Home | Acknowledgements | Chapter 1 | Chapter 2 | Chapter 3 | Chapter 4 | Chapter 5

Chapter 1
Quality Improvement: The Four Steps

The Purpose of QA/QI

A health center sets its objectives and performance standards in accord with its particular community’s needs, operational needs, financial well being and the requirements of its funding sources and payors. The Quality Improvement policy and procedures are designed and implemented to assure that the organization performs well those tasks that are important to its mission and objectives.

Although QA/QI system is important in holding an organization to its clinical objectives it should serve as an important management tool and help make the entire organization more effective and competitive. The QA/QI policies should help the board and management create and recreate an effective and efficient organization by setting and reinforcing objectives, stimulating training and education, identifying processes needing to be redesigned or re-engineered, and providing information for staff and departmental performance evaluation.

There are five basic areas or levels of a health center’s activity where quality counts and where the quality process should be applied. These are presented in the table below:

Quality Defined

Quality may be defined as doing the right things right and for the right price. That is, first, the quality process must include deciding on what the organization should do (e.g., provide x-ray services); second, determining if the service or activity is conducted in accord with standards (e.g., waiting time is low and x-ray interpretations are accurate); and third, the benefit of the activity must justify the cost and there must be resources to pay for it.

A 1974 policy statement on health care quality of the Institute of Medicine included a statement that quality assurance should lead to... "health care that effectively betters the health status and satisfaction of the population, within the resources that society and individuals have chosen to spend for that care." This definition is powerful because it includes the three points of focus that are key to a health service program’s success: health outcomes, patient satisfaction, and cost.

The Quality Improvement Process

The quality process involves four steps:

1. Setting objectives (Deciding what we are doing here.)
2. Designing our process and procedures for accomplishing the objectives (Deciding who will do what and what tools are needed to meet the objectives.)
3. Measuring and evaluating our performance (Deciding how well our systems worked.)
4. Responding to what we learned about our performance.

Comments on the Four Steps:

• All steps require management leadership and staff participation.
• Staff can be organized into departments, teams or workgroups to carry out the process.
• The sequence here is idealized. In fact, the process may start at different points. For example, we may have to start with performance standards imposed by a funding agency and then design the work process to meet the standard.

1. Setting Objectives

"The doers must be planners."

Objectives are set at the several levels of organizational activity (from strategic to clinical decision making). Who sets the particular objectives depends on the level. Strategic and budget objectives are usually set by the board; organizational objectives are set by the management; and operational, program and clinical objectives may be set by departments or teams. Another name for objectives is performance expectations. Depending on established management processes and organizational culture various methods of participation in setting objectives by staff and customers can be organized. However, it is important that the staff does understand what is expected from them and how it relates to the overall mission and strategic interests of the health center. Here are some additional ideas about objectives:

• Objectives should be in alignment with strategic and budget goals.
• Objectives should be set for departments and programs.
• Objectives should also be set for individual program and department leaders. (James Covey calls the individual objectives "Personal Performance Agreements".)
• For objectives to have meaning specific people must feel responsible for them. Therefore, do be clear about who is responsible (a group or an individual). Include performance against the objectives (or expectations) as part of the regular staff evaluation.
• The BPHC Annual Health Plan format is a convenient tool for recording and organizing the health center’s objectives at all levels, including the personal performance agreements. Be sure to include the department or team that is responsible. (See Chapter 4 for a copy of the form).

2. Designing Processes and Procedures

Since we are advised by gurus of quality improvement and work process redesign that most quality or productivity problems can be traced to system problems rather than to individuals, it is important to understand how these work systems come to be and how they can be improved. (The gurus referred to include Edward Demming, whose ideas are explored in the 1986 book by Mary Walton titled The Demming Management Method; Peter Senge, who wrote The Fifth Discipline Fieldbook, 1994; and Michael Hammer, author of Reengineering the Corporation, 1994, and Beyond Reengineering, 1996. These books all offer lucid guidance to systems thinking and quality improvement that is highly relevant to primary care center operations.)

The way the work is actually conducted in a health center varies, depending on the particular task and the specific center. Some work can be highly structured and described by rules and written procedures or, alternatively, work processes can be basically made up by the people doing the work or done by the seat-of-the-pants. Much of the work in health centers is a combination of explicit procedures approved by management and of modifications and additions created by the people carrying out the work. The actual work process is frequently the result of informal negotiation among the involved parties.

The work of the staff assigned to billing, collections and bookkeeping tends to be very structured. The work of receptionists and nurses tends to be more of a mix of structure and self-direction. The process of clinical care and clinical decision making is usually left to the clinicians to figure out. If program expectations only relate to the number of patient visits or the amount of clinical charges, and the clinicians have bought into these objectives, such a system can appear to work. However, once you add clinical quality objectives—for example, that all abnormal pap smears receive appropriate follow-up or that 80% of the women over age 50 receive mammography every two years—the seat-of-the-pants system will probably not produce the result you need no matter how much the staff is admonished. Getting results will likely require more structure, such as explicitly describing the flow of work and the delegation of duties, developing forms or materials to assist in the work, training staff and monitoring performance.

Quality and effectiveness requires that health center management apparently head in opposite directions at the same time. On the one hand, meeting patient needs requires taking responsibility and exercising good judgement on the part of staff. The complex nature of the work requires that staff does exercise judgement and creativity all the time and the quality of those judgements are important to the organization’s success. In fact, improved performance depends on expanding the areas for judgement on the part of staff and providing the necessary education, motivation and support for making sound judgements. The basis for sound judgement and creativity is identifying with the needs of the customer, understanding the health center’s mission and objectives and feeling part of a team.

On the other hand, reducing variations from standards of care requires that we create explicit systems that describe how staff will conduct the work to assure that we meet a standard of care for a particular patient or group of patients. This explicit description of who does what work and what tools they will use is a System of Care. The process of creating the system of care involves obtaining both the input and agreement of key players. Developing systems of care are great opportunities for educating staff about health center objectives and building teams. The development of a SOC can involve identifying or developing tools for the clinicians and staff to facilitate the work. These can include patient assessment and scoring forms, patient education materials, descriptions of referral resources, or computer or manual case management systems. Frequently, systems of care require the re-design of work processes—sometimes radical redesign. The latter is referred to as re-engineering.

What is critical to grasp is that, if the health center sets a performance standard, whether on its own or in response to an outside entity, management must see that work processes are designed to meet the standard.

3. Measuring Our Performance

"Measurement is essential to recognizable achievement."

Measuring performance serves several important functions. It is the way to reinforce the objectives of the health center and keep everybody on track. It stimulates analysis and understanding of the work processes that allow the staff to meet the performance standard. It is how you determine if you have met the expectations of external entities. It is also the way to determine when you have succeeded and when celebration and accolades are in order.

Measurement requires several steps:

• Pick an Objective or area of operation that should be evaluated. Pick something important since there are limited resources for the quality process.
• Decide on a Performance Measure or Indicator that can be measured that is related to the objective or operations. For accounts receivable management the indicator might be number of days of AR over 90 days old by third party. For clinical care issues we refer to a "standard of care". Standards of care are included in clinical practice guidelines or protocols. An example of a standard of care is that all women over 50 should have a mammogram every two years.
• Decide on the Performance Target or Criteria for success. For the AR example, the criteria might be no more than 30 days of a third party’s charges are over 90 days old from the time of billing. Or, for the clinical example, 80% of women aged 50-70 will have a mammogram within the two-year audit period.
• Decide on the Audit Methodology, which is the method of determining compliance with the criteria. The components of the method include what population or sample will be examined; how the data will be collected, recorded, tabulated and presented; and who does it. It may be that information is being recorded concurrently in a computer database and the required report can be produced automatically or data may have to be collected from medical records and then tabulated.
• Distributing the information to those responsible for acting on it and to relevant management or governing body.

Note that some audits will be done regularly according to a schedule in the QA/QI policy and some will be done in response to a one-time desire for performance information in a certain area.

4. Responding To What We Learned

"If the effort does not result in action plans, it is probably wasted."

It is the QA/QI Committee’s job to report to the departments and/or health center teams, as well as to management, on their findings as revealed by the evaluations and audits it conducts and reviews. It is management’s task to organize the response to problems or opportunities for improvement reported by the Committee. Management may be involved directly in making the necessary changes or delegate the issue to the department or create an ad hoc staff team to deal with the problem. It is usually appropriate to involve those staffers who are doing the work that is being evaluated in coming up with the solution.

There are a number of possible actions that management or the team may take to respond to a gap between actual performance and the standard. This response may involve one or more of the following actions:

1. Carry out additional analysis to get a better idea of the cause of the problem. Further analysis might involve surveying staff or patients to get ideas of the source of the problem or creating flow charts to help visualize present work process as well as to describe redesigned process.
2. Modify a procedure or policy description.
3. Change job descriptions.
4. Organize a training or education program for the staff involved.
5. Send staff to another center to learn another approach to the problem or talk to experts in the field.
6. Develop tools that will reinforce the standard of care in the actual practice situation such as an assessment form, a patient education packet or a program brochure.
7. Develop a System of Care that clearly describes the work process for meeting a clinical standard.

The QA/QI Framework

To carry out a QA/QI process the health center needs to establish a framework that meets the needs of the organization and the requirements of the BPHC. The framework should be set forth in a policy statement. (See Chapter 4 for a sample Quality Improvement Policy.) Essentially, the framework involves a QA/QI Committee working closely with the departments, programs, and sites of the health center; a planning process also involving departments and programs; and the externally imposed standards.

The QA/QI Committee

• A committee is formed by management with a charge to implement a QA/QI program. The committee should be interdisciplinary and may be made up of department heads or, in the case of small programs, the entire staff. There are some basic rules for the committee. It carries out its work with agendas and minutes. It establishes some method of decision-making and has a chairperson.
• The committee creates, and works from, a Calendar of Audits and Performance Reviews which includes standard audits done routinely every month, quarter, or year, and special audits.
• There is an Audit Form on which the audits are described and results and follow-up are noted.
• The QA/QI Committee reports go to management and the board.
• It is the Committee’s job to see that the real work of quality improvement takes place at the department or program level or at the various clinic sites. The people delivering the services should be measuring their performance and analyzing the results and planning and implementing the response to discovered problems.

The Planning Process

"Strategy development is more about choice than analysis."

"Strategy implementation is more about commitment than correctness."

The health center has a planning process that is carried out by the health center that sets budget and program objectives, including objectives that are to be monitored by the QA/QI Committee. (This process produces the annual plan required by the BPHC.) All departments and staff should have an opportunity for input into the plan and have access to the final plan. Objectives for the annual plan may come from QA audits, from a group process involving teams and departments, and from review of the quality requirements of funding or regulatory agencies.

Use the planning format offered by the BPHC that calls for objectives, work tasks required for the objective, and progress toward meeting the objective. Use a budget format that can allow for input and review by the different departments, or programs and/or satellite health centers. That is create a budget based on cost and revenue centers as well as the categorical budget in the BPHC applications. Budgets should have meaning to the people doing the work and provide a basis for evaluating the performance of the departments and programs that make up the health center.

The plan can and should be modified as the year proceeds and new objectives are developed and/or old ones become irrelevant. The plan can be the glue that holds together the creative forces of the organization and keeps the staff’s focus on what is important to the health center’s mission.

Externally imposed standards

Quality standards imposed by funding or licensing agencies, or third party payors, should be integrated with the quality improvement policy and process of the organization. Although the imposed standards may sometimes seem irrelevant to measuring real performance, frequently they can be used to add weight and credibility among the staff to objectives that will serve the organization. The quality standards in the Primary Care Effectiveness Review (PCER) or those of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) provide excellent guidance for what to include in a health center’s quality policy as well as in the annual health care plan. See Chapter 2 for a discussion of the quality and performance measures required at most primary care centers.

Go to Chapter 2