Is Your Organization Ready for Total
Quality Management? Mary Jean Barrett, R.N., B.S.N., M.B.A.* Ernst &
Young, Phoenix, Arizona
The evolution to a Total Quality Management (TQM) or Continuous Quality Improvement (CQI) philosophy is particularly attractive in the health care industry in its search for better ways of doing
business to
ensure
financial survival in the current
competitive environment. This article, however, suggests that some organizations may not benefit from attempting to implement methodology to achieve the widely accepted financial and operational benefits, not because of any weakness in the conceptual framework, but because of the culture and/or lack of dedicated resources required to ensure the acceptance and success of the approach. As a result, many providers are discovering that after a few years of implementation, benefits to the organization are not being recognized to the extent possible. Specific issues that have been identified as essential requirements to a successful implementation process or evolution to a continuous improvement culture are described in this article.
Many health care executives are considering or have initiated the implementation of a Total Quality Management (TQM) or Continuous Quality Improvement (CQI) model in their organizations to achieve the many benefits experienced by organizations in other industries and other countries. Over the last few years, much has been written about the positive results that can be obtained and how the principles of TQM or CQI should be applied in the health care environment to recognize these results. Recent experience, however, suggests that some organizations do not always have positive results following implementation of a TQM model and/or that benefits associated with the process might not have justified the direct and indirect expense. Many organizations have relabeled the concept to avoid the negative connotation that TQM has incurred as a result. For our purposes, TQM and CQI are used interchangeable in this article. This article does not challenge the validity of quality
improvement but rather organizations’ preparation and implementation of the processes required to achieve it. Many organizations might not be candidates for implementing management philosophy and the industry should recognize this fact, rather than invalidating the conceptual framework or the theory that it can be applied to health care providers. Individual organizations, likewise, need to conduct an internal inventory to determine if the culture of the organization will allow change and whether the necessary resources are available, or will be made available, before expending resources. Simply labeling the TQM/CQI concept as the culprit if expectations are not met should be
discounted. Executives should, therefore, determine if the appropriate data systems, tools, and human and other resources are available and if the culture of the organization is conductive and prepared to initiate or continue the T.QM process in order to have a successful evolution to a new leadership stage. Key considerations are discussed below and include the organizational structure, educational resources, information systems, clinical expectations, data collection, cost accounting information, and success indicators.
ORGANIZATIONAL STRUCTURE Health
care organizations have traditionally been in organized separate functional divisions, i.e., nursing care, ancillary services, support services (dietary, housekeeping), and administrative support services. Like many industries, these divisions report to a chief executive officer or administrator who is often the only executive who has responsibility for all the departments and, of course, can cross all lines with authority. Unlike many organizations in other industries, authority over the departments responsible for the quality of the organizations’ output is divided between peers reporting to the CEO at the executive level. For example, health care providers often have
*
To whom requests for reprints should be addressed at Ernst & Two Renaissance Square, Suite 900, 40 North Central Avenue, Phoenix, AZ 85004.
Young,
106
Downloaded from ajm.sagepub.com at UNIV OF PENNSYLVANIA on April 12, 2015
107 at least two executive vice
presidents presiding
over
nursing, ancillary services, and support services, departments that are accountable for separate operations necessary in the delivery of patient care. The challenge in implementing TQM, therefore, is determining where the day-to-day coordinator or facilitator will reside and where positional authority will derive in order to initiate change processes. Many organizations have designated these coordinators as support positions, which significantly limits their effectiveness because of the need to gain consensus from departmental employees and managers to initiate any focused activity. In many institutions, these professionals have eventually become educators and inspectors-but no change agents. Although the top executives continue to give verbal support of the TQM philosophy, they often are too busy for sufficient detail of activities to provide essential direction or authority to eliminate natural resistance to the changing of any process.
A
key priority, therefore, is first to evaluate the organization to determine where the &dquo;point person&dquo; will be positioned. This position(s) must have two things: dedicated time and authority. Therefore, if one of the executives requests to be responsible for the process, his or her time current structure of the
availability should first be reviewed. Additionally, if the position provides responsibility over some but not all operational departments, a mechanism must be established to allow authority over all departments for daily activities related to TQM. Regardless of who is designated as the day-to-day &dquo;driver&dquo; of the process, a task force for all executives needs to be created with regular meetings to address interdepartmental issues. Without mechanisms to cross functional lines with authority, departmental employees can easily initiate very subtle, but very effective, resistance to the process.
Because of the inherent challenge involved in changing human behavior, some organizations have created a new department identified as &dquo;Quality Management&dquo; and a second tier position to take the responsibility of implementation. Many of these individuals have a nursing or clinical background, which provides them with a broad understanding of the interdepartmental relationships in the patient care areas. This type of background can facilitate communication between departments. EDUCATIONAL PROGRAMS
Many organizations eliminated educational programs in the early 1980s in response to the tightening
of reimbursement
following the implementation of the
Nontechnical programs management training were often the first to go and have generally not been replaced. Only technical, patient care courses which only address task oriented skills are currently provided for nursing and patient care personnel in many organizations. Implementing a CQI philosophy requires the training of all personnel on the principles and process involved in the approach, from the executive to entry level positions. The principles of TQM also suggest that employees need to receive continuous opportunities to acquire new skills to improve their ability to function at their best and develop an understanding of general financial and operational management issues to best serve the needs of the organization in fulfilling its mission. As a result, organizations need to evaluate educational expense as it would any other capital expenditure recognizing that people are the primary resource in CQI environment. Budgeting educational programs as a percentage of the operating budget or as a significant expense is appropriate to emphasize the need for continuous education for all employees at all levels within the organization. Programs need to be developed for:
prospective payment system. such
as
· CQI principles and methodology .
. . .
.
General management Financial management Resource management Technical skills (varies Orientation
Need will vary depending
by department and level) on
the life cycle of the
organization, time frame, or status of implementation, services provided, organizational structure, etc. Existing programs, such as orientation, may need to be revised depending on how other educational programs are
structured.
Physician needs should be considered when developing educational programs and all educational programs should be made accessible and encouraged for members of the medical staff as they continue to be recognized as customers of the organization and critical members of the team. Incentives are being developed by some organizations to encourage this involvement such as combining sessions on issues of most interest to physicians (e.g., financial impact of the resource-based relative value scale) with those relating to management. More organizations are also hiring physicians to serve as medical directors to facilitate utilization review and quality assurance rather than
depending on voluntary
Downloaded from ajm.sagepub.com at UNIV OF PENNSYLVANIA on April 12, 2015
assistance. These
physicians,
108 if
SUCCESS INDICATORS
valuable in
coordinating educational sessions for hospital personnel and physicians. available,
are
INFORMATION SYSTEMS
As
CQI is measuring processes to improvement, it is essential that indicators are identified which represents the quality and efficiency of work performed in each department. a
key premise
in
monitor continuous
These indicators should be monitored on a concurrent Although chart audits and random sampling techniques will still be required for intensive, data specific evaluations, many indicators should be acces-
basis.
sible off an automated system to provide quality measuring at scheduled intervals using consistent meth-
odologies. Under TQM, however, the challenge of identifying and measuring indicators in most departments (which historically were not of concern) has been recognized. Even systems to
clinical outcomes and other quality assurance measures are available from only a few vendors and primarily in a microcomputer standalone environment. Integrated systems to measure resource management, costs, practice patterns, and quality outcomes for patient care departments, which link lab, pharmacy, radiology, critical car units, etc. emergency room, operating room, are not available in measure
organizations. TQM implementation, therefore, it is important to identify those data elements that can be captured and measured using available computerized systems. Without monitoring devices, an organization will not be capable of determining the benefits of specific process improvement, i.e., continuous immany
Before
provement. In order to document a base line for many different operational processes, the cost of performing patient care and support functions is needed to monitor improvements in resource utilization and/or labor usage. Many organizations have not expended the resources
develop a cost accounting system and, therefore, identify only what overall expenses are by department or cost center. The cost of activities performed for specific functions and procedures needs to be developed and documented to determine revised costs as operational efficiencies are achieved. For example, expenses incurred to bill an account or draw blood for a complete necessary to
can
blood count
can
be determined in order to later doc-
improvements in the activity as a result implementing process improvement or redesign.
ument
of
As noted above, a fundamental component of TQM is the engineering approach to measurement to demonstrate continuous improvement. As a service industry, health care organizations have not traditionally expended many resources on systems to provide this capability. Often, only data required by regulatory agencies were collected, and often painfully, through manual review processes. Because of the intensity of measurement recommended under a continuous improvement philosophy, new and/or enhanced systems are required to provide concurrent and retrospective data with limited manual effort required. Data collection through chart reviews,
focused reviews, etc., are valuable but too expensive to perform on a 100% basis and do not provide the reliability of measurement that automation does because of the human interaction involvement. Many organizations have chosen not to benchmark against better performers or base line current processes to avoid the competitive, financial orientation that often comes with measuring indicators of functional processes. This philosophy of implementing TQM because &dquo;it is the right thing to do&dquo; demonstrates commitment from the executive team and a long-term focus that makes many organizations successful. However, organizations need comprehensive monitoring devices to facilitate evaluation and provide incentive to all employees to make them all feel a part of the process. Furthermore, if the financial situation of an organization changes, executives can be asked to justify the resources of the program retrospectively. Lastly, an organization cannot know if the evolution to a TQM approach and philosophy is successful if the conditions of their institution &dquo;before&dquo; and &dquo;after&dquo; are
not measured.
Organizations are encouraged to develop two types of monitoring systems. The first is quantifiable measures that can frequently be automated on a system for progress monitoring. The second type of measurement is the soft qualitative measurement that may or may not be captured on automated tools, e.g., patient surveys. A sample of indicators that can be measured is listed in Table 1. As an organization initiates TQM, the development of macro-level indicators identified by the executive team is suggested. These types of indicators are often already measured but not in one comprehensive package for executive review. Examples include cost per case, average length of stay, full time equivalents, operating expenses, margins, days in receivables, bad debt, cash flow, denial rates, mortality and morbidity data, clinical outcomes summarized by department,
Downloaded from ajm.sagepub.com at UNIV OF PENNSYLVANIA on April 12, 2015
109 Table 1
Sample Success
to bear the brunt of cost containment which has
Indicators
frequently resulted in situations, particularly with primary care models, in which the RNs do not feel they can provide quality of care because of high patient-tonurse
ratios.
considering the implemanagement model whereby one professional RN monitors a patient’s case and coordinates all services and addresses potential placement issues. These &dquo;case managers&dquo; generally monitor a patient throughout an episodic stay or over a continuum of care following the patient after discharge to home care, outpatient services, nursing home, and so Many organizations
mentation of
are
also
a case
on.
The development of critical paths is also being recognized as a tool for benchmarking and/or base lining current physician practice patterns. Many organizations have this information available, sorted by physician, but do not share it with the medical staff fearing it might alienate some of them. Other organiDRG, diagnostic-related group; ALOS, average length of stay; OB, obstetrics ; UOS, unit of service; FTE, full time equivalent.
and
so forth. Following educational sessions and the origination of a workplan to initiate activities, detailed indicators chosen to monitor specific processes need
to be identified and measured.
CLINICAL EXPECTATIONS In uous
zations do not have the information systems available to supply procedural data by data and service for specific patients and case types since older systems often provide only charge information. Developing critical paths for high-volume or high-cost cases documents a basis for discussing resource management issues and facilitates the identification of quality issues based on established expectations. If an organization has previously attempted any of these actions and met with such resistance that the effort was abandoned, the organization may not be a candidate for TQM, at least until the culture of the organization is improved.
conjunction with a reorientation toward a continimprovement philosophy, many organizations
have found that the framework sets the stage for activities that have historically met resistance. With the new emphasis on data, executives can now often get the support necessary to implement critical paths, nursing acuity systems, severity of illness systems, quality outcome monitoring, etc. Such information provides administration, the medical staff, nursing, and ancillary services, with data that allows more sophisticated management and decision-making. The redesign of patient delivery models also is typically reevaluated through the continuous improve-
approach. Leveraging professional registered (RNs) by providing them with trained assistants, for example, allows RNs the time to perform the activities they were trained to perform (i.e., the planning of patient care, assessment, and education) while maintaining a neutral budget by supplementing professionals with less skilled personnel. Nursing is often the advocate of redesign because it has tended
CONCLUSION
Because there is
model
or
approach
to con-
sidered include: ~ ~
ment
nurses
no one
improvement that is appropriate for all organizations, executives must identify the approach that best matches the organization’s needs and philosophy. Additional organizational issues that need to be continuous
~
~ ~ ~
~
Commitment of all members of the executive team Receptiveness and current relationship with the medical staff Receptiveness and current relationship with the board Financial status of the organization Current morale of employees Tenure of the executive team and management Current perception of the organization in the local market
Downloaded from ajm.sagepub.com at UNIV OF PENNSYLVANIA on April 12, 2015
110 ~ ~
Actions taken by competing facilities Mission and strategy of the organization
of the approach that an organization chooses to use, a review to determine if an organization is prepared and that appropriate mechanisms and tools are available is suggested. Essential questions that need to be answered include: 1. Does the organizational structure provide the means for cross-functional process improvement? 2. Has the executive team been together, in place long enough, and/or otherwise earned the trust needed from middle management and employees to undertake a cultural change? 3. Have attempts been made in the past to redesign the patient care delivery model and develop critical paths and case management, etc, and, if so, were they successful? 4. Does the executive team have the commitment to endure the natural resistance that will result from the medical staff, management, and employees in reaction to the change? 5. Does the organization have the internal resources necessary for continuous and varied training pro-
Regardless
grams ? 6. Are information
systems installed to provide in-
tegrated, detailed data to monitor provement in all operational areas?
continuous im-
7. Is cost information available? 8. Have comprehensive indicators been identified for
monitoring across all departments that are representative of key processes? If the resources described in this article and/or the culture of the organization are not conducive to undertaking a transition to a continuous improvement focus for the whole organization, it may be more appropriate for individual organizations to first attempt single business process redesign efforts for processes that have been identified as needing improvement. Many individual processes require participation and cooperation from different departments which will require a team approach to resolve existing conachieve efficiencies. If the executive team is dedicated to the philosophy and has committed the essential resources for three to five years, as discussed, the organization should experience benefits to justify the costs of implementation. Organizations who started implementing quality improvement several years ago and are not satisfied with the results should review these key areas to identify opportunities to eliminate existing barriers to
cerns or
success.
Bibliography K. Making total quality management work. Healthcare Executive March/April 1991, pp 22-25. 2. Merry D. Illusion vs. reality: TQM beyond the yellow brick road. Healthcare Executive March/April 1991, pp 18-21. 3. Allawi S, Bellaire D, David L. Are you ready for structural change? Healthcare Forum Journal July/August 1991, pp 3942. 1.
Berger S, Sudman
Downloaded from ajm.sagepub.com at UNIV OF PENNSYLVANIA on April 12, 2015
Quality Management? Mary Jean Barrett, R.N., B.S.N., M.B.A.* Ernst &
Young, Phoenix, Arizona
The evolution to a Total Quality Management (TQM) or Continuous Quality Improvement (CQI) philosophy is particularly attractive in the health care industry in its search for better ways of doing
business to
ensure
financial survival in the current
competitive environment. This article, however, suggests that some organizations may not benefit from attempting to implement methodology to achieve the widely accepted financial and operational benefits, not because of any weakness in the conceptual framework, but because of the culture and/or lack of dedicated resources required to ensure the acceptance and success of the approach. As a result, many providers are discovering that after a few years of implementation, benefits to the organization are not being recognized to the extent possible. Specific issues that have been identified as essential requirements to a successful implementation process or evolution to a continuous improvement culture are described in this article.
Many health care executives are considering or have initiated the implementation of a Total Quality Management (TQM) or Continuous Quality Improvement (CQI) model in their organizations to achieve the many benefits experienced by organizations in other industries and other countries. Over the last few years, much has been written about the positive results that can be obtained and how the principles of TQM or CQI should be applied in the health care environment to recognize these results. Recent experience, however, suggests that some organizations do not always have positive results following implementation of a TQM model and/or that benefits associated with the process might not have justified the direct and indirect expense. Many organizations have relabeled the concept to avoid the negative connotation that TQM has incurred as a result. For our purposes, TQM and CQI are used interchangeable in this article. This article does not challenge the validity of quality
improvement but rather organizations’ preparation and implementation of the processes required to achieve it. Many organizations might not be candidates for implementing management philosophy and the industry should recognize this fact, rather than invalidating the conceptual framework or the theory that it can be applied to health care providers. Individual organizations, likewise, need to conduct an internal inventory to determine if the culture of the organization will allow change and whether the necessary resources are available, or will be made available, before expending resources. Simply labeling the TQM/CQI concept as the culprit if expectations are not met should be
discounted. Executives should, therefore, determine if the appropriate data systems, tools, and human and other resources are available and if the culture of the organization is conductive and prepared to initiate or continue the T.QM process in order to have a successful evolution to a new leadership stage. Key considerations are discussed below and include the organizational structure, educational resources, information systems, clinical expectations, data collection, cost accounting information, and success indicators.
ORGANIZATIONAL STRUCTURE Health
care organizations have traditionally been in organized separate functional divisions, i.e., nursing care, ancillary services, support services (dietary, housekeeping), and administrative support services. Like many industries, these divisions report to a chief executive officer or administrator who is often the only executive who has responsibility for all the departments and, of course, can cross all lines with authority. Unlike many organizations in other industries, authority over the departments responsible for the quality of the organizations’ output is divided between peers reporting to the CEO at the executive level. For example, health care providers often have
*
To whom requests for reprints should be addressed at Ernst & Two Renaissance Square, Suite 900, 40 North Central Avenue, Phoenix, AZ 85004.
Young,
106
Downloaded from ajm.sagepub.com at UNIV OF PENNSYLVANIA on April 12, 2015
107 at least two executive vice
presidents presiding
over
nursing, ancillary services, and support services, departments that are accountable for separate operations necessary in the delivery of patient care. The challenge in implementing TQM, therefore, is determining where the day-to-day coordinator or facilitator will reside and where positional authority will derive in order to initiate change processes. Many organizations have designated these coordinators as support positions, which significantly limits their effectiveness because of the need to gain consensus from departmental employees and managers to initiate any focused activity. In many institutions, these professionals have eventually become educators and inspectors-but no change agents. Although the top executives continue to give verbal support of the TQM philosophy, they often are too busy for sufficient detail of activities to provide essential direction or authority to eliminate natural resistance to the changing of any process.
A
key priority, therefore, is first to evaluate the organization to determine where the &dquo;point person&dquo; will be positioned. This position(s) must have two things: dedicated time and authority. Therefore, if one of the executives requests to be responsible for the process, his or her time current structure of the
availability should first be reviewed. Additionally, if the position provides responsibility over some but not all operational departments, a mechanism must be established to allow authority over all departments for daily activities related to TQM. Regardless of who is designated as the day-to-day &dquo;driver&dquo; of the process, a task force for all executives needs to be created with regular meetings to address interdepartmental issues. Without mechanisms to cross functional lines with authority, departmental employees can easily initiate very subtle, but very effective, resistance to the process.
Because of the inherent challenge involved in changing human behavior, some organizations have created a new department identified as &dquo;Quality Management&dquo; and a second tier position to take the responsibility of implementation. Many of these individuals have a nursing or clinical background, which provides them with a broad understanding of the interdepartmental relationships in the patient care areas. This type of background can facilitate communication between departments. EDUCATIONAL PROGRAMS
Many organizations eliminated educational programs in the early 1980s in response to the tightening
of reimbursement
following the implementation of the
Nontechnical programs management training were often the first to go and have generally not been replaced. Only technical, patient care courses which only address task oriented skills are currently provided for nursing and patient care personnel in many organizations. Implementing a CQI philosophy requires the training of all personnel on the principles and process involved in the approach, from the executive to entry level positions. The principles of TQM also suggest that employees need to receive continuous opportunities to acquire new skills to improve their ability to function at their best and develop an understanding of general financial and operational management issues to best serve the needs of the organization in fulfilling its mission. As a result, organizations need to evaluate educational expense as it would any other capital expenditure recognizing that people are the primary resource in CQI environment. Budgeting educational programs as a percentage of the operating budget or as a significant expense is appropriate to emphasize the need for continuous education for all employees at all levels within the organization. Programs need to be developed for:
prospective payment system. such
as
· CQI principles and methodology .
. . .
.
General management Financial management Resource management Technical skills (varies Orientation
Need will vary depending
by department and level) on
the life cycle of the
organization, time frame, or status of implementation, services provided, organizational structure, etc. Existing programs, such as orientation, may need to be revised depending on how other educational programs are
structured.
Physician needs should be considered when developing educational programs and all educational programs should be made accessible and encouraged for members of the medical staff as they continue to be recognized as customers of the organization and critical members of the team. Incentives are being developed by some organizations to encourage this involvement such as combining sessions on issues of most interest to physicians (e.g., financial impact of the resource-based relative value scale) with those relating to management. More organizations are also hiring physicians to serve as medical directors to facilitate utilization review and quality assurance rather than
depending on voluntary
Downloaded from ajm.sagepub.com at UNIV OF PENNSYLVANIA on April 12, 2015
assistance. These
physicians,
108 if
SUCCESS INDICATORS
valuable in
coordinating educational sessions for hospital personnel and physicians. available,
are
INFORMATION SYSTEMS
As
CQI is measuring processes to improvement, it is essential that indicators are identified which represents the quality and efficiency of work performed in each department. a
key premise
in
monitor continuous
These indicators should be monitored on a concurrent Although chart audits and random sampling techniques will still be required for intensive, data specific evaluations, many indicators should be acces-
basis.
sible off an automated system to provide quality measuring at scheduled intervals using consistent meth-
odologies. Under TQM, however, the challenge of identifying and measuring indicators in most departments (which historically were not of concern) has been recognized. Even systems to
clinical outcomes and other quality assurance measures are available from only a few vendors and primarily in a microcomputer standalone environment. Integrated systems to measure resource management, costs, practice patterns, and quality outcomes for patient care departments, which link lab, pharmacy, radiology, critical car units, etc. emergency room, operating room, are not available in measure
organizations. TQM implementation, therefore, it is important to identify those data elements that can be captured and measured using available computerized systems. Without monitoring devices, an organization will not be capable of determining the benefits of specific process improvement, i.e., continuous immany
Before
provement. In order to document a base line for many different operational processes, the cost of performing patient care and support functions is needed to monitor improvements in resource utilization and/or labor usage. Many organizations have not expended the resources
develop a cost accounting system and, therefore, identify only what overall expenses are by department or cost center. The cost of activities performed for specific functions and procedures needs to be developed and documented to determine revised costs as operational efficiencies are achieved. For example, expenses incurred to bill an account or draw blood for a complete necessary to
can
blood count
can
be determined in order to later doc-
improvements in the activity as a result implementing process improvement or redesign.
ument
of
As noted above, a fundamental component of TQM is the engineering approach to measurement to demonstrate continuous improvement. As a service industry, health care organizations have not traditionally expended many resources on systems to provide this capability. Often, only data required by regulatory agencies were collected, and often painfully, through manual review processes. Because of the intensity of measurement recommended under a continuous improvement philosophy, new and/or enhanced systems are required to provide concurrent and retrospective data with limited manual effort required. Data collection through chart reviews,
focused reviews, etc., are valuable but too expensive to perform on a 100% basis and do not provide the reliability of measurement that automation does because of the human interaction involvement. Many organizations have chosen not to benchmark against better performers or base line current processes to avoid the competitive, financial orientation that often comes with measuring indicators of functional processes. This philosophy of implementing TQM because &dquo;it is the right thing to do&dquo; demonstrates commitment from the executive team and a long-term focus that makes many organizations successful. However, organizations need comprehensive monitoring devices to facilitate evaluation and provide incentive to all employees to make them all feel a part of the process. Furthermore, if the financial situation of an organization changes, executives can be asked to justify the resources of the program retrospectively. Lastly, an organization cannot know if the evolution to a TQM approach and philosophy is successful if the conditions of their institution &dquo;before&dquo; and &dquo;after&dquo; are
not measured.
Organizations are encouraged to develop two types of monitoring systems. The first is quantifiable measures that can frequently be automated on a system for progress monitoring. The second type of measurement is the soft qualitative measurement that may or may not be captured on automated tools, e.g., patient surveys. A sample of indicators that can be measured is listed in Table 1. As an organization initiates TQM, the development of macro-level indicators identified by the executive team is suggested. These types of indicators are often already measured but not in one comprehensive package for executive review. Examples include cost per case, average length of stay, full time equivalents, operating expenses, margins, days in receivables, bad debt, cash flow, denial rates, mortality and morbidity data, clinical outcomes summarized by department,
Downloaded from ajm.sagepub.com at UNIV OF PENNSYLVANIA on April 12, 2015
109 Table 1
Sample Success
to bear the brunt of cost containment which has
Indicators
frequently resulted in situations, particularly with primary care models, in which the RNs do not feel they can provide quality of care because of high patient-tonurse
ratios.
considering the implemanagement model whereby one professional RN monitors a patient’s case and coordinates all services and addresses potential placement issues. These &dquo;case managers&dquo; generally monitor a patient throughout an episodic stay or over a continuum of care following the patient after discharge to home care, outpatient services, nursing home, and so Many organizations
mentation of
are
also
a case
on.
The development of critical paths is also being recognized as a tool for benchmarking and/or base lining current physician practice patterns. Many organizations have this information available, sorted by physician, but do not share it with the medical staff fearing it might alienate some of them. Other organiDRG, diagnostic-related group; ALOS, average length of stay; OB, obstetrics ; UOS, unit of service; FTE, full time equivalent.
and
so forth. Following educational sessions and the origination of a workplan to initiate activities, detailed indicators chosen to monitor specific processes need
to be identified and measured.
CLINICAL EXPECTATIONS In uous
zations do not have the information systems available to supply procedural data by data and service for specific patients and case types since older systems often provide only charge information. Developing critical paths for high-volume or high-cost cases documents a basis for discussing resource management issues and facilitates the identification of quality issues based on established expectations. If an organization has previously attempted any of these actions and met with such resistance that the effort was abandoned, the organization may not be a candidate for TQM, at least until the culture of the organization is improved.
conjunction with a reorientation toward a continimprovement philosophy, many organizations
have found that the framework sets the stage for activities that have historically met resistance. With the new emphasis on data, executives can now often get the support necessary to implement critical paths, nursing acuity systems, severity of illness systems, quality outcome monitoring, etc. Such information provides administration, the medical staff, nursing, and ancillary services, with data that allows more sophisticated management and decision-making. The redesign of patient delivery models also is typically reevaluated through the continuous improve-
approach. Leveraging professional registered (RNs) by providing them with trained assistants, for example, allows RNs the time to perform the activities they were trained to perform (i.e., the planning of patient care, assessment, and education) while maintaining a neutral budget by supplementing professionals with less skilled personnel. Nursing is often the advocate of redesign because it has tended
CONCLUSION
Because there is
model
or
approach
to con-
sidered include: ~ ~
ment
nurses
no one
improvement that is appropriate for all organizations, executives must identify the approach that best matches the organization’s needs and philosophy. Additional organizational issues that need to be continuous
~
~ ~ ~
~
Commitment of all members of the executive team Receptiveness and current relationship with the medical staff Receptiveness and current relationship with the board Financial status of the organization Current morale of employees Tenure of the executive team and management Current perception of the organization in the local market
Downloaded from ajm.sagepub.com at UNIV OF PENNSYLVANIA on April 12, 2015
110 ~ ~
Actions taken by competing facilities Mission and strategy of the organization
of the approach that an organization chooses to use, a review to determine if an organization is prepared and that appropriate mechanisms and tools are available is suggested. Essential questions that need to be answered include: 1. Does the organizational structure provide the means for cross-functional process improvement? 2. Has the executive team been together, in place long enough, and/or otherwise earned the trust needed from middle management and employees to undertake a cultural change? 3. Have attempts been made in the past to redesign the patient care delivery model and develop critical paths and case management, etc, and, if so, were they successful? 4. Does the executive team have the commitment to endure the natural resistance that will result from the medical staff, management, and employees in reaction to the change? 5. Does the organization have the internal resources necessary for continuous and varied training pro-
Regardless
grams ? 6. Are information
systems installed to provide in-
tegrated, detailed data to monitor provement in all operational areas?
continuous im-
7. Is cost information available? 8. Have comprehensive indicators been identified for
monitoring across all departments that are representative of key processes? If the resources described in this article and/or the culture of the organization are not conducive to undertaking a transition to a continuous improvement focus for the whole organization, it may be more appropriate for individual organizations to first attempt single business process redesign efforts for processes that have been identified as needing improvement. Many individual processes require participation and cooperation from different departments which will require a team approach to resolve existing conachieve efficiencies. If the executive team is dedicated to the philosophy and has committed the essential resources for three to five years, as discussed, the organization should experience benefits to justify the costs of implementation. Organizations who started implementing quality improvement several years ago and are not satisfied with the results should review these key areas to identify opportunities to eliminate existing barriers to
cerns or
success.
Bibliography K. Making total quality management work. Healthcare Executive March/April 1991, pp 22-25. 2. Merry D. Illusion vs. reality: TQM beyond the yellow brick road. Healthcare Executive March/April 1991, pp 18-21. 3. Allawi S, Bellaire D, David L. Are you ready for structural change? Healthcare Forum Journal July/August 1991, pp 3942. 1.
Berger S, Sudman
Downloaded from ajm.sagepub.com at UNIV OF PENNSYLVANIA on April 12, 2015
