Health Care Quality Management

Tools and Applications

Thomas K. Ross

• Editorial: Jossey-Bass
• Año: 2013
• ISBN:
  9781118603895
• Edición: 1
• Categoría: Medizin
• Categoría: Gesundheitswesen, Verwaltung & Pflege

In today's challenging health care environment, health care organizations are faced with improving patient outcomes, redesigning business processes, and executing quality and risk management initiatives. Health Care Quality Management offers an introduction to the field and practice of quality management and reveals the best practices and strategies health care organizations can adopt to improve patient outcomes and program quality.

• Filled with illustrative case studies that show how business processes can be restructured to achieve improvements in quality, risk reduction, and other key business results and outcomes
• Clearly demonstrates how to effectively use process analysis tools to identify issues and causes, select corrective actions, and monitor implemented solutions
• Includes vital information on the use of statistical process control to monitor system performance (variables) and outcomes (attributes)
• Also contains multiple data sets that can be used to practice the skills and tools discussed and reviews examples of where and how the tools have been applied in health care
• Provides information on root cause analysis and failure mode effects analysis and offers, as discussion, the clinical tools and applications that are used to improve patient care

By emphasizing the tools of statistics and information technology, this book teaches future health care professionals how to identify opportunities for quality improvement and use the tools to make those improvements.

PART 1
THE STATE OF QUALITY MANAGEMENT IN HEALTH CARE

When examining quality in health care, one is immediately struck by the slowness of change. Some companies measure their error rates in millions, while the health care industry continues to measure error rates in hundreds. Dr. David Bates found 1.4 pharmaceutical errors per admission; this is a far cry from the three errors per one million opportunities other organizations pursue. A major difference between health care and other industries lies in defining quality. Health care produces thousands of outputs for patients who vary dramatically in age and condition, so defining what constitutes good medical practice is extremely challenging.

Chapter One introduces the reader to definitions of quality to induce the reader to think differently about the subject. The lives of the early quality pioneers in health care are examined to highlight their goals, challenges, and the impact they had on medical practice. Machiavelli noted, “There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.” The reader will see that those attempting to change medical practice face stiff opposition from those who believe things are as they should be. Chapter One reviews the evolution of production processes and demonstrates how quality control methods have evolved with technology and consumer demand. It is essential that health care providers adopt the perspective and tools of other industries and employ system thinking throughout their work. Only a broad, system perspective will enable health care to adopt changes that will cut across departments and organizations and improve health outcomes. The central idea of this text is: no measurement, no management, no mission. If an organization cannot define and measure what it produces, it will not be able to effectively manage its operations, and without management it will neither fulfill its mission nor endure.

Variation in medical practice and inability to predict outcomes are the main problems in health care. Chapter Two discusses how variability arises from differences in medical knowledge and patient preferences and from the tendency of humans to commit error. Variability arising from treatment choice and ability to carry out the treatment plan is the basis for the observed differences in the use of treatments and resources among patients. If variability is the problem, standardization through practice guidelines is one solution. The chapter concludes by reviewing paradigms for examining health care quality.

Chapter Two describes Nash’s Three Faces of Quality, which defines the foundation, means, and goals needed for an effective quality management system. Effective quality management begins with a foundation built on science and statistics and requires the development of tools that will provide medical personnel with information to identify and improve suboptimal processes. Given the unique nature of health care, the industry must recognize the benefit of standardizing treatment while ensuring the ability of providers to respond to unique cases.

Chapter Three examines previous attempts to ensure health care quality and the economic incentives in the current system. It is clear that economic incentives and regulation have altered how health care is delivered, but it is less clear whether either has substantially improved quality. Current programs are reviewed, reminding us that we will get more of what we pay for, and so we must be mindful of how resources are shifted. If we want quality, then we must measure it directly. Half measures and proxies can produce more harm than good.

CHAPTER 1
QUALITY IN HEALTH CARE

LEARNING OBJECTIVES

1. 1. Set the context for the study of quality in health care
2. 2. Understand the goals of quality management
3. 3. Define quality and health care quality and understand their components
4. 4. Recognize the contributions and challenges faced by health care quality pioneers
5. 5. Understand the evolution of production and quality management processes
6. 6. Apply system thinking to health care processes

Introduction

The most prolific serial killers in the United States are among the least known. While the Green River killer in Washington and the Killer Clown of Chicago are well known, serial killers in health care have been responsible for a higher number of deaths over extended periods of time. What does serial killing have to do with quality management in health care? The issue is, how can health care workers kill dozens of patients without being detected? More to the point, how can highly trained personnel working together to improve the health of their patients realize the worst possible outcome without unleashing an investigative process to identify and understand what was responsible for the deaths of their patients?

The most prolific serial killer in U.S. medical history may be Donald Harvey, who killed between 37 and 87 patients in two hospitals in Ohio and Kentucky over a 17-year period. Harvey was able to continue his murder spree by targeting critically ill patients and changing his method of killing. The death of critically ill patients is not unexpected, and there was no easy-to-identify pattern in Harvey’s killings that would suggest something other than natural forces were at work. Harvey’s unmasking was rapid when it finally occurred. He targeted a man whose condition was thought to be improving by his family and the hospital staff; his unexpected death sparked an investigation.

The authorities determined the death was a homicide and immediately began investigating the man’s family. Satisfied that no member of his family was responsible, the police began investigating his medical providers. Shortly after beginning their investigation at Harvey’s employer, they learned from multiple coworkers that Harvey was known as “the Angel of Death” due to his frequent presence when patients expired. Unfortunately, Harvey was no angel. He soon confessed to killing many patients.

Charles Cullen provides a second example. Unlike Harvey, Cullen worked in 10 health care institutions in New Jersey and Pennsylvania. Over 16 years Cullen murdered between 18 and 40 patients. Cullen killed many of his patients by administering overdoses of digoxin. Despite concerns over suspicious deaths, investigations were handled internally by his employers and failed to discover any wrongdoing. Cullen frequently changed jobs, and any concerns, if relayed, did not prevent him from finding continuous employment in the health care field. In the end it was only the dogged efforts of the family of one of his victims that resulted in his arrest for the death of their loved one and in the discovery of the other cases.

The issue for quality management is, how can the worst possible health care outcome occur repeatedly without signaling that there is a problem in the system that requires investigation? Walshe and Shortell in “When Things Go Wrong: How Health Care Organizations Deal with Major Failures” (2004) note that health care failures differ substantially from failures in other industries. Harvey’s case exemplifies the first of these differences: it is not uncommon for critically ill people to die, so questions are not raised when the expected happens. A second difference is that the cost of health care failure is borne almost entirely by patients and their families. Contrast a patient death with a plane crash. In a plane crash not only the passengers die; the flight crew also perishes and a multimillion-dollar aircraft is destroyed. A third difference is that health care is largely a self-governing profession that often works to conceal errors rather than have its shortcomings exposed to public scrutiny (Walshe and Shortell 2004).

---

outcome

the results of medical treatment

---

---

system

a set of interrelated elements...