Four Steps to Improving Healthcare Quality

A combined proactive and reactive method offers more benefits than either approach used alone

Published: Wednesday, September 19, 2012 - 10:10

When a medical institution aspires toward excellence and patient safety, quality enhancement proves to be a key factor essential to the process.

It goes without saying that there are countless risks in the healthcare system, and that it is always a priority to minimize these. There is nothing new about that. However, this article takes the stance that the inevitable reactive approach to negative events is not the only method that can be used to reduce risks and therefore enhance quality. We will examine how a combined approach with an equal emphasis on preventive measures can be a highly effective management pattern that breaks down barriers and cuts through conventions.

What exactly are we trying to achieve?

“Patient safety” is defined as a healthcare discipline primarily involving the reporting, analysis, and prevention of medical or process errors that can lead to adverse healthcare events.

“Quality” in public health is understood to be the degree to which policies, programs, services, and research for the population increase the desired healthcare outcome and conditions in which the population can be healthy.

Why is this target so difficult to reach?

Healthcare institutions invest enormous effort and resources to improve quality and patient safety, but often fail to reach that aspired “ultra-safe” environment. The following factors, adapted from Patient Safety and Quality: An Evidence-Based Handbook for Nurses (Agency for Healthcare Research and Quality, 2008), have been identified as typical system barriers in striving toward this goal:

Error reporting
The processes for reporting errors are often time-consuming and confusing. Errors are often misinterpreted as routine problems typical of a hectic and complex environment.

Fear and ego
A lack of confidentiality discourages staff members, who are already battling to overcome feelings of shame or arrogance from having the courage to participate in the error reporting process. It is only human to find it difficult to admit one’s mistakes, and this is exacerbated by the understandable fear of malpractice lawsuits.

Culture of blame
There is a tendency in healthcare organizations to use the information collected from reported errors to take punitive action instead of investing it wisely in system improvements (referred to as a “culture of blame”).

Collaboration and communication
Given the interdisciplinary nature of healthcare and the need for cooperation among those who deliver it, teamwork, especially collaboration and communication, is critical to ensure patient safety. There is currently a very real lack of specific training and culture to encourage teamwork as a priority. When investigating the root cause of a problem, medical staff find it difficult to see the bigger picture. The tendency is to ignore the consequences that stem from processes across other departments or along the whole value chain (e.g., external suppliers, internal department).

Excessive and outdated rules
Excessive professional rules and regulations are a negative side effect of excellence. Generated by the accumulation of layers that are intended to improve safety, we end up with an overly complex and burdensome system. The frequency of new rules and guidance materials is often high and poorly aligned with internal system updates. Old rules and guidance materials are often not discarded or removed, consequently making it difficult to comply with the latest applicable regulations.

U.S. legislators are already “reacting” to this situation

The Patient Protection and Affordable Care Act is a new healthcare regulation that, when it comes into force in the United States, will intensify the need to overcome the aforementioned barriers. Before we consider how healthcare companies can adjust to change, let us briefly examine the effect that this new legislation will have on the medical sector. The following points are adapted from the Patient Protection and Affordable Care Act signed into law by President Obama in 2010.

• Payment for services will be directly linked to quality. A value-based purchasing program for hospitals will link Medicare payments to quality performance on common, high-cost conditions such as cardiac, surgical, and pneumonia care.
• Plans providing extra benefits to healthcare institutions must give priority to cost-sharing reductions, wellness, and preventive care prior to covering benefits not currently covered by Medicare.
• Incentives for physicians to report Medicare quality data. Physicians will receive feedback reports beginning in 2012. Long-term care hospitals, inpatient rehabilitation facilities, and hospice providers will participate in value-based purchasing, and quality reporting will start in 2014, with penalties for nonparticipating providers.
• Support for prevention and public health innovation. A new CDC program will help state, local, and tribal public health agencies improve surveillance for and responses to infectious diseases and other important conditions. An Institute of Medicine conference on pain care will evaluate the adequacy of pain assessment, treatment, and management; identify
and address barriers to appropriate pain care; increase awareness; and report to Congress on findings and recommendations.
• The government will make substantial investments to improve the quality and delivery of care and support research to inform consumers about patient outcomes resulting from different approaches to treatment and care delivery.

These new conditions have been a major incentive to Tefen, a management consulting firm, to develop a proactive and reactive methodology that will assist healthcare organizations prepare for the above changes, while simultaneously helping them achieve excellent quality and patient safety.

The benefits of combining proactive and reactive approaches in risk management

Based on the current, traditional approach, healthcare systems typically wait until an adverse event occurs during medical treatment and then react to this. The organization then conducts “lessons-learned exercises” based on the event that occurred: initiating action and “repairing” projects as follow-ups to lessons learned from previous adverse events.

These actions and projects usually contain “local fixing” acts that address the safety issues causing the event. Apart from this “reaction,” the organization usually continues its customary daily routine until the next unforeseen problem or chain of problems occurs.

The less frequent and more difficult method to implement is the preventive approach. A proactive stance encourages an organization to take action now to prevent the next adverse event from happening. Revealing the risk factors before they cause an accident is not an easy task.

A combination of the two above-mentioned approaches was found to be most suitable for the daily reality of healthcare systems. This combination offers more benefits than either approach on its own.

Four steps to applying a combined proactive and reactive approach

Step one: Analyze current position on two-axes diagram
Initially the organization should analyze its current position on the two-axes diagram shown below.

The classic total quality management (TQM) methodology cited in this article forms the foundation for the proactive and reactive methodology developed by Tefen to reach excellence in quality and patient safety. To perform this analysis, use TQM factors, which are measured by TQM tools according to the following table:

Step two: How do we know what is going to cause the next accident?
We need to identify and define inevitable and expected events, such as infections. To pinpoint risks that are hard to recognize, hospitals should analyze processes as well as the customer and supplier value chains. To allow this step to be repeated continuously, organizations should systematically collect data, regularly monitoring and integrating information from a variety of safety hazard sources. They can encourage staff to report errors by ensuring anonymity. These data should be used only for safety analysis and not for punitive action. By comparing aggregated data and benchmarks with national data sets, a point of reference can then be created. Most hospitals know they should identify events, but they need a tool to do so—something like the UHC Patient Safety Net tool.

Step three: Means of actions and measurements
This is the time to define a proactive approach for prevention of the inevitable or expected events and to derive specific means of action. This should be backed up by designing a methodology to measure the efficiency of defined safety solutions to known problems. Possible TQM tools for this include audits, surveys, control charts, brainstorming, and fishbone diagrams. This should be a continuous process aimed at eliminating potential problems.

Step four: A prioritizing policy
The policy should equally prioritize issues with quicker and more apparent outcomes as well as longer and less apparent processes. Classic TQM implementation usually requires long-term resource allocation at the expense of short-term, urgent resource requirements. Prioritizing both long- and short-term activities may help you explain the value of the long-term, less apparent benefits of a process to the staff, thus increasing their motivation and understanding of the final goals.

The methodology described above is relevant to any healthcare organization wishing to overcome barriers in order to thoroughly improve quality and patient safety.

About The Author

Tefen Management Consulting

Tefen, an international management consulting firm, designs and implements strategies and solutions for contiuous growth and sustainable performance excellence. Utilizing lean, Six Sigma, and simulation tools, Tefen focuses on increased sales, higher productivity, reduced operational costs, and optimized business processes. Founded in 1982, Tefen’s headquarters are in Tel Aviv, Israel, with the U.S. headquarters in New York.