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Reflection 3

This reflection paper must include comment and content based on this week’s module and/or reflection on a specific topic that has resonated with you this semester.

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Students are required to submit a reflection paper that highlights a topic/subject of choice from the module readings. This could be something new learned, or alternatives to some solutions, or personal experience that relates to any of the course reading materials. Criteria is as follows:

· 1½ to 2 pages in length, typed in double space in Word using 12-point Times New Roman font (coverage page and references page not included).

· Insightful and of academic merit.

· Citing of references is not required unless you provide an exact quote from either your textbook or an assigned reading; however, you must state somewhere in the paper which chapter or assigned reading your topic/subject of choice is located.

Chapter 12

Organizing for Quality

Outline

Introduction

Quality Management System

Quality Management Plan

A Hospitable Environment

Introduction

An organization’s governing body, usually the board of trustees, is ultimately responsible for the quality of health care services. The board exercises this duty through oversight of quality management activities. If a health care organization does not have a board of trustees, the legal owners of the business assume the responsibility of quality.

To accomplish quality management (QM) functions, health care organizations have a quality management system or framework that defines and guides all measurement, assessment, and improvement activities.

Introduction (2)

Many HC organizations are required by accreditation standards or government regulations to have a plan in place that outlines their quality management activities and strategies, known as a quality management plan.

Although a written quality management plan is not required, many accredited organizations have them in place.

Quality Management System

HC quality management systems vary according to their governance and management structure. In general, six groups fulfill QM roles:

The board-oversees and supports measurement, assessment and improvement activities

Administration-responsible for the organization and management of measurement, assessment, and improvement activities

Coordinating Committee (or Individual)-directs measurement, assessment, and improvement activities

Medical Staff-develop and participate in measurement, assessment, and improvement activities related to the performance of physicians and other medical professionals who practice independently

Departments-develop and participate in measurement, assessment, and improvement activities related to non-physician performance

Quality Support Services-assist all groups in the organization with measurement, assessment, and improvement activities

Please review the aforementioned groups and their responsibilities on pages 304-310.

Quality Management System (2)

Quality Support Services-these are individuals or job titles in an organization that work together to assist with quality management activities. In larger organizations, an entire department may be devoted to these job functions. In smaller organizations, these responsibilities may fall to one or two individuals.

Common quality related positions include:

Quality Director

Patient Safety Coordinator

Physician Quality Advisor

Case Manager/Utilization Reviewer

Patient Advocate

Risk Manager

Infection Control Coordinator

Compliance Officer

Data Analyst

You can read about the specific job duties of these positions on pages 309-310.

Quality Management Plan

The Quality Management Plan describes the organization’s process for measuring, assessing and improving performance. It can also be referred to as a:

Performance improvement plan (most commonly known as this)

Quality and patient safety plan

The purpose of the plan is to serve as a blueprint for all quality functions and activities. At a minimum it includes the following elements:

A quality statement

A description of the quality management infrastructure

Details of performance measurement, assessment, and improvement activities

An evaluation of the effectiveness of quality management activities

Quality management plan (2)

Quality statement-describes the goal to which all QM activities ae directed. The quality statement reflects the organization’s ideals and often incorporates its mission, vision, and values.

Quality management infrastructure-this element of the plan describes each stakeholder and their associated responsibilities. At a minimum, the infrastructure description should include the following:

Major stakeholders and expectations for their participation in QM functions

Committee structure, such as committees involved, their chairs and members, meeting frequency, bylaws if applicable, and methods of communicating)

Quality management plans (3)

Performance measurement, assessment, and improvement activities-these part of the plan details the variables to be measured and the execution of assessment and improvement activities.

It is important to note that in some organizations the QM plan does not change, it is reviewed yearly and updated if needed but in others it is what we describe as a living document-it is updated and revised frequently.

Evaluation of the effectiveness of QM activities-this section of the plan details evaluation activities. The coordinating committee is responsible (yearly) for evaluating overall QM performance by:

Determining whether the quality infrastructure has improved organizational performance

Making changes when necessary

Critical Concept 12.3 on pages 314-315 depict a template for a quality plan

A hospitable environment

Introduction

To improve quality, an organization must have the will to improve, the capacity to translate that will into positive change, the infrastructure necessary to support improvement, and an environment hospitable to quality.

Environment in this sense relates to culture. Culture is a system of shared actions, values, and beliefs that guides the behavior of an organization’s members.

There are three levels of organizational culture:

Observable Culture-the way things are done in the organization

Shared Values-awareness of organizational values and recognition of their importance

Common Assumptions-realties that members take for granted and share as a result of their joint experiences

Organizational culture

Is pivotal to successful continuous improvement, it influences the manner in which QM is implemented and executed.

Cultural tone affects the way all members of the organization interact. In a culture committed to quality, senior leaders and managers lead by example and encourage an environment of open, candid dialogue, and continuous improvement.

It should be noted that there is not a “correct” culture, what works for one organization may not work for others.

However, there are characteristics that are shared across organizations with a high performing culture (please see Critical Concept 12.4 on page 318).

Organizational culture (2)

Organizational culture is the root of many performance problems. If issues are identified (such as lack of trust, complacency, inefficiency, etc.) then leadership must work to achieve cultural change. Cultural change is generally instituted in the following steps:

Uncover core values and beliefs, including both stated goals and goals embedded in employee behavior

Look for cultural characteristics that are undermining the organization’s capacity to continuously improve

Establish new behavioral norms that demonstrate desired values

Repeat the steps over a long period. Emphasize to new hires the importance of the organization’s culture. Reinforce desirable behavior.

End of chapter 12

3 0 1

L e a r n i n g O b j e c t i v e s

C H A P T E R 1 2

O R G A N I Z I N G F O R Q U A L I T Y

After reading this chapter, you will be able to

➤ identify groups responsible for quality in a healthcare organization,

➤ describe typical participants in healthcare quality management activities,

➤ explain the purpose and content of a quality management plan,

➤ recognize aspects of organizational culture that influence the effectiveness of

quality management, and

➤ discuss strategies for overcoming environmental characteristics inhospitable to

quality

improvement.

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I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t3 0 2

➤

Governing body

➤ High-performing

healthcare

organization

➤

Organizational culture

➤ Organized medical

staff

➤ Performance

excellence

➤ Quality management

plan

➤ Quality management

system

➤ Risk

management

Q
uality does not happen by accident. Organizations must make an intentional
effort to measure, assess, and improve performance. Not only must an organiza-
tion’s board of trustees and senior management be committed to quality, but they

also must create a framework for accomplishing quality activities and an environment that
supports continuous improvement. Active and personal board involvement in quality and
patient safety oversight contributes to building a high-performing healthcare organiza-
tion (Jiang et al. 2009).

An organization’s governing body—the board of trustees—is ultimately responsible
for the quality of healthcare services (Wagonhurst and Habte 2008). The board exercises
this duty through oversight of quality management activities. If a healthcare provider does
not have a board of trustees (e.g., in the case of a limited partnership physician clinic), the
legal owners of the business assume this responsibility.

Although the day-to-day activities of measurement, assessment, and improvement
are delegated to senior leaders, physicians, managers, and support staff, the board’s oversight
role can greatly influence quality. For example, board members set the approach to handling
quality issues. In addition, the questions trustees raise can lead to new insights or inform
the board and management of actions they need to take (Zastocki 2015).

To accomplish quality management functions, healthcare organizations create a qual-
ity management system or framework that defines and guides all measurement, assessment,
and improvement activities. This infrastructure can be organized in many ways. Variables
that affect the organization of the quality framework include

◆ the type of organization,

◆ the size of the organization,

◆ available resources,

High-performing

healthcare
organization

An organization that is

committed to success

and continuously

produces outstanding

results and high

levels of customer

satisfaction.

Governing body

The individuals, group,

or agency with ultimate

legal authority and

responsibility for the

overall operation of

the organization;

often called the board

of trustees, board of

governors, or board of

directors.

Quality management

system

A set of interrelated or

interacting elements

that organizations use

to direct and control

the implementation

of quality policies

and achieve quality

objectives.

K e y w o r d S

Spath, P. (2018). Introduction to healthcare quality management, third edition : Third edition. ProQuest Ebook Central http://ebookcentral.proquest.com
Created from westernkentucky on 2021-03-25 08:07:15.
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C h a p t e r 1 2 : O r g a n i z i n g f o r Q u a l i t y 3 0 3

◆ the number and type of externally imposed quality requirements, and

◆ internal quality improvement priorities.

Small independent healthcare providers, such as outpatient clinics and university
student health centers, typically have informal quality management infrastructures; the clinic
manager performs most, if not all, quality management activities and reports information
directly to the clinic owner or medical director.
Large health systems that include several hospitals
as well as nonhospital providers have formal, well-
defined quality frameworks.

Many healthcare organizations are required
by accreditation standards or government (federal
and state) regulations to have a plan that explains
their method of fulfilling

quality management

activities. Some standards and regulations have
explicit requirements regarding plan content
and the structure of improvement activities. For
instance, hospitals in Pennsylvania must have a
patient safety committee that includes two resi-
dents of the community, who are served by—but
are not agents, employees, or contractors of—the
facility (Commonwealth of Pennsylvania 2002). Laboratories that voluntarily comply with
the standards of the Clinical and Laboratory Standards Institute (2017) must have a quality
manual that documents the quality management structure and activities. The Joint Com-
mission (2016) accreditation standards do not require a written plan, but they do require
that organizations take a systematic approach to performance improvement.

Although written plans may not be required, most accredited organizations have them
in place to illustrate that they have organized their internal quality management activities.
Good business sense dictates the importance of having a written, board-approved quality
management plan that describes the organization’s quality infrastructure and required
quality management

activities.

Qu a l i t y ma n a g e m e n t Sy S t e m
Healthcare organizations’ quality management systems vary according to the entity’s gov-
ernance and management structure. In general, the following six groups typically fulfill
quality management roles:

1. The board, which oversees and supports measurement, assessment, and
improvement activities

Quality management
plan

A formal document

that describes

the organization’s

quality management

system in terms of

organizational structure,

responsibilities of

management and staff,

lines of authority, and

required interfaces

for those planning,

implementing, and

assessing quality

activities.

DID YOU KNOW??

Avedis Donabedian, physician and professor of public health

at the University of Michigan from 1966 to 1989, became inter-

nationally known for his research on healthcare improvement.

Before his death on November 9, 2000, he identified “the deter-

mination to make it work” as the most important prerequisite

to ensuring quality of care: “If we are truly committed to qual-

ity, almost any mechanism will work. If we are not, the most

elegantly constructed of mechanisms will fail” (Eldar 2001, 92).

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t3 0 4

2. Administration, which is responsible for the organization and management of
measurement, assessment, and improvement activities

3. The coordinating committee (or individual), which directs measurement,
assessment, and improvement activities

4. The medical staff, which develops and participates in measurement,
assessment, and improvement activities related to the performance of
physicians and other medical professionals who practice independently

5. Departments, which develop and participate in measurement, assessment, and
improvement activities related to nonphysician performance

6. Quality support services, which assist all groups in the organization with
measurement, assessment, and improvement activities

t h e b o a r d

The governing body or board—usually called the board of trustees, board of governors, or board
of directors—is a group of people who have ultimate legal authority and responsibility for
the operation of the healthcare organization, including its quality management activities.
The board of trustees’ involvement in quality management activities includes, but is not
limited to,

the following responsibilities:

◆ Defining the organization’s commitment to continuous improvement of
patient care and services in the organization’s mission statement

◆ Prioritizing the organization’s quality goals (with administration and the
medical staff)

◆ Incorporating the results of assessment and improvement activities into
strategic planning

◆ Learning approaches to and methods of continuous improvement

◆ Providing financial support for measurement, assessment, and improvement
activities

◆ Promoting healthcare quality improvement

◆ Evaluating the organization’s progress toward its quality goals

◆ Reviewing the effectiveness of the quality management program

C h a p t e r 1 2 : O r g a n i z i n g f o r Q u a l i t y 3 0 5

a d m i n i S t r at i o n

The responsibility for implementing quality management activities throughout the orga-
nization lies with administration—the chief executive officer, the chief operating officer,
the vice presidents, and other senior leaders. In contrast to the board’s high-level role,
administration ensures that day-to-day quality management operations are meeting the
organization’s needs.

Administration’s involvement in quality management activities includes, but is not
limited to, the following responsibilities:

◆ Defining the organization’s quality management infrastructure

◆ Assigning quality management responsibilities and holding people
accountable for fulfilling them

◆ Allocating the resources necessary to support quality management activities

◆ Encouraging those who use or provide the organization’s services to
participate in quality management activities

◆ Promoting physician and employee education about the concepts and
techniques of quality

management

◆ Using performance data for strategic planning purposes and to design and
evaluate new services or programs

◆ Identifying opportunities for performance improvement and helping to
achieve these improvements (with the medical staff)

◆ Keeping the board informed of quality and patient safety issues

t h e C o o r d i n at i n g C o m m i t t e e

The quality coordinating committee, often called the quality council, performance improve-
ment committee, or quality and patient safety committee, guides all measurement, assessment,
and improvement activities. In small organizations, an individual, rather than a commit-
tee, may fill this role. The coordinating committee’s involvement in quality management
activities includes, but is not limited to, the following responsibilities:

◆ Meeting periodically to direct the activities of the organization’s quality
management program

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t3 0 6

◆ Setting expectations; developing plans; ensuring implementation of processes
to measure; and assessing and improving the quality of the organization’s
governance, management, clinical, and support processes

◆ Analyzing summary reports of system- and activity-level measures of
performance and performance improvement activities, and providing reports
of these analyses to the board of

trustees

◆ Setting improvement priorities and chartering interdepartmental,
multidisciplinary improvement teams

◆ Directing resources necessary for measurement, assessment, and improvement
activities

◆ Establishing quality goals for the organization, with board approval

◆ Coordinating and communicating all quality management activities
throughout the organization

◆ At least annually, overseeing evaluation of the quality management program’s
effectiveness in meeting the organization’s quality goals, and revising strategy
where necessary

◆ Communicating quality management activities to the board of trustees

◆ Ensuring that the quality management infrastructure and activities meet
accreditation and regulatory requirements

Typically, the quality coordinating committee is made up of physicians, nurses,
other clinicians, and administrative representatives, but its composition depends in part
on the size of the healthcare organization. Most important, the people who oversee and are
accountable for quality in the organization should be included. Exhibit 12.1 lists examples

Teaching Hospital Neighborhood Health Clinic

• Chief operating officer
• Vice president of medical affairs
• Vice president of nursing
• Vice president of clinical support

services
• Medical staff president
• Director of quality and patient safety

• Medical director
• Senior staff nurse
• Clinic manager
• Director of health information

management

exhibit 12.1
Composition

of Quality
Coordinating

Committee in Two
Organizations

C h a p t e r 1 2 : O r g a n i z i n g f o r Q u a l i t y 3 0 7

of committee members for two types of organizations—a major teaching hospital and a
neighborhood health clinic.

t h e m e d i C a l S ta f f

The Medicare Conditions of Participation (CoPs) for Hospitals, along with The Joint
Commission accreditation standards, require that hospitals have an organized medical
staff. A hospital’s medical staff is composed of physicians, dentists, and other profes-
sional medical personnel who provide care to the hospital’s patients independently. The
theory behind the quality role of the organized medical staff is that lay members of the
board are neither trained nor competent to judge the performance of physicians and
other medical professionals. Therefore, they delegate to the medical staff the responsibil-
ity of evaluating the quality of patient care provided by physicians and other medical
professionals and advising the board of the results. The board retains legal authority to
make final decisions.

The Medicare CoPs and Joint Commission standards require that

medical personnel

have bylaws and rules or regulations that establish mechanisms by which they accomplish
their tasks. The medical staff infrastructure for accomplishing its quality management
responsibilities is found in these documents. The Joint Commission (2016) standards
require, at a minimum, the formation of a medical staff executive committee to represent
physicians in the organization’s governance, leadership, and performance improvement
functions. Additional medical staff committees or groups may be formed to fulfill other
quality management functions. For instance, chapter 3 introduced the concept of clinical
decision-making—the process by which physicians and other clinicians determine which
patients need what and when. The medical staff is responsible for evaluating the appropri-
ateness of physicians’ clinical decisions.

Critical concept 12.1 is an excerpt from one hospital’s medical staff regulations that
describes the quality management duties of the pharmacy and therapeutics committee.
One duty of this committee is to evaluate whether physicians are overusing, underusing,
or misusing medications.

In organizations that lack an organized medical staff, the medical director or the
governing board assumes physician-related quality management responsibilities. For instance,
the Medicare CoPs for freestanding ambulatory surgery centers (ASCs) require the facility
to have “a governing body that assumes full legal responsibility for determining, imple-
menting, and monitoring policies governing the ASC’s total operation. The governing body
has oversight and accountability for the quality assessment and performance improvement
program, ensures that facility policies and programs are administered so as to provide qual-
ity health care in a safe environment, and develops and maintains a disaster preparedness
plan” (CMS 2016).

Organized medical

staff

A formal organization

of physicians, dentists,

and other professional

medical personnel

with the delegated

responsibility and

authority to maintain

proper standards

of medical care and

plan for continued

betterment of that care.

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t3 0 8

d e pa r t m e n t S

All departments and services in a healthcare organization participate in quality manage-
ment activities. Managers of these departments and services are responsible for overseeing
performance in their respective areas. Manager involvement in quality management activities
includes, but is not limited to, the following responsibilities:

◆ Providing leadership oversight for departmental quality management activities

◆ Measuring, assessing, and improving clinical and operational performance

◆ Ensuring the competence of people working in the department

◆ Identifying opportunities to improve performance in the department and
throughout the organization, and helping to achieve these improvements

◆ Reporting the results of departmental quality management activities to
departmental staff, oversight

committees, and the board

CRITICAL CONCEPT 12.1 Quality Management Responsibilities of a
Hospital’s Pharmacy and Therapeutics Committee!

Medical staff involvement in quality management activities includes, but is not limited to,

the following responsibilities:

• Providing leadership oversight for the physician-related aspects of quality

management

• Measuring, assessing, and improving clinical aspects of patient care

• Evaluating the clinical competence of physicians and other medical professionals

who care for patients independently in the organization

• Identifying, within all departments in the organization, opportunities to improve

patient care, and helping to achieve these improvements

• Reporting the results of quality management activities to the medical staff, oversight

committees, and the board
Spath, P. (2018). Introduction to healthcare quality management, third edition : Third edition. ProQuest Ebook Central http://ebookcentral.proquest.com
Created from westernkentucky on 2021-03-25 08:07:15.
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C h a p t e r 1 2 : O r g a n i z i n g f o r Q u a l i t y 3 0 9

Q u a l i t y S u p p o r t S e r v i C e S

Many individuals in a healthcare organization assist with quality management activities.
Their job titles and areas of expertise vary considerably among organizations. In smaller
organizations, the responsibilities may be combined. In some cases, only one or two employ-
ees may support all of the organization’s quality management activities. A discussion of
common quality-related positions follows. Several of these offer certification examinations.
The websites for their certifying agencies are found at the end of this chapter.

Quality director. The quality director is the administrative head of quality manage-
ment functions and may be a member of the organization’s senior administrative team. The
quality director serves as an internal consultant and assists the organization with measure-
ment, assessment, and improvement activities. The director often manages a department
of data analysts and other staff who support quality management functions.

Patient safety coordinator. In response to the increased emphasis on patient safety
improvement (covered in chapter 8), some healthcare organizations have appointed a
patient safety coordinator or patient safety officer. Oversight of patient safety improvement
activities may include evaluating patient incident data, facilitating root cause analyses and
other patient safety improvement projects, and coordinating the flow of patient safety
information throughout the

organization.

Physician quality advisor. Some organizations appoint a physician as a full- or part-
time advisor to the quality management program. Organizations that have a medical director
may assign quality advisor duties to that position. The physician quality advisor provides
input to the senior administrative team and to the medical staff on issues related to physi-
cian performance measurement and improvement activities. The quality advisor works
closely with the quality director and the president of the medical staff to ensure appropriate
medical staff participation in quality management activities. The physician quality advisor
may also provide guidance for utilization management (UM) activities.

Case manager/utilization reviewer. Case managers and utilization reviewers are respon-
sible for facility-wide UM activities (covered in chapter 10). These individuals conduct
prospective, concurrent, and retrospective reviews to determine appropriateness of medi-
cal care and to gather information on resource use. In addition, they assist with discharge
planning to coordinate patient services between caregivers and provider sites.

Patient advocate. The patient advocate is the primary customer service contact for
patients and staff members for the resolution of customer service problems related to a
patient’s healthcare experience. The patient advocate, sometimes called the patient represen-
tative or ombudsman, participates at all levels of the quality

management program.

Risk manager. The risk manager coordinates the organization’s risk management
activities. The goal of risk management is to protect the organization from financial losses
that may result from exposure to risk. This goal is achieved through initiatives aimed at

Risk management

The act or practice

of dealing with risk,

which includes

planning for risk,

assessing (identifying

and analyzing) risk

areas, developing

risk-handling options,

monitoring risks

to determine how

they have changed,

and documenting

the overall risk

management program.
Spath, P. (2018). Introduction to healthcare quality management, third edition : Third edition. ProQuest Ebook Central http://ebookcentral.proquest.com
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I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t3 1 0

preventing harm to patients, visitors, and staff. In addition to other duties, the risk manager
may be responsible for maintaining the organization’s patient incident report system and
may serve as the organization’s patient safety officer.

Infection control coordinator. The infection control coordinator, usually a nurse,
provides surveillance, education, and consulting services for physicians and staff in matters
related to preventing patient infections. The infection control coordinator gathers data for
infection-related performance measures and is also responsible for facilitating the implemen-
tation of government regulations and accreditation standards relevant to infection control.

Medical staff services coordinator. This medical staff services professional is primarily
responsible for supporting the administrative and medical–legal components of the medical
staff organization, including peer review and credentialing of physicians and allied health
practitioners.

Compliance officer. In recent years, some healthcare organizations have added a
compliance officer to the quality team. This person interprets accreditation standards and
government regulations pertaining to quality management and helps physicians and staff
adhere to all standards and regulations.

Data analyst. Data analysts are responsible for gathering and reporting performance
measurement information. These individuals may have a clinical background (e.g., nursing,
therapy) or a nonclinical background (e.g., health information management). Some data
analysts may report to the quality director, and some may be employed in other depart-
ments, such as nursing or surgical services. Several data analysts are needed to support
quality management activities in large healthcare organizations. Reporting and analysis
of measurement results will continue to require the services of data analysts even when
electronic data sources make data collection less burdensome.

A growing number of the data elements necessary for measurement purposes can be
captured electronically; however, these measures
require staff resources as well to ensure the data
“accurately reflect the clinical picture” (Panzer et
al. 2013, 1974). As the data for some quality mea-
sures are not routinely documented in the patient’s
electronic health record (EHR), staff may need
to collect some of the data (Panzer et al. 2013).
Hybrid methods of data collection, involving
EHR-derived data and medical record reviews, are
still needed. For instance, a 2014 national survey
of 394 randomly selected physician practices found
that physicians and support staff spent 15.1 hours
per week tracking quality metrics for Medicare and
other payers and regulators (Casalino et al. 2016).

LEARNING POINT
Quality Infrastructure*

Every healthcare organization has a quality infrastructure

designed to fulfill the goals of quality management. As the

complexity of the organization increases, so does the need for a

formal, well-defined quality infrastructure. Six groups typically

involved in an organization’s quality management activities are

the board of trustees, administration, the coordinating com-

mittee, the medical staff, all departments, and quality support

services.

C h a p t e r 1 2 : O r g a n i z i n g f o r Q u a l i t y 3 1 1

Providers are not the only group adding support staff to meet quality management
expectations. More than 90 percent of health plans produce and submit performance data
to the National Committee for Quality Assurance (NCQA 2017). These health plans invest
significant resources in data collection and have hired additional staff to review patient
records. State and national groups that receive data from providers and health plans have
added support staff to analyze and report aggregate results for the growing number of
quality measures. Nearly all state health agencies have increased staffing to conduct per-
formance management activities aimed at improving the quality and outcomes of public
health services.

Qu a l i t y ma n a g e m e n t pl a n
The document describing the organization’s structure and process for measuring, assess-
ing, and improving performance may be called a quality management plan, a performance
improvement plan, a quality and patient safety plan, or one of a number of other descriptive
titles. For simplicity, the term quality management plan will be used throughout this chap-
ter. The purpose of the plan is to serve as a blueprint for quality and patient safety in the
organization. At a minimum, the plan includes the following elements:

◆ A quality statement

◆ A description of the quality management infrastructure

◆ Details of performance measurement, assessment, and improvement activities

◆ An evaluation of the effectiveness of quality management activities

Q u a l i t y S tat e m e n t

The quality statement describes the goal to which all quality management activities are
directed. The statement reflects the organization’s ideals—what it wants for patients and
the community. An organization’s quality statement often incorporates its mission, vision,
and values. For example, this is the quality statement of St. Hope Foundation (2017), a
patient-centered medical home in Texas:

Our goal is to serve you with high quality, culturally compassionate and accessible health
care so that you get the care you need in a way that works best for you.

The board and administration jointly develop the quality statement. In facilities
with an organized medical staff, physicians are also involved in its creation.

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t3 1 2

Q u a l i t y m a n a g e m e n t i n f r a S t r u C t u r e

The plan describes each quality management stakeholder and its responsibilities. Some plans
describe infrastructure and stakeholder activities in great detail and are several pages long.
Plans do not need to describe every element, however. Quality management responsibilities
are often specified in employee job descriptions, and duplicating these statements in the
quality plan is redundant. In general, the quality management plan should be sufficiently
detailed to convey the organization’s approach to quality management. At a minimum, the
description of the infrastructure should include the following:

◆ Major stakeholders (individuals and groups) and expectations for their
participation in quality management functions

◆ Committee structure (e.g., committees involved, committee chairs
and members, meeting frequency, methods of communicating quality
management activities throughout the organization)

Drawing an organizational structure diagram may help depict the relationships and
flow of information among individuals, groups, and committees. Exhibit 12.2 illustrates
the flow of performance information in a hospital.

p e r f o r m a n C e m e a S u r e m e n t , a S S e S S m e n t , a n d i m p r o v e m e n t a C t i v i t i e S

Variables to be measured and the execution of assessment and improvement activities are
detailed in the quality management plan. The improvement model also may be docu-
mented, as well as the groups that charter and participate in improvement projects. In some

exhibit 12.2
Flow of

Performance

Information in a

Hospital

Department-specific
system- and
activity-level
measures

System-level
measures

Physician-specific
measures

Quality
CouncilPerformance measures

Financial

Clinical

Operational

Patient safety

Customer satisfaction

Environment of care

Regulatory/
accreditation
compliance

Hospital
departments

and
multidisciplinary

committees

Board
of

trustees

Medical staff
executive

committee

Quality
council

Medical staff
department

chairs

Medical staff
departments

C h a p t e r 1 2 : O r g a n i z i n g f o r Q u a l i t y 3 1 3

organizations, the quality plan does not change often—each year it is reviewed and updated
slightly to reflect infrastructure changes and new regulatory or accreditation requirements,
but the fundamentals remain the same.

Elements of the quality program that frequently change, such as quality improve-
ment goals and objectives, measures of performance, and sources of performance data, are
described in appendixes to the plan or in other organizational documents. Critical con-
cept 12.2 lists an example of one of the six 2016–17 quality goals and related objectives
established by the Nevada Department of Health and Human Services (2016) for Nevada
Medicaid and Nevada Check Up members. New or updated goals and objectives are set for
the following year and the document is revised to reflect those changes. The organization’s
performance measures and information sources are also frequently updated.

e va l u at i o n o f t h e e f f e C t i v e n e S S o f Q u a l i t y m a n a g e m e n t a C t i v i t i e S

Periodically (usually annually), the coordinating committee evaluates overall quality man-
agement performance by (1) determining whether the quality infrastructure has improved

CRITICAL CONCEPT 12.2 2016–17 Quality Goals and Objectives for
Nevada Medicaid and Nevada Check Up Members!

Goal 2: Increase use of evidence-based practices for members with chronic conditions.

Objective 2.1: Increase rate of HbA1c testing for members with

diabetes.

Objective 2.2: Decrease rate of HbA1c poor control (>9.0%) for members with diabetes.

Objective 2.3: Increase rate of HbA1c good control (<8.0%) for members with diabetes.

Objective 2.4: Increase rate of eye exams performed for members with diabetes.

Objective 2.5: Increase medical attention for nephropathy for members with diabetes.

Objective 2.6: Increase blood pressure control (<140/90 mm Hg) for members with

diabetes.

Objective 2.7a: Increase medication management for people with asthma—medication

compliance 50 percent.

Objective 2.7b: Increase medication management for people with asthma—medication

compliance 75 percent.

Source: Reprinted from Nevada Department of Health and Human Services, Quality Assessment and

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t3 1 4

organizational performance and (2) making changes as necessary. The coordinating com-
mittee also determines whether the organization has met the year’s quality goals and uses
its findings to plan the following year’s quality improvement activities.

Critical concept 12.3 is a quality plan template that can be customized to suit the
needs of a healthcare organization that lacks an organized medical staff structure, such as
an outpatient clinic, a freestanding ASC, or a nursing home.

CRITICAL CONCEPT 12.3 Quality Plan Template for Organizations That
Do Not Have an Organized Medical Staff!

Quality Statement

The purpose of quality management activities is to improve clinical and operational pro-

cesses and outcomes through continuous measurement, assessment, and improvement

activities. The quality program of (insert organization name) strives to ensure that all

aspects of healthcare service, whether clinical or nonclinical, are designed for optimal

performance and patient safety and delivered consistently across the organization.

Quality Infrastructure and Responsibilities

The governing body of (insert organization name) has overall responsibility for the quality

program and delegates operational responsibilities through the management structure.

The objectives of the quality program are to

• establish a system for ongoing monitoring of performance to identify problems or

opportunities to improve patient care, operational performance, and customer sat-

isfaction;

• resolve identified problems and improve performance using quality improvement

principles and techniques;

• ensure that performance improvement actions are taken and the effectiveness of the

actions is evaluated;

• refer unresolved performance deficiencies to the medical director (or management

structure, as appropriate) for resolution; and

• maintain a consistent and systematic approach to quality improvement that involves

planning activities, enacting plans, monitoring performance, and acting on improve-

ments and deficiencies.

(continued)

C h a p t e r 1 2 : O r g a n i z i n g f o r Q u a l i t y 3 1 5

a ho S p i ta b l e en v i r o n m e n t
To improve quality, an organization must have the will to improve, the capacity to trans-
late that will into positive change, the infrastructure necessary to support improvement,
and an environment hospitable to quality. The last factor—environment—relates to the
organization’s culture. Culture is a system of shared actions, values, and beliefs that guides
the behavior of an organization’s members. The corporate culture of a business setting
is one example of such a system. Edgar H. Schein (1986), a clinical psychologist turned
organizational theorist, identified three levels of organizational culture:

Level 1: Observable culture—the way things are done in the organization

Organizational culture

Prevalent patterns of

shared beliefs and

values that provide

behavioral guidelines

or establish norms for

conducting business.

CRITICAL CONCEPT 12.3 Quality Plan Template for Organizations
That Do Not Have an Organized Medical Staff (continued)!

A quality management committee, consisting of (insert the number and type of posi-

tions reflective of the organizational structure), is responsible for coordinating and inte-

grating all measurement, assessment, and improvement efforts. The committee reports

its findings to the medical director and management for review or implementation and

problem resolution at that level, or for referral to the governing body, if indicated.

Other organizational representatives involved directly and indirectly in quality man-

agement activities include managers, members of the clinical and nonclinical staffs, and

administrative support staff. Appropriate staff members are involved in activities within

the sphere of their responsibilities and expertise.

The quality management committee is responsible for identifying measures of per-

formance for important aspects of patient and operational services. Organizational rep-

resentatives are responsible for ongoing monitoring and evaluation of performance and

resolution of problems affecting their areas of responsibility. These activities are reported

at least quarterly to the quality management committee for analysis, further study, or

implementation (as necessary).

Recommendations and actions of the quality management committee are docu-

mented and forwarded to the governing body.

The quality management committee periodically reviews organization-wide quality

management activities to ensure the goals of the quality program are being met and

performance is continuously improving. At least annually, the quality plan is reviewed

and revised as necessary.

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t3 1 6

Level 2: Shared values—awareness of organizational values and recognition of their
importance

Level 3: Common assumptions—realities that members take for granted and share
as a result of their joint experiences

The organizational culture at all three levels is pivotal to successful continuous
improvement. Culture influences the manner in which quality management is imple-
mented and executed. Cultural tone—whether trust or fear, collaboration or isolation,
interdependency or autonomy—affects the way senior leaders, managers, physicians, and
employees interact in the quality management process. Quality leaders have long recognized
the importance of culture as a driver of performance excellence. The term performance
excellence was introduced by Peters and Waterman in 1982 to refer to an overall way of
working that balances stakeholder concerns and increases the probability of long-term
organizational

success.

Several of the 14 quality principles espoused by W. Edwards Deming (1986) more
than 25 years ago (see chapter 2) address the cultural aspects of quality improvement:

◆ Help people do a better job

◆ Drive out fear

◆ Break down barriers

◆ Restore pride of workmanship

◆ Make quality everyone’s job

In a culture committed to quality, senior
leaders and managers lead by example and encour-
age an environment of open, candid dialogue and
continuous improvement. The people who do the
work are actively involved; management seeks their
views and listens to what they have to say (Sher-
wood 2013). Everyone in the organization is clear
on the expected level of performance and receives
feedback on progress. Staff members are acknowl-
edged and recognized for the contributions they
make to further the organization’s quality goals.
People trust and have confidence in leadership’s
determination to continuously improve organiza-
tional performance.

The relationship between a supportive qual-
ity culture and an organization’s ability to achieve aggressive improvement goals has been

Performance
excellence

Term introduced

by Tom Peters and

Robert Waterman in

their book In Search

of Excellence (1982)

to refer to an overall

way of working that

balances stakeholder

concerns and increases

the probability of long-

term organizational

success.

LEARNING POINT
Planning for Quality*

Every healthcare organization has a quality management infra-

structure. An effective infrastructure begins at the board level

and cascades vertically and horizontally to levels throughout

the organization. The size, function, and number of components

that support quality management activities vary according to the

size of the organization and the types of healthcare services it

provides. A healthcare organization’s quality management infra-

structure is often documented in a quality management plan.

C h a p t e r 1 2 : O r g a n i z i n g f o r Q u a l i t y 3 1 7

substantiated numerous times (Mannion, Davies, and Marshall 2005; Shortell et al. 2005;
Nembhard et al. 2009; Mardon et al. 2010; Carney 2011; Sorra et al. 2012; Berry et al.
2016; Joint Commission 2017). In 2004, for instance, the Commonwealth Fund published
the results of a study that identified supportive quality culture as a key factor contributing
to the success of four high-performing US hospitals. The top-performing hospitals demon-
strated a high degree of motivation and commitment to ensuring quality patient care. This
commitment was reflected in and nurtured by the following elements (Meyer et al. 2004):

◆ Active leadership and personal involvement on the part of the senior team and
the board of trustees

◆ An explicit quality-related mission and best-in-industry quality improvement
targets

◆ Standing and ad hoc quality committees

◆ Regular reporting of performance measures with accountability for improved
results

◆ Promotion of a safe environment for reporting errors

A study of home health agencies found the overarching characteristic of high-
performing agencies is an engrained culture of commitment to the quality of patient care
and continuous self-review and improvement (University of Colorado, Denver 2011).

In 2009, The Joint Commission revised its leadership standards to reflect the need
for a culture that supports quality performance. Leaders in accredited organizations are
expected to “create and maintain a culture of safety and quality throughout the organiza-
tion” (Joint Commission 2017, 5). Compliance with these standards requires leaders to

◆ regularly evaluate the organization’s culture of safety and quality,

◆ define and encourage acceptable work behaviors that support a culture of
safety and quality, and

◆ identify and manage behaviors that undermine a culture of safety and quality.

There is no “correct” culture. A culture that works in one organization may not
work in another. A culture’s suitability depends on how well it supports the organization’s
quality management goals. Is the culture undermining quality improvement efforts? Some
red flags that signal incompatibility are as follows:

◆ Tolerance of poor communication, corner-cutting, and poor performance

◆ Acceptance of improper procedures, complacency, and inefficiency

◆ Lack of trust

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t3 1 8

◆ Sacrifice of quality or patient safety to save money or time

◆ Comments heard such as, “Nobody ever listens to me” or “This is the way we
do things around here”

Organizational culture is the root of many performance problems. If any of these
red flags is evident, the organization’s leaders must identify inhospitable attributes of the
culture and modify the values, beliefs, and actions that affect the success of quality manage-
ment activities. By nurturing the culture to an appropriate level, the organization will reap
the rewards of quality management. Aspects of culture often found in high-performing
organizations are summarized in critical concept 12.4.

CRITICAL CONCEPT 12.4
Characteristics of a High-Performing Culture!

• Senior leaders and managers communicate and support high-quality performance

through words and actions.

• Open communication is practiced; people are free to voice opinions, share ideas, and

make decisions.

• Conflict and disagreement are dealt with openly.

• People are dedicated to continuous improvement; higher quality goals are set once

initial goals are met.

• People know what they are accountable for, take ownership of their responsibilities,

and continuously strive to perform better.

• People support one another; the concept of teamwork is apparent throughout the

organization.

• Individual and collective performance is monitored, reinforced, and corrected on an

ongoing basis.

• Individual and team successes are acknowledged and celebrated.

• Individual competencies are systematically developed on an ongoing basis.

• Employees constantly learn from the best practices of top-performing organizations.

• Performance excellence is pursued for its own sake.

C h a p t e r 1 2 : O r g a n i z i n g f o r Q u a l i t y 3 1 9

Cultural change can be difficult and time consuming to achieve because culture is
rooted in the collective history of an organization and in the subconscious of its staff. In
general, cultural change is instituted through the following steps:

◆ Uncover core values and beliefs, including both stated goals and goals
embedded in employee behaviors. Two sources of healthcare organization
culture surveys are listed in the website resources at the end of the chapter.

◆ Look for cultural characteristics that are undermining the organization’s
capacity to continuously improve. Conduct a series of focus groups with a
representative sample of survey participants to identify areas needing change
and practical interventions that will make a difference. Turn this information
into a comprehensive cultural-change action plan.

◆ Establish new behavioral norms that demonstrate desired values.

◆ Repeat these steps over a long period. Emphasize to new hires the importance
of the organization’s culture. Reinforce desirable behavior.

Throughout most of his life, nineteenth-
century French chemist Louis Pasteur insisted that
germs—not the body—were the cause of disease.
Not until the end of his life did he come to believe
the opposite. After reaching this conclusion, he
declined treatment for potentially curable pneu-
monia, reportedly saying, “It is the soil, not the
seed” (Spath and Minogue 2008). In other words,
a germ (the seed) causes disease when our bodies
(the soil) provide a hospitable environment. This
bacteriology lesson is relevant to the performance
improvement efforts in healthcare organizations.
The organization’s culture (the soil) must provide
a hospitable environment for quality management activities (the seeds) to succeed.

Healthcare quality is not only dependent on the efforts of well-meaning frontline
employees. The organization’s leaders must systematically channel and manage the
efforts to achieve optimal organizational performance. Healthcare organizations should
have an appropriate quality management structure that operates at all levels and has the
power to evaluate and improve all aspects of patient care and services.

C o n C l u S i o n

LEARNING POINT
Environment Supports Quality*

An organization’s environment—its culture—influences the

success of quality management activities. Leaders must cre-

ate a culture that supports their organization’s goals and,

when necessary, change that culture to encourage continuous

improvement.
Spath, P. (2018). Introduction to healthcare quality management, third edition : Third edition. ProQuest Ebook Central http://ebookcentral.proquest.com
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I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t3 2 0

Defining the quality management infrastructure and activities in a written
document demonstrates the organization’s formal commitment to quality. A written plan
clearly communicates to employees the organization of quality management activities
and the groups or individuals responsible for quality components.

Organizing for quality also involves creating a supportive organizational culture
in which performance can flourish. Culture—the collective values, beliefs, expectations,
and commitments that affect behavior at all levels—should further the quality goals
of the organization. A culture built on trust and support will achieve high performance.
Organizations will reap the most benefits from quality management when managers and
employees value the process; encourage open, candid dialogue; support career growth;
and pursue improved personal and organizational performance.

In the 2001 report Crossing the Quality Chasm: A New Health System for the 21st
Century, the Institute of Medicine identified six dimensions of US healthcare that need
improving. Not only did the report provide a basis for defining healthcare quality, but
it also created a significant challenge for the healthcare industry. How can we make
healthcare safer, more effective, patient centered, timely, efficient, and equitable?
National policy changes and new regulations and standards have limited influence on
what actually happens on the front lines of patient care. Addressing the challenge of
improving healthcare quality requires that every organization continuously measure,
assess, and improve performance.

1. Some healthcare organizations post their quality plan on the web. Search the
Internet for quality plans from two different types of healthcare organizations (e.g.,
hospital, long-term care facility, ambulatory clinic, health plan). You may need
to use search terms other than quality management plan, such as performance
improvement plan, patient safety plan, or quality plan. Summarize the similarities
and differences between the two plans.

2. Consider the cultural assumptions and beliefs underlying a perfectionist mentality:
Perfection is always expected; mistakes are not allowed. This assumption can create
an environment inhospitable to quality improvement. How would you change that
perception?

3. Consider the organization you now work in, or if you are not currently employed,
consider your last employer. What three words or phrases would you use to describe
the company or department culture? Does the culture prompt or inhibit quality
performance?

f o r d i S C u S S i o n

C h a p t e r 1 2 : O r g a n i z i n g f o r Q u a l i t y 3 2 1

• Case manager certification
https://ccmcertification.org
www.acmaweb.org/acm

• Healthcare compliance officer certification
www.aapc.com/certification/cpco.aspx
www.compliancecertification.org/CHC/CertifiedinHealthcareCompliance.aspx

• Health Care Quality & Management Certification
www.abqaurp.org/ABQMain/Certification

• Health data analyst certification
www.ahima.org/certification/chda

• Healthcare quality certification
http://nahq.org/certification/certified-professional-healthcare-quality

• Healthcare risk manager certification
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• Medical staff services certification
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• American College of Healthcare Executives and IHI/NPSF Lucian Leape Institute,
Leading a Culture of Safety: A Blueprint for Success
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C e r t i f i C at i o n i n f o r m at i o n f o r Q u a l i t y S u p p o r t p r o f e S S i o n a l S

W e b S i t e S

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t3 2 2

• American Hospital Association, Trustee Services
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• American Society for Healthcare Risk Management, Different Roles, Same Goal: Risk
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Safety Attitude Questionnaires and Safety Climate Surveys
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questionnaire/

• Center for Rural Health, The Board’s Role in Quality
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• Health Resources and Services Administration, Developing and Implementing a QI
Plan
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• Lucian Leape Institute, Through the Eyes of the Workforce: Creating Joy, Meaning,
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practitioners, and suppliers
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material.asp

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