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After reading Case 1, discuss the following:What is the strategy? What strategic impact do they hope to have? Does this reflect what is currently happening in the health sector?What are the strengths and weaknesses of TQM in this case?What, if any, role does corporate headquarters have?Is there support among various staff?What should be done next?Develop an Analysis Plan and a Set of Recommendations:
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I
CONTINUOUS QUALITY
IMPROVEMENT USING PLAN,
DO, STUDY/CHECK, ACT
(PDSA/PDCA) AND QUALITYIMPROVEMENT TOOLS
Part I presents four cases that illustrate the basic techniques of Continuous Quality Improvement (CQI) under quite varied circumstances. Each
organization formed teams, defined improvement opportunities, collected and analyzed data, then modified its processes based on internal
and external evidence, assessed the results of these experiments, and then
acted on those results. They differ, however, in terms of the type of institution, type of service, cultural setting, impetus for change, staff leadership, and top management leadership. They also represent a range of
economic and global diversity, with the first three cases taking place in the
United States and the fourth in a resource poor setting in Ghana.
The first case, West Florida Regional Hospital, presents a very early and
very straightforward example of the methodology that Dr. Paul Batalden
and his associates at Hospital Corporation of America (HCA) developed
in the early 1980s. Dr. Batalden has been a strong influence on the work
of Dr. Brent James and Intermountain Healthcare, on editors of this casebook, and on many other healthcare leaders. Case 1 displays the core of his
early approach, which emphasized participation in Quality 101 by all
1
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P ART I
C ONTINUOUS Q UALITY I MPROVEMENT
participating leaders and the use of a quality council to prioritize and motivate the efforts of teams of volunteers.
Holtz Children’s Hospital (Case 2) is a contemporary case illustrating
how much has changed attitudinally since 2000–2002 when the Institute
of Medicine published its influential studies of the problem of medical
errors in the United States. What had once been a local and often ad hoc
application of a set of techniques by the management and staff of a delivery site has become a major focus of professional groups, governments,
payer groups, accrediting agencies, and patient advocacy groups. In
response, many hospitals have a quality and safety staff group. They are
required to report publicly certain key clinical quality indicators and have
many available guidelines, checklists, and protocols that are widely
accepted. Central line infections, once considered a natural consequence
of care, are now considered a medical error and have become a condition
for which payers are balking at covering the costs of treatment. This case
presents how the team researched the causes of central line infections,
implemented changes, and rapidly reduced their incidence.
Case 3 shows the use of externally-induced process improvement based on
data mining of payer-required status reports. The U.S. Center for Medicare
and Medicaid (CMS) has funded a series of Quality Improvement Organizations (QIOs) to work with providers on process improvement. Clemson’s
Nursing Home had been identified as an outlier in terms of the use of
restraints and received a request to participate in a workshop to develop a
continuous-improvement approach to the problem. While this is a voluntary
program, any operator in a highly-regulated industry puts a high priority on
conforming to the expectations of the regulators. This case illustrates, again,
the set of tools that those called on to improve processes tend to use.
Case 4 illustrates the use of CQI in the malaria control program of one
region of Ghana. It is one of four international cases in this casebook. In
Ghana the lack of resources—human and financial—often block the
righteous spiral of improvement reported elsewhere. The focus of the case
is on an experiment conducted in 2002–2003 that was relatively inconclusive, but which touches on the ongoing discussion about measuring
process vs. outcome and the relative strengths and weaknesses of observational study designs in assessing the impact of CQI initiatives. The case
also follows up on the status of the malaria program a number of years
later. There have been many changes in the national healthcare environment, but the institutionalization of CQI is not one of them, although
there remain both domestic and foreign-aid champions of the approach.
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1
West Florida Regional
Medical Center
Curtis P. McLaughlin
INTRODUCTION
West Florida Regional Medical Center (WFRMC) is a Hospital Corporation of America (HCA)-owned and operated, for-profit hospital complex on the north side of Pensacola, Florida. Licensed for 547 beds, it
operated approximately 325 beds in December 1991, plus the 89-bed
psychiatric Pavilion and the 58-bed Rehabilitation Institute of West
Florida. The 11-story office building of the Medical Center Clinic, P.A.,
was attached to the hospital facility, and a new cancer center was under
construction.
The 130 doctors practicing at the Medical Center Clinic and its satellite clinics admitted mostly to WFRMC, whereas most of the other doctors in this city of 150,000 practiced at both Sacred Heart and Baptist
Hospitals downtown. Competition for patients was intense, and in 1992,
as many as 90% to 95% of patients in the hospital were admitted subject
to discounted prices, mostly Medicare for the elderly, CHAMPUS for
military dependents, and Blue Cross/Blue Shield of Florida for the
employed and their dependents.
The continuous quality improvement (CQI) effort had had some real
successes over the previous four years, especially in the areas where package prices for services were required. All of the management team had
been trained in quality improvement techniques according to HCA’s
Deming-based approach, and some 25 task forces were operating. The
experiment with departmental self-assessments, using the Baldrige Award
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criteria and an instrument developed by HCA headquarters, had spurred
department heads to become further involved and begin to apply quality
improvement techniques within their own work units. Yet John Kausch,
the Center’s CEO, and his senior leadership sensed some loss of interest
among some managers, whereas others who had not bought into the idea
at first were now enthusiasts.
THE HCA CQI PROCESS
John Kausch had been in the first group of HCA CEOs trained in CQI
techniques in 1987 by Paul Batalden, M.D., Corporate Vice President for
Medical Care. John had become a member of the steering committee for
HCA’s overall quality effort. The HCA approach was dependent on the
active and continued participation of top local management and on the
Plan-Do-Check-Act (PDCA) cycle of Deming. Figure 1–1 shows that
process as presented to company employees. Dr. Batalden told the case
writer that he did not work with a hospital administrator until he was
convinced that that individual was fully committed to the concept and
was ready to lead the process at his or her own institution—a responsibility that included being the one to teach the Quality 101 course on site
to his or her own managers. John Kausch also took members of his management team to visit other quality exemplars, such as Florida Power and
Light and local plants of Westinghouse and Monsanto.
In 1991, John Kausch became actively involved in the Total Quality
Council of the Pensacola Area Chamber of Commerce (PATQC) when a
group of Pensacola area leaders in business, government, military, education, and health care began meeting informally to share ideas in productivity and quality improvement. From this informal group emerged the
PATQC under the sponsorship of the Chamber of Commerce. The vision
of PATQC was “helping the Pensacola area develop into a total quality
community by promoting productivity and quality in all area organizations, public and private, and by promoting economic development
through aiding existing business and attracting new business development.” The primary employer in Pensacola, the U.S. Navy, was using the
total quality management (TQM) approach extensively, was quite satisfied with the results, and supported the Chamber of Commerce program.
In fact, the first 1992 one-day seminar presented by Mr. George F. Butts,
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THE HCA CQI PROCESS
5
Find a process to improve
Organize team that knows the process
P
Clarify current knowledge of the process A
D
C
P
Understand causes of process variation
A
D
C
Select the process improvement
Act
Check
• To hold gain
• To reconsider
owner
• To continue
improvement
• Improvement
Plan
• Data Collection
–KQC’s
–Other
• Data for
–Process
improvement
–Customer
outcome
• Lessons learned
• Improvement
• Data collection
• Data analysis
Do
Figure 1–1 HCA’s FOCUS–PDCA Cycle
Source: Hospital Corporation of America, Nashville, Tennessee, © 1988, 1989. Not for further
reproduction.
consultant and retired Chrysler Vice President for Quality and Productivity, was held at the Naval Air Station’s Mustin Beach Officer’s Club.
Celanese Corporation, a Monsanto division, and the largest nongovernmental employer in the area, also supported PATQC.
The CQI staffing at WFRMC was quite small, in keeping with HCA
practice. The only program employee was Ms. Bette Gulsby, M.Ed.,
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CEO
Coach
Assistant/VP
Dept. Head
Dept. Head
CFO/VP
Dept. Head
Dept. Head
DON/VP
Dept. Head
Dept. Head
Quality Improvement Council
Figure 1–2
Organization Chart with Quality Improvement Council
Mentor
CEO
Coach
Assistant/VP
Dept. Head
Dept. Head
CFO/VP
Dept. Head
Dept. Head
DON/VP
Dept. Head
Dept. Head
CEO QIP Support
Figure 1–3
Organization Chart with CEO QIP Support Mentor
Director of Quality Improvement Resources, who served as staff and
“coach” to Mr. Kausch and as a member of the quality improvement
council. Figures 1–2 and 1–3 show the organization of the council and
the staffing for Quality Improvement Program (QIP) support. The “mentor” was provided by headquarters staff, and in the case of WFRMC, was
Dr. Batalden himself. The planning process had been careful and detailed.
Exhibit 1–1 shows excerpts from the planning processes used in the early
years of the program.
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EXHIBIT 1–1
THE HCA CQI PROCESS
Planning Chronology for CQI
Initiation Plan—3 to 6 months, starting May 25, 1988
May 25: Develop initial working definition of quality for
WFRMC.
May 25: Define the purpose of the Quality Improvement
Council (QIC) and set schedule for 2–4 PM every Tuesday
and Thursday.
May 25: Integrate Health Quality Trends (HQT) into continuous improvement cycle and hold initial review.
June 2: Start several multifunctional teams with their core from
those completing the Leadership Workshop with topics selected
by the Quality Improvement Council using surveys, experience,
and group techniques.
June 2: Department Heads complete “CEO assessment” to identify
customers and expectations, determine training needs, and
identify department opportunities. To be discussed with assistant administrators on June 15.
June 16: Present to QIC the Task Force report on elements and recommendations on organizational elements to guide and monitor QIP.
June 20: Division meetings to gain consensus on Department plans
and set priorities. QIC reviews and consolidates on
June 21. Final assignments to Department Heads on June 22.
June 27: Draft initial Statement of Purpose for WFRMC and present to QIC.
June 29–July 1:Conduct first Facilitator’s Training Workshop for 16.
July 1: Task Force reports on additional QIP education and training
requirements for:
• Team training and team members’ handbook
• Head nurses
• Employee orientation (new and current)
• Integration of community resources (colleges and industry)
• Use of HCA network resources for Medical Staff, Board of
Trustees
(continues)
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EXHIBIT 1–1
July 19: Task Force report on communications program to support
awareness, education, and feedback from employees, vendors,
medical staff, local business, colleges and universities, and HCA.
August 1: Complete the organization of the QIC.
Quality Improvement Implementation Plan to June 30, 1989
Fall: Pilot and evaluate “Patient Comment Card System.”
Oct. 21: QIC input to draft policies—guidelines regarding forming
teams, quality responsibility, and guidelines for multifunctional
teams. Brainstorm at Oct. 27 meeting, have revisions for Nov.
10 meeting, and distribute to employees by November 15.
Oct. 27: Review proposals for communicating QIP to employees to
heighten awareness and understanding, communicate on HCA
and WFRMC commitments; key definitions, policies, guidelines;
HQT; QIP; teams and improvements to date; responsibility and
opportunities for individual employees; initiate ASAP.
Nov. 15: Prepare statements “On further consideration of HCA’s
Quality Guidelines;” discuss with department heads, hospital
staff, employee orientation; use to identify barriers to Quality
Improvement (QI) and opportunities for QI. Develop specific
action plan and discuss with QIC.
Dec. 1: Identify and evaluate community sources for QI assistance—statistical and operational—including colleges, companies, and the Navy. Make recommendations.
Early Dec.: Conduct Quality 102 course for remaining Dept.
Heads. Conduct Quality 101 course for head nurses and several
new Dept. Heads.
Jan. 1, 1989: Develop and implement a suggestion program consistent with our HCA Quality Guidelines, providing quick and
easy ways to become involved in making suggestions/identifying
situations needing improvement, providing quick feedback and
recognition; and interfacing with identifying opportunities
for QIP.
(continues)
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THE HCA CQI PROCESS
9
EXHIBIT 1–1
QIP Implementation Plan, July 1989–June 1990
Aug. 1: Survey Department Heads to identify priorities for additional education and training.
Sept. 14–15: Conduct a management workshop to sharpen and
practice QI methods. To include practice methods; to increase
management/staff confidence, comfort; to develop a model for
departmental implementation; to develop process assessment/QIP implementation tool; to start Quality Team Review.
September: Develop a standardized team orientation program to
cover QI tools and group process rules.
Fall: Expand use of HQTs and integrate into Health Quality
Improvement Process (HQIP)—improve communication of
results and integration of quality improvement action plans. Psychiatric Pavilion to evaluate and implement HQT recommendations from “Patient Comment Card System”—evaluate and pilot.
October: Incorporate QIP implementation into existing management/
communication structure. Establish division “steering committee functions” to guide and facilitate departmental implementation. Identify QI project for each Department Head/Assistant
Administrator.
Establish regular Quality Reviews into Department Manager
meetings.
December: Evaluate effectiveness of existing policies, guidelines,
and practices for sanctioning, supporting, and guiding QI
teams. Include Opportunity Form/Cross Functional Team Sanctioning; Team leader and Facilitator responsibilities; Team
progress monitoring/guiding; Standardized team presentation
format (storyboard). Demonstrate measurable improvement
through Baxter QI team.
Monthly: Monitor and improve the suggestion program.
January: Pilot the Clinical Process Improvement methodology.
All year: In all communications, written and verbal, maintain constant message regarding WFRMC commitment to HQIP; report
successes of teams and suggestions; and continue to educate
about principles and practices of HQIP strategy.
(continues)
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EXHIBIT 1–1
January: Successfully demonstrate measurable improvement from
focused QIP in one department (Medical Records).
Spring: Expand use of HQTs and integrate into HQIP.
• Pilot HQT in Rehab Center.
• Evaluate and implement Physicians’ HQT.
• Pilot Ambulatory Care HQT.
Summer: Expand use of HQTs and integrate into HQIP.
• Human Resources—Pilot HQT.
• Payers—Pilot HQT.
WFRMC has been one of several HCA hospitals to work with a selfassessment tool for department heads. Exhibit 1–2 shows the cover letter
sent to all department heads. Exhibit 1–3 shows the Scoring Matrix
for Self-Assessment. Exhibit 1–4 shows the Scoring Guidelines, and
Exhibit 1–5 displays the five assessment categories used.
FOUR EXAMPLES OF TEAMS
IV Documentation
The nursing department originated the IV Documentation Team in September 1990 after receiving documentation from the pharmacy department that over a 58-day period there had been $16,800 in lost charges
related to the administration of intravenous (IV) solutions. The pharmacy
attributed the loss to the nursing staff ’s recordkeeping. This was the first
time that the nursing department was aware of a problem or that the
pharmacy department had been tracking this variable. There were other
lost charges, not yet quantified, due to recording errors in the oral administration of pharmaceuticals as well.
The team formed to look at this problem found that there were some
15 possible reasons why the errors occurred, but that the primary one was
that documentation of the administration of the IV solution was not
entered into the medication administration record (MAR). The MAR was
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EXHIBIT 1–2
FOUR EXAMPLES
OF
TEAMS
11
Departmental Quality Improvement
Assessment
In an effort to continue to monitor and implement elements
of improvement and innovation within our organization, it
will become more and more necessary to find methods which
will describe our level of QI implementation.
The assessment or review of a quality initiative is only as
good as the thought processes which have been triggered
during the actual assessment. Last year (1990) the Quality
Improvement Council prepared for and participated in a quality
review. This exercise was extremely beneficial to the overall understanding of what was being done and the results that have been
accomplished utilizing various quality techniques and tools.
The Departmental Implementation of QI has been somewhat
varied throughout the organization and although the variation is
certainly within the range of acceptability, it is the intent of the QIC
to better understand each department’s implementation road map
and furthermore to provide advice/coaching on the next steps for
each department.
Attached please find a scoring matrix for self-assessment. This
matrix is followed by five category ratings (to be completed by each
department head). The use of this type of tool reinforces the selfevaluation which is consistent with continuous improvement and
meeting the vision of West Florida Regional Medical Center. …
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