Gant charting
c. Scalability
d. Benchmarking
Which of the following are parts of the
dimensions of the strategic balanced
scorecard?
a. Financial performance
b. New technology
c. Competitor activity
d. Board/management team
Part 2: Medical Staff Peer Review
and Disciplinary Processes
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TJC Standards: The Role of the Medical Staff
“The organized medical staff has a critical role in the
process of providing oversight of quality of care,
treatment, and services. The organized medical staff
is a self-governing body that is charged with
overseeing the quality of care, treatment, and services
delivered by practitioners who are credentialed and
privileged through the medical staff process”
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TJC Standards: Medical Staff and Hospital
Governing Board
Must create and maintain a set of bylaws that defines its role
“The hospital’s governing board has the ultimate authority and
responsibility for the oversight and delivery of health care
rendered by its LIPs and other practitioners credentialed
and privileged through the medical staff process or any
equivalent process.”
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Standards: Disciplinary Processes
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Medical Staff Bylaws must include:
Corrective Action
Description of the indications and procedures for automatic
and summary suspension
Description of mechanism to recommend medical staff
membership and/or termination, suspensions, or reduction
in privileges
Fair Hearing
A mechanism for a fair hearing and appeal procedure
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TJC Standards: Role of Medical Staff
Peers
“Peer recommendations from peers in the same
professional discipline as the applicant are used
as part of the basis for the initial granting of
privileges.”
“There is a process that defines circumstances
requiring a focused review of a practitioner’s
performance and evaluation of a practitioner by
peers.”
4/11/2016
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TJC Standards: Focused Performance
Review
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Define circumstances
Method for selecting review panels
Timeframes
Define circumstances requiring external review
Medical staff
Involved in evaluation of individuals
Communicate findings to appropriate parties
Implement changes to improve performance
4/11/2016
Part 3: Risk Management
Principles and Programs
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TJC Standards: Principles of Risk
Management
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Involve both clinical and administrative activities
Most effective when pro-active, rather than
reactive
Include collecting data on potentially high risk
processes
Risk Management Program
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The internal risk management program is the
responsibility of the governing board of the health
care facility. Each licensed facility shall hire a risk
manager, licensed under s. 395.10974, who is
responsible for implementation and oversight of
such facility’s internal risk management program as
required by this section. A risk manager must not be
made responsible for more than four internal risk
management programs in separate licensed
facilities, unless the facilities are under one
corporate ownership or the risk management
programs are in rural hospitals
Risk Management Principles
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Which programs, departments, and activities in the
organization are subject to risk management policies and
procedures?
Serve as a principle operational guide to prevent incidents
Leadership emphasis on the importance of strict
compliance, training and retraining for new employees
Incident reports, insurance, universal precautions,
exposure, workplace violence, fire alarms and prevention,
weapons, hazardous substances, communication
interruptions, and emergency evacuation
Risk Management
Components
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Define objectives
Put into place structure and organization
Employ information and reports
Establish IT infrastructure
Clarify and recognize roles and
responsibilities
Monitor- identify risks early. Mitigate,
intervene, and control effectiveness
Contemporary Risk
Management: Enterprise-wide
Enterprise Risk Management (ERM):
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A structured analytical process
Focuses on identifying and eliminating the
financial impact and
Volatility of a portfolio of risks rather than on risk
avoidance alone
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TJC Standards: Concepts Related to Risk
Management
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Safety
Patient
Environment of Care
Sentinel Event
Near Miss
Root Cause Analysis
Complaint Management
Systems
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Prompt and effective resolution of complaints
Recovery of patient/customer confidence
Best resolved at the point of service to assure
customer loyalty
Must have a mechanism for learning from
complaints and ensuring that staff receives the
information needed to eliminate the underlying
cause of the complaints
Aggregation, analysis, and root cause
determination leads to effective elimination of
the cause if possible
Patient Safety
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Freedom from accidental injury
Adverse event- when a patient experiences harm or
injury from a medical intervention
Harm can be preventable. Often errors occur without
harm reaching the patient (near miss)
James Reason- Swiss cheese model of harm. When
holes align harm can get thru layers of defensive
barriers
Error traditionally was blamed on the individual but
really is considered a system problem. We need to
fix the system/process, but also to hold individuals
accountable to expectations- a just culture
Patient Safety Tools
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Root Cause Analysis (RCA)- retrospective,
investigative tool to identify and understand
the root causes of an adverse event with a
focus on processes and systems
Failure Mode and Effects Analysis (FMEA)proactive, preventative tool which provides a
systematic way to ask: what has failed? What
could fail and how? What are the
consequences? Improvements are applied to
prevent adverse events
The Joint Commission
National Patient Safety Goals
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Use at least two patient identifiers when
providing care
Eliminate transfusion errors related to patient
misidentificaiton
Report critical test results timely
Reduce the likelihood of harm from use of
anticoagulation therapy
Comply with hand hygiene guidelines
The Joint Commission
National Patient Safety Goals
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Implement best practices to prevent central
line associated blood stream infections
Implement best practices to prevent surgical
site infections
Reduce the risk of falls
Identify patients at risk for suicide
A time out is performed before a procedure
The Joint Commission
Sentinel Event
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A “sentinel event” is an unexpected
occurrence involving death or a serious
physical or psychological injury, or the risk
thereof. Serious injury specifically includes
loss of limb or function. The phrase “or risk
thereof” includes any process variation for
which recurrence would carry a significant
chance of a serious adverse outcome
The principles of quality improvement require that healthcare
executives
change their management philosophy from:
a. Finding fault with employees to finding problems in processes
b.
Finding fault with employees to involving them in the
improvement of
processes
c. Focusing on enhanced inspection techniques to focusing on
variance
d. Focusing on employees’ roles to focusing on process outcomes
Which of the following would represent the
most common cause of adverse
drug events (ADEs)?
a. Lack of standardization
b. Lack of knowledge of drug
c. Preparation errors
d. Transcription errors
1. ____ According to the Picker Institure, which of the following are Dimensions of Care as it relates
to Inpatient Care, is incorrect:
a) Coordination of Care, Information and Education, Promoting Physical Comfort
b) Promoting Emotional Comfort, Involving family and friends, Preparing for discharge
c) Respecting Individuality, Coordination of Care, Preparing for Discharge
d) Access, Information and Education, Continuity and Transition
Answer: D. Access & Continuity and Transition are components of Ambulatory Care
The single most important way patients can
help prevent medical errors
from affecting them is to:
a. Interact with their caregivers
b. Research medical error rates among
organizations
c. Read and understand consent forms
d. Choose large, reputable healthcare providers
Incident reports should be initiated by:
a. A member of the medical/professional staff
or by any employee
b. Any person with direct patient-care
responsibilities
c. The department director or supervisor
d. The risk manager/quality assurance
coordinator
1. ____ JACHO performance standards mandate collecting data for high risk processes. High risk
processes include all of the following EXCEPT:
a) Patient complaints
b) Restraint use
c) Outcome of resuscitation efforts
d) Blood product use
Answer: A. Is not a high risk process,
Part 4: Performance Excellence
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An integrated approach to organizational
performance management that results in:
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Delivery of ever-improving value to patients and other
customers, contributing to improvement healthcare quality
Improvement of overall organizational effectiveness and
capabilities as healthcare providers
Organizational and personal learning
Source: www.baldrige.gov
Quality Improvement
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1924 Walter Shewhart designed a tool to help
guide the appropriate action to take in
response to variation. The “Control Chart”
can differentiate random (common cause)
variation from assignable (special) causes
W. Edwards Deming in the 1970s created his
14 Points. He also described the Plan-DoStudy(Check)- Act cycle
Quality Improvement
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Joseph M. Juran- described three interrelated
processes: quality planning, quality control,
and quality improvement. The Juran Trilogy
Taiichi Ohno- developed the Toyota
Production System (Lean). He described 7
categories of MUDA or waste. These don’t
add value to the process. These include:
overproduction, inventory, repairs/rejects,
motion, processing, waiting, and transport
Quality Improvement
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Crosby introduced the idea of “zero defects”
in 1961
Feigenbaum originated the concept of TQCTotal Quality Control- excellence driven
rather than defect driven. Three steps to
Quality- Leadership, Technology, and
Organizational Commitment
Ishikawa- developed the Cause and Effect
Diagram
Definitions
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Quality is always judged in comparison to
economic limitations
Quality of Care- degree to which health
services increase the likelihood of desired
health outcomes and are consistent with
current professional knowledge
Appropriate care- care for which expected
health benefits exceed negative
consequences
Terminology
Quality Assurance - focuses on output
Quality Improvement - emphasizes
prevention of error (also known as CQI –
Continuous Quality Improvement)
Quality Control - focuses on proper function of
equipment
Performance and Process
Improvement
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Quality Assurance
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Defining performance through the use of
thresholds
“Find and eliminate worst”
Find faulty outputs & repair or disregard them
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Quality Improvement:
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“Find and implement the best”
Find fault find solutions
Find faulty processes & repair them so they do
not produce faulty outputs
HEDIS
The Healthcare Effectiveness Data and
Information Set (HEDIS) is a tool used by
more than 90 percent of America's health
plans to measure performance on important
dimensions of care and service
NCQA website
Institute for Healthcare
Improvement
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The Model for Improvement (two parts):
Three fundamental questions, which can be addressed
in any order
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What are we trying to accomplish?
How will we know if a change is an improvement?
What changes can we make that will result in an improvement?
The Plan-Do-Study-Act (PDSA) cycle used to test and
implement changes in real work settings
In BOG Manual = Plan Do Check Act
IHI Website
Total Quality Management
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“TQM is a philosophy or an approach to
management that can be characterized by its
principles, practices, and techniques. Its
three principles are customer focus,
continuous improvement, and teamwork
…each principle is implemented through a
set of practices…the practices are, in turn,
supported by a wide array of techniques”
Source: Dean JW and DE Bowen. 1994. “Management Theory and
Total Quality: Improving Research and Practice through Theory
Development.” Academy of Management Review 19(2):392-418.
Continuous Improvement
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Assumes no upper limit of improvement
Considers both elements outside of direct
control and due to interactions in a complex
system
Assumes the customer’s perspective is
dominant
Focuses on overall group performance rather
than identification and correction of outliers
Requires organization-wide commitment
Performance and Process
Improvement
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Total Quality Management (TQM)
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Introduced in the late 1980’s
Evolved into Continuous Quality Improvement (CQI)
or Process Improvement (PI)
Designed to be proactive, leading to the elimination of
the underlying causes of defective work processes or
processes that permit unwarranted variation
Quality Assurance (QA)
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Tends to refer to the inspection process that evaluates
conformance to standards, accuracy and other
performance on an “after the fact” basis
TQM/CQI
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Focuses on the system rather than the individual
The Joint Commission points out that the goal of
improving organizational performance is to ensure
that the organization designs processes well and
systematically monitors, analyzes, and improves its
performance to improve patient outcomes
Quality Management must be embraced by the
hospital leadership team in order for the right care to
be provided by the front-line staff
Process or statistical tools allow for analysis,
measurement, and improvement
Core Values of C.I.
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Patient centered care
Individualized response
Physician as patient’s agent
Science as a guide- evidence based practice
Change is a way of life
Participation in decisions- no surprises
Mutual respect
Respect rules and processes
Quality Landmarks
Institute of MedicineNational Roundtable on Healthcare Quality
Report 1998
To Err is Human 1999
Crossing the Quality Chasm 2001
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Quality definition
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Quality care is the degree to which health
services for individuals and populations increase
the likelihood of desired health outcomes and
are consistent with current professional
knowledge
To Err is Human- as many as 98,000 people die
every year in hospitals as a result of injuries
from their care. Total national costs of
“preventable” adverse events are estimated at
between $17-29 billion annually
Crossing the Quality ChasmSix Aims
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Safe care
Effective
Efficient- cost effective and free of waste
Timely- no patient waits/delays
Patient centered- system should revolve
around the patient, respecting preferences
and putting the patient in control
Equitable- no disparities in treatment/access
Quality: Structure, Process,
Outcomes
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“Process”- what takes place during the
delivery of care. Appropriateness- whether
the right action was taken. Skill- how well the
actions were carried out
“Outcomes”- whether the goals of care were
achieved. Come to include costs of care,
patient satisfaction, and health related
functional outcomes, including functional
status or mortality
Structure, Process, Outcomes
Donabedian in1966 noted all evaluations of
quality can be classified in terms of which
three aspects of caregiving they measure:
“Structure”- focus is on the static
characteristics of the individuals who provide
care and the settings where care is delivered
Ex- education, training, certification of care
providers and the adequacy of the facility’s
staffing, equipment, and organization
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Clinical Quality Measures
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Example: childhood immunizations
Structure
Number / location of pediatric clinics
Available vaccines (i.e. inventory)
Process
“What is done to a patient…”
Immunization rates (ex. MMR)
Outcomes “What happens to a patient…”
Measles rates
Source: Brook RH, Kamberg CJ, McGlynn EA. Health system reform
and quality. JAMA 1996;276:476-480.
Plan-Do-Check-Act Cycle
Variation in healthcare
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Variation is the difference between an observed event and
a standard or norm
The Dartmouth Atlas of Health Care Project in 2003 found
that there was great regional variation in patients admitted
to an intensive care unit, ranging from 23-45% without a
discerning clinical reason
Random variation- is a physical attribute of the process,
adheres to probability, and can’t be traced to a root cause
Assignable variation- arise from causes outside of the
intrinsic process and can be traced, identified, and
eliminated
Performance variation- difference between any given result
and the optimal or ideal result
Lean Thinking or the Toyota
Production System
Removal of waste- anything not necessary to
produce the product or service
 Emphasis on Flow
 Customer defines value- anything else is waste
Five Steps:
Identify which features create value
Identify the sequence of activities, called value stream
Make the activities Flow
Let the customer pull the product through the process
Perfect the Process
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Six Sigma
Developed by HP, Motorola, and GE
 Aim is to reduce variation (eliminate defects)
 Uses statistical tools
Five Steps: DMAIC
Define
Measure
Analyze
Improve
Control
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Sigma = statistical term. Six sigma =
99.99966% error free rate (3.4 defective
products per million)
FOCUS-PDCA Model
Find an opportunity for improvement
 Organize an effort (assign a team)
 Clarify current understanding of the process
 Understand the process variation and
capability
 Select a strategy for improvement
The PDCA cycle tests the strategy to determine
if it results in improvement
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Kaizen
Japanese word for “improvement”
Includes concepts such as:
Customer orientation
Quality control circles
Automation
Just in time
Zero defects
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Associates for Process
Improvement (API) Improvement
Model
Three questionsWhat are we trying to accomplish?
How will we know that a change is an
improvement?
What changes can we make that will result in
improvement?
These are used to run a test of change using
the PDSA (Plan Do Study Act) cycle
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Baldrige
The goal of the Malcolm Baldrige National Quality
Improvement Act of 1987 was to enhance the
competitiveness of U.S. businesses
Its scope was expanded to health care and education
organizations (in 1999) and to nonprofit/government
organizations (in 2005)
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Source: www.baldrige.gov
Baldrige Criteria categories
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Leadership
Strategic Planning
Focus on patients, customers, markets
Measurement, analysis, and knowledge
management
Staff focus
Process Management
Organizational Performance results
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The basic tools used in CQI are:
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Flowcharts, Control charts, Cause-and-effect
diagrams, Histograms, Check sheets, Pareto
charts, Scatter diagrams
Quality Tools
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Flowchart- map of each step of a process, in the
correct sequence
Cause and Effect diagram- Ishikawa or Fish-bone.
The problem (effect) is stated in a box on the right
side of the chart and likely causes are listed around
major headings (bones) that lead to the effect
Pareto Chart- is a display of the frequency of
occurrences that helps to show the vital few
contributors to a problem so management can
concentrate on correcting them. 80% of the variation
in any process is likely caused by only 20% of the
variables
Quality Tools
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Run Chart- plots of data arranged
chronologically. Used to determine causes of
special cause variation using a center line as
the mean
Control Chart- chronological data along with
upper and lower control limits defining the
limits of common cause variation. Used to
monitor and analyze variation from a process
to see if stable and predictable or unstable
and unpredictable
Quality Tools
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Histogram- a graphical display of the
frquency distribution of the quality
characteristic of interest
FMEA- Failure Mode and Effects Analysismethod for looking at potential problems and
their causes as well as predicting undesired
results
Improvement Tools and
Techniques
Fishbone – root cause
http://www.leankaizen.co.uk/fishbone-diagram-i-ishikawa-diagram.html
Pareto chart
Use to show the frequency of problems or causes in a process.
Dashboards and Scorecards
Dashboard- a real time/current indicator
panel to monitor key performance metrics
 Scorecards- record and report prior-period or
past performance rather than real time
performance
The key issue is how these are used by
leadership to align priorities and achieve
desired organizational results
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Dashboards and Scorecards
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Senior leadership uses measurement to align
organizational effort and achieve higher
levels of organizational performance
Kaplan and Norton introduced the “Balanced
Scorecard”- creates a balance between
financial and other important dimensions of
organizational performance. These often
include quality, service, customers, as well as
finance
IT and Quality
Information technology has tremendous
effect/potential on Quality:
Internet and connectivity to information/education.
Clinical Decision Support systems
Electronic Medical Records
Clinical and Administrative Databases- help with
analyzing data, sharing best practice, order sets,
and predictive modeling.
Computerized Physician Order Entering- can help
decrease errors
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Theory of Constraints
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Focuses on system improvements to
maximize customer value while minimizing
expense
The strength of the process is limited by its
weakest link. TOC concentrates on the
process that slows the speed of product
through the system
Which is the Shewhart process for
performance improvement?
a. Plan, check, do, act
b. Plan, do, check, act
c. Analyze, formulate, implement, evaluate
d. Analyze, implement, control, evaluate
Continuous quality improvement assumes
that:
a. Achievement will be rewarded
b. There is direction from top management
c. There is no upper limit to excellence
d. Interconnected work teams are in place
1. ____ Which of the following best represents a process measure?
a) The number of nurses to patient ratio
b) The number of post-op infections
c) The immunization rate of beneficiaries
d) The rate of measles infections of the children in your healthcare organization
Answer: C.
1. ____ Which type of tool used for diagnosing problems is labeled as the "low tech" tool that
involves a simple data collection form on which you make tally marks to determine how
often something occurs?
a) Fishbone Diagram
b) Check Sheet
c) Pareto Chart
d) Flow Chart
Answer: B.
Performance improvement teams should
consist of:
a. Experts in process management
b. Members from the involved Microsystems
c. Middle managers with experience
d. Physicians and other users
1. ____ Donabedian's definition of quality was two fold-technical and interpersonal but measures
included all except:
a) Process
b) Structure
c) Graphs
d) Outcomes
Answer: C. From: Concepts of Quality Management p. 5
1. ____ The second step is in the Shewhart Cycle is:
a) Acting
b) Planning
c) Implementing
d) Doing
Answer: D.
1. ____ Which of the following represents the three types of medical quality indicator measures?
a) Structure – Practice - Outcome
b) Satisfaction – Process - Outcome
c) Structure – Process - Outcome
d) Structure – Process - Performance
Answer: C.
1. ____ Which statement is most accurate?
a) CQI is one of the three principles of TQ
b) TQ is a component of CQI
c) TQ is a principle of Customer Focus
d) Customer Focus is a principle of CQI
Answer: A.
1. ____ The ‘number of patient complaints’ is an example of what type of clinical quality indicator
or measure?
a) Structure
b) Process
c) Outcomes
d) Productivity
Answer: C.
1. ____ A philosophy or an approach to management that can be characterized by its principles,
practices and techniques. Its three principles are customer focus, continuous
improvement, and teamwork. Each principle is implemented through a set of practices.
The practices are, in turn, supported by a wide array of techniques. This philosophy is:
a) CQI – continuous quality improvement
b) QA – quality assurance
c) TQM – total quality management
d) PI – process improvement
Answer: C.
1. ____ Which of the following Quality Performance Measurements will provide evidence of
Improvement?
a) Patterns
b) Outcomes
c) Indicators
d) Measures
Answer: B.
A bar chart format, with the items rank
ordered on a dependent variable,
such as cost, profit, or satisfaction that
Examines the components of a
problem in terms of their contribution to it is
known as:
a. A run chart
b. A frequency table
c. Pareto analysis
d. Deming cycle
1. ____ Which best describes the fishbone diagram?
a) A simple bar graph that displays data in descending order from left to right
b) A graphic representation of data over time and assists in the monitoring of progress,
both after and improvement intervention and ongoing operations.
c) A diagram used to document how people or things actually move through the physical
workspace.
d) A tool used for identifying and organizing the possible cause and effect of a problem in
a structured format
Answer: D. Continuous Quality Improvement, Chapter 3
1. ____ Which one of the following tools in Quality Improvement is known to picture a series of
events in a process
a) Lead-Time Analysis
b) Fishbone
c) Flowchart
d) Pareto chart
Answer: C. Continuous Quality Improvement Tools, Chapter 3, 34-48
1. ____ The PDSA Cycle is also known as the:
a) Stuart Cycle
b) Shewhart Cycle
c) Gerteis Cycle
d) None
Answer: B. Shewhart Cycle, Continuous Quality Improvement
1. ____ Which of the following is not a principle of Total Quality?
a) Customer Focus
b) Organization Focus
c) Continuous Improvement
d) Teamwork
Answer: B. Three Principles of Quality, Chapter 2, pp. 17-26
Clinical quality measures include:
A. Structure, Process, and Outcomes
B. Process, Outcomes, and Efficiency
C. Economy, Efficiency, and Structure
D. Outcomes, Economy and Efficiency
Answer: A. Structure, process and outcomes.
4/11/2016
1. ____ What are the three (3) principles of Total Quality Management?
a) Structure, Process Outcomes
b) Patient satisfaction, practice patterns, clinical indicators
c) Customer focus, continuous improvement, teamwork
d) Find & implement best, find fault then solutions, find faculty processes & repair
Answer: C. Reference manual: Quality and performance Improvement, p. 17
A bar graph that ranks the data in descending
order from left to right is the definition of:
A.
Pareto Chart
B.
Fishbone Diagram
C. Check Sheet
D. Cause and Effect Diagram

Answer: A. Answers B and D, Fishbone Diagram and Cause and Effect Diagram refer to the same tool, which
identify and organize possible causes of a problem. Answer C is a simple data collection tool utilizing tally
marks to identify how often something occurs. All are tools used to identify problems.
4/11/2016
Quality Improvement emphasizes:
A.
B.
C.
D.

Outcomes
Processes
Prevention
Proper function of equipment
Answer: C. Prevention. Quality Assurance focuses on output. Quality Control focuses on the proper
functioning of equipment in the organization.
4/11/2016
Which of the following is not a principle of total
quality?
A.
B.
C.
D.
Customer focus
Continuous Improvement
Medical Quality
Teamwork
Answer: C
4/11/2016
In an internal medicine practice the measure of the
percent of elderly patients appropriately
receiving an influenza vaccine is considered
an example of a:
A.
Process measure
B.
Outcome measure
C. Capacity measure
D.
Structure measure

Answer: A. Concepts of Quality Management
4/11/2016
Part 5: Customer Satisfaction
Principles and Tools
Definitions
 Customer: Anyone who has expectations regarding
a process’s operation or outputs





Patients
Internal customers: within your organization
External customers: outside your organization
Stakeholder: Anyone who is interested in or is
affected by the work you do
Market: The environment in which you operate and
do business
Customer Satisfaction
Principles and tools




Customers (a.k.a stakeholders) include patients, families,
physicians, payers, business, community organizations,
and schools
Employees of healthcare organizations must develop
effective listening skills and there must be investment in
frequent customer satisfaction survey methods
The number one survey used is the H.C.A.H.P.S. inpatient
survey as it is publicly reported and Medicare
reimbursement will be affected by poor scores
A.H.C.A. now places detailed reports of complaint
investigations on the web for consumer review
Transparency



Ability to judge care, costs and satisfaction from outside
the organization by viewing published elements that
paint a picture of supposed competency
The more transparent the data and information are the
better consumers and stakeholders will be able to
compare and make decisions regarding care
BOG Exam Reference Manual
CAHPS

The National Committee for Quality
Assurance (NCQA) requires all health plans
to submit Consumer Assessment of Health
Plans (CAHPS) data as part of their Health
Employer Data and Information Set (HEDIS)
for accreditation. In the Hospital setting the
CAHPS is called HCAHPS for Hospital
Consumer Assessment of Health Plans.
These are used today to gauge Patient
Satisfaction with their hospital care
Patient Expectations:
Picker Institute
(dimensions of care)
4/11/2016
Leapfrog Group
“In an effort to improve predictability, some
businesses have joined to create
organizations such as the Leapfrog Group,
an organization representing close to 40
million people, to mandate certain processes
be initiated to improve quality for their
constituents.”
BOG Exam Manual
Resources



https://www.cahps.ahrq.gov
http://www.hcahpsonline.org
http://www.pickerinstitute.org
Pay-for-performance
CMS initiative rewards hospitals that show improvement in
specific areas compared to other hospitals
The reward can come in the form of getting the entire
Medicare payment or getting additional money from
hospitals that were penalized and didn’t show
improvement
One area where pay-for-performance may be used is in
measuring customer satisfaction with the Consumer
Assessment of Healthcare Providers and Systems
Hospital Survey (H-CAHPS), mandated by CMS

BOG Exam Reference Manual
Part 6: Clinical Pathways and
Disease Management

Definitions



Evidence-based medicine
Evidence-based management
Evidence-based performance
Evidence Based Medicine

The conscientious, explicit and judicious use
of current best evidence in making decisions
about the care of individual patients. The
practice of evidence- based medicine means
integrating individual clinical expertise with
the best available external clinical evidence
from systematic research
Clinical (Care) Pathways


A methodology for the mutual decision
making and organization of care for a welldefined group of patients during a welldefined period
Aim is to enhance the quality of care by
improving patient outcomes, promoting
patient safety, increasing patient satisfaction,
and optimizing the use of resources
Clinical Practice Guidelines


Are systematically developed statements to
assist practitioners and patient decisions
about appropriate healthcare for specific
clinical circumstances
Examples can be found on the Internet in the
Agency for Healthcare Research and Quality
(AHRQ) established National Guideline
Clearinghouse (NGC)
Clinical methodologies

Clinical pathways



Evidenced-based medicine



Compliance with regulatory guidelines
Maintains standard of care
Population health


Reduction in length of stay
Increased patient satisfaction
The effects of healthcare reform
Pay for Performance

Value-Based purchasing
More Definitions




Protocols- determine how functional elements of
care are carried out
Care Plans- expectations for the care of “individual”
patients based on evaluation of their needsaggregates of functional protocols
Care Guidelines/Pathways- formally established
expectations that define the normal steps or
processes in the care of a clinically related “group”
of patients
The professional is always considering the
modification of the expectation to the individual
needs
Protocols



Developing thru consensus helps buy-in
Should be reviewed regularly for updates
Should include provisions for the attending
physician to justify exceptions
Protocols improve processes
by:






Eliminating unnecessary or redundant tasks
(waste)
Alerting for tasks previously overlooked or
omitted
Standardizing supplies with savings
Substituting lower-cost personnel for specific
activities
Reducing errors or delays
Reengineering the care process
Success factors for clinical
change






Organizational capabilities for change
Infrastructure for implementation
Implementation strategies
Medical group characteristics
Guideline characteristics
External environment
Barriers to Physician
Adherence to Guidelines







Knowledge
Attitude
Lack of familiarity
Lack of awareness
Lack of agreement with guidelines- both specific
and general
Lack of motivation
Patient and environmental factors- lack of time,
resources, etc…
Prevention and Health
Promotion






Prevention- direct interventions to avoid or reduce disease
or disability
Health promotion- all activities to change patient or
customer behavior
Primary prevention- activities before the disease occurs
that eliminate or reduce its occurrence
Secondary prevention- reduces the consequences of
disease, often by early detection and treatment
Tertiary prevention- avoidance of complications or
sequellae
Cost effectiveness can be improved by reducing the
intervention costs or the adverse consequences or by
increasing the effectiveness of the preventive intervention

Successful approach:




A mechanism to develop a local, evidence-based
consensus on care
Well-designed processes to implement that consensus
A deliberate program of outreach to the community on
disease prevention and health promotion
A system to review actual performance and identify future
improvement
Source: Griffith
1. ____ Which of the following is NOT one of the three types of Clinical Expectations
a) Functional Protocols
b) Care Plans
c) Patient Management Protocols
d) Discharge Plans
Answer: D. Chapter 7–Improving Quality and Economy in Patient Care, page 248
In a hospital setting, a critical pathway is
best described as:
a.
A document that focuses on efficiency and
describes a standard set of activities
to be performed for a defined category of
patients
b.
A set of guidelines that focus on identifying
those decision points which should
lead to the consistent provision of appropriate
clinical practice
c.
Any attempt to standardize clinical activities
based upon diagnostic categories
and projected outcomes
d. Decision tree that focuses on physician
decision making
Part 7: Utilization Review and
Management Regulations
Regulations
 Public:
 Local rules and regulations governing hospitals and other
healthcare delivery organizations (ex. building codes)
 State rules and regulations governing hospitals and other
healthcare delivery organizations (ex. licensure,
environmental, insurance)
 Federal rules and regulations governing hospitals and other
healthcare delivery organizations (i.e. CMS, OSHA, FDA)
 Private:
 NCQA
Utilization Management

Utilization Review




Pre-admission
Concurrent review
Outpatient review
Case Management
Physician Gate-Keeping
Definitions

Efficiency- maximization of the quality of a
comparable unit of healthcare delivered for a
given unit of health resources used
Utilization Review




Purpose in hospitals and related healthcare
organizations has expanded
Length of stay
Clinical pathways
Disease management




Care coordination
Discharge planning
Data gathering
Process improvement
National Quality Initiative

The Joint Commission




Accreditation proces
National Patient Safety Goals
Sentinel Events
The Leapfrog Group
CMS


Conditions for participation
Quality Reporting/Transparency
Pay for Reporting/Pay for Performance
National Quality Initiatives



The Hospital IQR program is intended to equip consumers with quality of care
information to make more informed decisions about healthcare options. It is also
intended to encourage hospitals and clinicians to improve the quality of inpatient care
provided to all patients. The hospital quality of care information gathered through the
program is available to consumers on the Hospital Compare website
There are a total of 23 quality of care measures for hospitals participating in the
Hospital Outpatient Quality Reporting (OQR) Program. The quality of care measures,
listed below, include 14 clinical performance measures, seven Medicare fee-forservice claims-based measures, and two structural measures
Hospital Value-Based Program (VBP)aims to encourage hospitals to improve the
quality and safety of care that Medicare beneficiaries and all patients receive during
acute-care inpatient hospital stays. Hospital VBP will do so by motivating hospitals to:



Eliminate or reduce the occurrence of adverse events.
Adopt care standards and protocols that medical evidence shows result in the best outcomes
for the most patients
Re-engineer hospital processes at all levels in ways that improve patients’ experience of care
The Joint Commission


2002 Shared Visions-New Pathways: shift from
preparing for survey to continuous systematic
improvement/continuous compliance
2004 New Hospital Accreditation Process




Revised standards
Targeted process based on organization’s data
Online standards compliance documentation
Electronic communication
Tracer methodology
Medical records (TJC)
• Must contain sufficient information to identify the patient
and to support the diagnosis and treatment
• Must furnish adequate documentation of results
• Include medical history, diagnostic and therapeutic
orders, all reports, consultations, tests, progress notes
and clinical resume entered and signed by the attending
physician
• Failure to maintain complete, accurate and current
records has adverse effects for defendants in
malpractice litigation
BOG Exam Manual
“Accountability Measures — Using
Measurement to Promote Quality
Improvement”



In 2002, accredited hospitals were required to collect and report
data on performance for at least two of four core measure sets
(acute myocardial infarction, heart failure, pneumonia, and
pregnancy)
Hospitals provide data to the Joint Commission from a selection of
57 inpatient measures; currently, 31 of these are publicly reported
Example: in 2009, 96.8% of hospitals showed performance levels
greater than 90% in administering beta-blockers at discharge to
patients who had had an acute myocardial infarction, as compared
with 49.1% in 2002
Mark
R. Chassin, M.D., M.P.P., M.P.H., Jerod M. Loeb, Ph.D., Stephen P. Schmaltz, Ph.D.,
and Robert M. Wachter, M.D.,N Engl J Med 2010; 363:683-688August 12, 2010
Continuous Improvement
Process



Insight into process> measurement of current
process outcomes> comparison to
benchmark expectations> PDCA> redesign
work process, change motivation and
incentives, and new training and education
These all lead to changing clinical behavior
Participation and empowerment are critical
components of the process
Decision Theory- routes to
improving Quality




Increasing the value of intervention
Reducing the cost of intervention
Improving the selection of intervention
Reducing the cost of delay
Premises to control cost and
quality




The community at large must establish the
desired level of economy
Community decisions require input and advice
from healthcare professionals
The control of cost and quality depends on the
entire institutional infrastructure
Cost and quality is affected by the array of
services selected- this can be stabilized by a
clinical improvement program building
consensus providing each patient with optimal
treatment
Study Questions
For the Quality Indicators discussion, the best
definition for Effectiveness is:
A.
the ability to provide the desired effect
B.
how well an approach or process taking place
in the usual practice setting accomplishes its
intended purpose
C. ratio of outputs to inputs
D. how well things are done compared to a
standard

Answer: B. Efficacy is defined by A; Productivity is defined by C; Efficiency is
defined by D.
4/11/2016
According to JCAHO standards, "...the ultimate
authority and responsibility for the oversight
and delivery of healthcare rendered..."
belongs to :
A. The CEO
B. The hospital's governing board
C. The Chief Medical Officer
D. The General Counsel

Answer: B. The hospital's governing board
4/11/2016
1. ____ Decision theory suggests four routes to improving the contribution of medicine to health or
improving the quality of care. Which of the following is not one of the four routes:
a) Improving the selection of intervention
b) Reducing the cost of expenses
c) Increasing the value of intervention
d) Reducing the cost of intervention
Answer: B. The Well-Managed Healthcare Organization, page 243
1. ____ Which of the following statements is true:
By understanding the quality continuum in healthcare, managers can begin to see:
a) Success at CQI but not attainment of quality organizational culture
b) Why defining clinical practice guidelines does not in itself guarantee healthcare quality
c) Why organizational development efforts, independent of clinical context, may not yield
expected results
d) All of the above
Answer: D.
Medicare DRG payment is highly dependent
upon a hospital’s case mix
index. This index represents the average
relative weight for all Medicare
patients treated in a:
a. Specific nursing unit or specialty area
b. Specific period
c. Common geographic market
d. Specific facility
The applicability of continuous
improvement in healthcare organizations
assumes:
a. An upper limit of improvement
b. The physician’s perspective is dominant
c. An organizational commitment
d. The elimination of outliers
Additional Sample Questions
http://www.ache.org/mbership/credentialing/EX
AM/govselftest.cfm
4/11/2016
Which of the following is an output-related
performance measure?
a. Provider productivity
b. Board satisfaction
c. Customer loyalty index
d. Paid nursing hours
In order to verify that an instrument is reporting the correct
values for quantitative lab tests, the laboratory often
uses graphs known as "Levy-Jennings charts" to
document daily results obtained from assaying a
product that contains a known amount of glucose (or
calcium, magnesium, etc.). Those charts are best
described as:
A.
QA
B.
QC
C.
QI
D.
QI

Answer: B.
4/11/2016
1. ____ The decision theory suggests that there are four routes to improve the contribution to
improve the quality of healthcare services. Which of the following are not in accordance
with that theory?
a) Reduce the cost of intervention
b) Reduce the cost of delay
c) Increase the value of the Intervention
d) Include the selection of intervention that cost more than their value
Answer: D. Improving the selection of intervention that cost more that their value. The WellManaged Healthcare Organization, JR Griffith, pp. 243)
1. ____ The Tagushi Law relates to:
a) Uniformity
b) Efficiency
c) Productivity
d) All
Answer: D.
1. ____ The Dual Nature of Quality is important for healthcare managers to understand because:
a) It evaluates not only the physician's ability to diagnose an illness correctly, but also
evaluates the physician's ability to carry out a procedure related to that diagnosis.
b) It includes both content quality and service quality
c) Managers can only impact administrative aspects of quality, while physicians control
the patient encounter. They must work together to achieve total quality
d) Each competing aspect of quality works against the other unless clearly defined
management roles are embraced.
Answer: B. Content quality refers to clinical expertise and service quality refers to personal
components of care (empathy and communication)
1. ____ Which CQI tool is most effective for representing data over time to assist in the monitoring
of progress:
a) Workflow diagram
b) Run chart
c) Lead-time analysis
d) Pareto chart
Answer: B. Continuous Quality Improvement Tools, Chapter 3, page 48
1. ____ Clinical improvement strategies are driven by:
a) Cost Analysis
b) Benchmarking of Outcomes
c) Unsatisfactory Outcomes
d) Peer Review
Answer: C. pp261 The Well-Managed Healthcare Organization
1. ____ Which is not a type of quality measure?
a) Structure
b) Appropriateness
c) Process
d) Outcomes
Answer: B.
1. ____ A more mature healthcare organization will display the following characteristic along the
quality continuum for healthcare managers:
a) Hospital leaders demonstrate quality through their actions and through the direction
they set for the organization
b) Quality is the job of specialist, while responsibilities for both JCAHO and continuous
improvement belong to the CQI department
c) Meeting JCAHO standards is the primary focus
d) Elimination of defects is the hallmark of the quality program
Answer: A. Page 12-13, Chapter 1 (Concepts of Quality Management)
1. ____ Clinical quality measures include all except:
a) Appropriateness
b) Labor expenses
c) Efficiency
d) Effectiveness
Answer: B.
1. ____ The major elements of continuous improvement approach include all of the following
except:
a) Emphasis on the necessity for organization-wide commitment
b) Focus on improvement of overall or group performance
c) Focus on correction of outliers
d) Assumes no upper limit
Answer: C. p.246 The Well Managed Healthcare Organization
1. ____ Which one is not one of the three principles of total quality?
a) Customer Focus
b) Performance indicators
c) Team work
d) Continuous improvement
Answer: B.
1. ____ Direct interventions undertaken to avoid or reduce disease or disability are collectively
known as:
a) Continuous Quality Improvement
b) Health Promotion
c) Case Management
d) Prevention
Answer: D. The Well-Managed Healthcare Organization, p. 264
Which of the following networks is intended
to reduce costs and improve
quality by giving access to financial, clinical
and administrative
information?
a. Community health information network
(CHIN)
b. Local area health network (LAHN)
c. Virtual private health network (FPHN)
d. Health file transfer network (HFTN)
What is a primary reason for conducting
continuing education for staff?
a. Staff will think the organization cares about
them
b. There are significant short-term operating
efficiencies
c. It is a long-term commitment to the patient
d. The Joint Commission and NCQA required it
1. ____ Which of the following is not defined as a dimension of care relevant to Patient
Expectations in the ambulatory care setting?
a) Access
b) Courtesy
c) Accurate and timely billing
d) Continuity and transition
Answer: C. Source: Picker Institute
You are planning to conduct an assessment
of the utilization patterns in
your organization’s emergency department
over the past three years.
Which of the following techniques would be
most appropriate?
a. Strategic Planning
b. Trend Analysis
c. Situational Analysis
d. Survey Research
The arrival of women for obstetrical
deliveries or patient flow in an
emergency department can best be analyzed
through the use of which
technique?
a. Pert Charting
b. Stochastic Modeling
c. Gant Charting
d. Monte Carlo Simulation
One approach for measuring technical
quality of clinical support services
is:
a. Patient satisfaction scores
b. Degree of continuity of care
c. Appropriateness testing
d. Process review
Summary

Provided an overview of topics not covered in
depth in the readings:





Benchmarking techniques
Medical staff peer review and disciplinary processes
Risk management principles and programs
Utilization review and management regulations
Highlighted topics found in the recommended
readings:



Performance and process improvement
Customer satisfaction principles and tools
Clinical pathways and disease management
4/11/2016
References and Resources



The Well Managed Healthcare Organization
by John Griffith and Ken White
Applying Quality Management in Healthcare:
A Process for Improvement by Diane L. Kelly
Additional Resources:
http://www.ache.org/mbership/credentialing/EXAM/booklist.
cfm
4/11/2016
Resources Related to Quality















Agency for Healthcare Research and Quality (AHRQ), www.ahrq.gov
American Association of Homes and Services (AAHSA), www.aahsa.org
American Healthcare Association (AHCA), www.ahca.org
American Hospital Association (AHA), www.aha.org
American Medical Association (AMA), www.ama-assn.org
American Society for Quality (ASQ), www.asq.org
Centers for Medicare and Medicaid Services (CMS), www.cms.hhs.gov
Delmarva Foundation (DF), www.delmarvafoundation.org
Healthcare Quality Certification Board (CPHQ), www.cphq.org
Institute for Quality Improvement (IHI), www.ihi.org
Joint Commision on Accreditation of Healthcare Organizations (JCAHO),
www.jointcommission.org
Journal of the American Medical Association (JAMA), www.jama.ama-assn.org
National Association for Healthcare Quality (NAHQ), www.nahq.org
National Committee for Quality Assurance (NCQA), www.ncqa.org
National Quality Forum (NQF), www.qualityforum.org
4/11/2016