Abstract
Rapidly rising health care costs and increased focus on patient outcomes and safety have ensured that “business as usual” is no longer acceptable or sustainable. Achieving the highest quality care for patients with congenital and acquired heart disease requires efficient and consistent application of evidence-based best practices. This requires physicians and health care organizations to reevaluate current practices and to employ performance improvement principles and strategies that have proven to be successful in other industries.
This chapter highlights the importance of quality in today’s health care environment and details how quality and performance improvement marries with the traditional concept of evidence-based medicine to enhance care. The basics of performance improvement methodologies are reviewed, and improvement at the unit and organizational level is discussed. Finally, the importance of collaborative efforts in this complex patient population is presented.
Key Words
Quality improvement, Performance improvement, Dashboards, Patient outcomes, Patient safety
With increased emphasis on tracking patient outcomes, reducing hospital-acquired conditions, promoting cost-conscious care, and inclusion of quality metrics as determinants of reimbursement, quality has become a major focus in health care. However, defining what quality means in any given health care setting can be challenging. An isolated decrease in patient mortality does not necessarily equate to quality care, nor does improvement in any one other metric, particularly if that improvement comes at the expense of another important outcome.
The Institute of Medicine (IOM) has provided six domains that define quality in the health care setting :
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Safe: Avoiding harm to patients from the care that is intended to help them
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Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively)
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Patient centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions
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Timely: Reducing wait times and sometimes harmful delays for both those who receive and those who give care
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Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy
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Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status
As health care providers, our primary goal is to deliver optimal outcomes to our patients, but this must be balanced with a fiscal responsibility to provide care that is both cost-conscious and sustainable. The primary tenet of medicine, “first do no harm,” prioritizes patient safety in all that we do. In this manner the pursuit of quality care must consider not only singular patient outcomes but also other balancing measures, risk stratification and error proofing, and outcomes important to the greater populace. Similarly, attention must be paid to ensure this care is delivered in a consistent and equitable manner.
Quality Improvement/Performance Improvement
Determining the best medical treatments for patients has traditionally been driven by rigorous research in the form of basic science, translational research, and tightly controlled randomized clinical trials. Unfortunately, there is often a lag of more than a decade between new research defining a best practice and that practice becoming standard of care. Similarly, even when a best practice is known, it is commonly applied in an inconsistent fashion. This delivery gap is where quality improvement is an essential part of providing care ( Fig. 2.1 ). Quality improvement methodologies are essential to ensuring consistent delivery of best care practices, particularly as patients’ health issues have become more complicated and health care delivery systems have become more complex.
Although many of its concepts are relatively new to health care, the field and process of quality improvement should not be dismissed as a “soft science.” Quality and performance improvement are built on proven strategies that have repeatedly enhanced patient care. Just as with traditional research, the best results in quality and performance improvement initiatives will be realized when rigorous methodology is applied.
Much of quality improvement science was developed and streamlined in business and manufacturing settings, with more recent introduction to the health care environment. The adaptation of these principles to the hospital setting may inherently lead to conflict and confusion, given the primary goal of business is to improve shareholder value, whereas the primary goal in medicine is to improve patient care. As a result, the direct translation of these business principles to health care can result in uncertainty as to the true focus of a given project, as well as which specific strategy is best suited for the problem being addressed. An added challenge to quality and performance improvement in the health care environment is the almost ubiquitous need for human factors management for successful project implementation. In the next several sections we describe some of the necessary strategies to achieve transformative care for patients.
Identifying Targets for Improvement
Health care is complex and constantly changing. Although providers and patients can typically identify many processes that either contribute to suboptimal outcomes or are substantial sources of dissatisfaction, determining specific targets for improvement can be challenging. It is also often unclear which improvement target should take priority at any given time and what resources might be available for the next improvement project.
The selection of improvement targets is generally achieved through the balance of two factors: those projects that can have the greatest impact on patient care and those changes that can be easily made. The latter of these, often termed low-hanging fruit, often provide short-term projects with low resource requirements. Early “wins” with these projects can help bolster a culture of continuous improvement and gain momentum for those projects with the greatest potential impact. It is these impactful projects that will likely require greater resources and long-term commitment, and it is these projects where specific quality improvement methodologies and human factors engineering will be required to realize change.
Any quality improvement project should start with a clear statement of the project’s goal. SMART statements are the generally accepted method for defining the aim and scope of the project:
S pecific: Provide clear and unambiguous targets for improvement.
M easurable: Ensure that the outcome is objectively quantifiable and able to be tracked.
A chievable: Is the project goal attainable in terms of scope, resources, and time available?
R elevant: The “so-what” question. Is this an important initiative for the organization, the patients, or the staff? Is this the right intervention to affect the targeted outcome?
T ime oriented: What time frame will this project span?
An example of a SMART statement with all the necessary elements might be: “We will reduce the number of pressure ulcers (grade 2 or higher) among patients in our unit to less than 2 ulcers per 1000 patient days by August 1st.” This is a clearly measurable target with specific scope in terms of population and time frame. Of course, determination of “achievable” and “relevant” must be decided in collaboration with the unit leadership and with consideration for the current state as well as available resources for the project.
Leadership backing of quality improvement efforts is essential for several reasons. First, leadership can help prioritize those projects that are of greatest importance to the organization and, in the process, can also verify that necessary resources will be made available for project completion. The lack of such support can easily lead to project failure due to lack of means or inability to maintain momentum. Second, organizational leadership will be aware of other improvement initiatives that may be ongoing simultaneously. Coordinating these efforts can avoid confusion around institutional priorities and promote collaboration between medical teams. Finally, public affirmation by organizational leadership regarding the priority of an improvement project will help gain support from the staff and assist with sustainability after the initial intensive push for process change.
Early identification of key stakeholders and incorporation of these individuals into the planning process is essential to the success of any quality improvement effort. Building a multidisciplinary group of individuals with unique perspectives and priorities will help provide a clear and robust analysis of the problem at hand. Furthermore, inclusion of these individuals in development of interventions will bolster early multidisciplinary support for the project and potential solutions. Ideal project members are experienced frontline individuals with content expertise and strong teamwork skills who also hold significant influence in their work area (regardless of leadership titles or lack thereof). Paired with visible organizational leadership support, the buy-in of these influential frontline staff members will help garner widespread acceptance of new process flow or other solutions.
Defining project scope is another key ingredient to designing a successful improvement initiative. A natural tendency while assessing an array of issues in a given work area is to try to solve multiple problems at once. Unfortunately, this approach may lead to lack of clarity and spread resources too thin to accomplish project goals. Prioritization of a specific target outcome and use of a key driver diagram ( Fig. 2.2 ) can help narrow the focus of the project to the most impactful interventions. Development of a SMART statement is then an ideal strategy to define clear boundaries and focus the scope of a given project.
Measurement/Metrics
Before starting any improvement project, it is essential to adequately capture the current state of the process or outcome of interest. Only by knowing the starting point will the project team know if change was achieved. Ideally, the outcome of interest should be easily measured, with high validity, and have a clear impact on patient outcomes.
Data collection efforts (i.e., accurate measurement and analysis) in health care typically lag behind similar efforts in industry. This is a function of multiple issues, including, but not limited to, lack of contemporary information technology (IT), lack of IT investment, noncomplementary IT (i.e., systems that do not “speak” to each other), and conflicting priorities. Increased use of electronic medical record systems has allowed for simplified tracking of certain key outcomes in many institutions, but these data sources may require careful monitoring to ensure validity.
Any process change may have unintended consequences; therefore it is essential to also monitor a balancing outcome that may be negatively affected by the proposed solution or process change. For example, if a new protocol is implemented providing prophylactic anticoagulation to a high-risk population, it would be important to monitor the incidence of bleeding in these patients. Balancing measures for process changes often include cost, time, or an outcome for a conflicting process.
Tracking improvement progress is best achieved through the use of control charts ( Fig. 2.3 ), where the identified primary outcomes are tracked as a function of time, with notations on the chart for specific interventions or external changes that might influence the outcome of interest. These charts provide a clear visual representation of improvement over time and can facilitate statistical analysis of a process that lies within or drifts out of control parameters. Control charts also allow for ongoing monitoring of the outcome once the improvement initiative has concluded.
Improving Care
A variety of quality management and performance improvement (PI) methodologies are readily available for use in the hospital setting. Most of these methodologies have been adapted from business and manufacturing and then successfully translated to health care. Some of the more common quality improvement methodologies are summarized in Table 2.1 , along with the tools commonly applied for each methodology. These methodologies often use similar tools, but each is suited for different aspects of process control or improvement across the continuum of health care delivery. Although an in-depth discussion of different methodologies is beyond the scope of this chapter, Table 2.1 highlights the primary utility of each strategy and principal strengths and weaknesses.
| Methodology | Primary Role | Key Strengths | Potential Limitations | Tools Commonly Utilized |
|---|---|---|---|---|
| Model for Improvement (Institute for Healthcare Improvement) | Rapid process improvement |
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| PDSA cycles, key driver diagrams, process mapping, cause and effect diagrams |
| Six Sigma | Minimize variability, reduce defects |
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| DMAIC, process mapping, Pareto charts, cause-and-effect diagrams, value stream mapping |
| LEAN | Reduce waste, increase efficiency |
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| Value stream mapping, process mapping |
| Failure modes effect analysis (FMEA) | Error proofing |
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| Process mapping, error proofing, FMEA worksheets, SWIFT analysis |
| Root cause analysis | Error investigation |
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| Process mapping, error proofing |
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