Introduction to Health Care Quality

Theory, Methods, and Tools

Yosef D. Dlugacz

• Publisher: Jossey-Bass
• Year: 2016
• Print ISBN: 9781118777916
• eBook ISBN: 9781118779590
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Introduction to Health Care Quality explores the issues of quality management in today's health care environment, and provides clear guidance on new and perennial challenges in the field. The idea of 'quality' is examined in the context of a variety of health care situations, with practical emphasis on assessment, monitoring, analysis, and improvement. Students will learn how to utilize statistical tools, patient data, and more to understand new models of reimbursement, including pay for performance and value-based purchasing. They will also learn how to learn how to incorporate technology into everyday practice. Each chapter centers on an essential concept, but builds upon previous chapters to reinforce the material and equip students with a deeper understanding of the modern health care industry. Real-world situations are highlighted to show the intersection of theory and application, while cutting-edge methodologies and models prepare students for today's data-driven health care environment.

Health care quality is defined and assessed according to setting, with factors such as standards, laws, regulations, accreditation, and consumerism impacting measurement and analysis in tremendous ways. This book provides an overview of this complex field, with insightful discussion and expert practical guidance.

Health care today is worlds away from any other point in history. As the field grows ever more complex, quality management becomes increasingly critical for ensuring optimal patient care. Introduction to Health Care Quality helps students and professionals make sense of the issues, and provide top-notch service in today's rapidly changing health care environment.

PART ONE
QUALITY MANAGEMENT FUNDAMENTALS

CHAPTER ONE
FOUNDATIONS OF HEALTH CARE QUALITY

Chapter Outline

1. Defining Quality
2. Contributions of Quality Theorists—Nothing New under the Sun
3. Quality Management Methodologies
4. Organizations Making an Impact on Quality and Safety Standards
5. Centers for Medicare and Medicaid Services
6. Institute for Healthcare Improvement
7. Agency for Health Research and Quality
8. National Quality Forum
9. The Leapfrog Group
10. Data: The Foundation of Quality Management
11. Summary
12. Key Terms
13. Quality Concepts in Action
14. References
15. Suggestions for Further Reading
16. Useful Websites

Key Concepts

• Understand issues involved in defining the concept of quality in health care.
• Introduce important quality theorists.
• Describe quality methodologies.
• Explain the role of agencies and groups that have an impact on health care quality.
• Review the role of data as the foundation of quality management.

Quality, which is easily recognized—and even more easily recognized in its absence—is surprisingly hard to define. One knows it when one experiences it, be it in a car, a restaurant, or a health care organization, and one knows when it is missing. It can be considered an attitude or orientation, a dedication of individuals in an organization to strive for excellence, or quality can be based on an individual's perception and his or her value system.

Perhaps the least controversial definition of quality was proposed in 1990 by the Institute of Medicine (IOM), an independent, nonprofit organization that advises decision makers and the public about health care issues: “Quality of 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” (Lohr, 4). It should be noted that “desired health outcomes” are difficult to define and measure, and may be dependent on knowing the population and the community served. To understand quality, it is useful to know the history of how quality management has evolved, the significant thinkers and theorists who have contributed to defining quality, and the organizations that have influenced how health care is delivered in the United States.

Defining Quality

Quality standards are not fixed entities but rather should be thought of as a moving target, going between better quality or worse quality, defined by the expectations of customers. If customer expectations are met, quality is considered to be high. However, meeting customer expectations is complicated because customers themselves may not even be aware of or able to articulate their expectations regarding quality. For this reason, many organizations conduct satisfaction surveys and analyze complaints in order to better understand what customers want from their health care experience.

In fact, health care quality has to meet the expectations of many groups of customers: patients and their families, physicians, organizations, regulators, payers, and communities. Each of these customers may have different expectations of quality, such as access to care (do customers/patients get the care they need?) and effectiveness of care (are they better?). Medical outcome expectations, or effectiveness, are usually set through professional organizations and adopted as standards of care. Today, patients and payers have information and opinions about their care that is eroding the primacy of physicians to be the sole setters of expectations. Patients, communities, governmental agencies, and payers are setting standards in addition to physicians.

Contributions of Quality Theorists—Nothing New under the Sun

Many of the early quality theorists defined methods, tools, and techniques that are still being used today in health care settings. Many of the problems identified by these quality thinkers still exist today. Many of the solutions they proposed are still being discussed today. Each of these prominent theorists contributed something to our understanding of what quality means and how to provide quality outcomes. A brief introduction to some of the highlights of their work in quality follows.

Florence Nightingale

In thinking about medical quality, the place to start is with Florence Nightingale (1820–1910), an English social reformer and statistician. She is considered to be the founder of modern nursing and became famous for her nursing skills with wounded soldiers during the Crimean War. However, her work encompassed more than improving nursing practice and broadening nursing education. In addition, she was an advocate for health care reform and wrote works to educate laypeople about medical knowledge. Nightingale was also a social reformer, especially of women's rights and hunger relief. She had the good fortune to be born into a wealthy family to a progressive‐thinking father who encouraged her education, especially her exceptional mathematical and analytic skills.

Nightingale can be credited with creating the framework for quality management, using data as the bases for graphics about monthly improvements in mortality associated with her sanitary reforms. She understood the association among overcrowding, sanitation, infection, and mortality. In this way, she linked cause with effect. She pioneered the visual representation of statistical information, using the pie chart (see Figure 1.1) and the histogram (see Figure 1.2) to illustrate sources of patient mortality.

Figure 1.1 Causes of Patient Mortality Pie Chart

Figure 1.2 Causes of Patient Mortality Histogram

These figures reveal the same information in different formats. Both, however, make it clear at a glance that the majority of deaths (60 percent) were the result of poor hygiene and sanitation, double the number of deaths from battle wounds. Graphical displays are powerful representations of information.

Nightingale's comprehensive statistical analysis of rural India's sanitation was instrumental in reform. In 1873, she reported that mortality among the soldiers in India had declined from 69 to 18 per 1,000. She knew that “statistics of a hospital ought to include not only the nominal list of the dead, but the cause of death” as well (Joint Commission on Accreditation of Healthcare Organizations [JCAHO] 1999, 146). Today, 150 years after her work, the health care community sees the value of using outcomes measurements (data describing a patient's health state) in identifying quality care and cost effectiveness. Nightingale “realized that if judgments of outcomes were to matter, it would require attention to accurate data collection and accurately defined measures” (Batalden and Mohr 1999, 11).

In addition to understanding and exposing cause and effects and promoting outcomes measurements based on creditable data, Nightingale also understood that problems could be caused not by individuals alone but by systems. She understood the structures, processes, and waste in health care organizations; she set standards for staffing. All these ideas are still being discussed in quality management departments today. Many people think they are discovering new ideas, but Nightingale was using these ideas, and most productively, long ago.

Ernest A. Codman

Like Nightingale, Ernest Amory Codman (1869–1940) was a medical reformer who sought to improve medical care by analyzing outcomes, or what he called end results. He tracked his patients on end‐results cards, noting demographic data, diagnosis, treatment, and outcomes—data that health care organizations are still attempting to accurately collect and analyze today. Codman worked to standardize care and reduce variation in order to create efficiency as well as good outcomes. He was the first physician to promote the study of outcomes and evidence‐based medicine (making judicious use of the most current research and information to make medical decisions); before Codman, only Florence Nightingale had concerned herself with these ideas.

Codman believed that physicians should be held accountable for the success of their care, and if their patients did not have good outcomes, physicians should question why not and change their practice accordingly. Codman's idea was straightforward: “The common sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire, ‘If not, why not?’ wit...

Table of contents

• Cover
• Title Page
• Copyright
• Table of Contents
• Dedication
• List of Figures and Tables Preface
• Preface
• Acknowledgments
• About the Author
• Introduction
• Part I: Quality Management Fundamentals
• Part II: Applying Quality Tools and Techniques
• Index
• End User License Agreement