Quality improvement: the view from JCAHO.

Examples illustrating the philosophy behind the accreditation surveys

The management at Villa Clement Health Center, a nursing facility in Greenfield, WI, decided something had to be done about the poor meal distribution arrangements: the tray system was old and inefficient, there was no formal assembly line, and residents could not be sure hot meals would arrive hot. The system had been that way for a long time, and the prospects for rapid improvement did not seem promising.

Within a year, however, Villa Clement was implementing a new, efficient tray assembly line system with new equipment -- and projecting savings estimated at $49,000 annually. In addition, the process was made more efficient so that some staff were able to be used to fill other needs.

The secret of Villa Clement's success, says Joan Carlson, President of Villa Clement, was not to fire the kitchen staff; the secret was using a "quality improvement approach."

"Quality improvement" (QI) (often used interchangeably with "total quality management" (TQM), or "continuous quality improvement (CQI), are frequently heard buzz-words throughout the health care community, but QI is much more than just the latest management fad: a quality improvement system is key to developing better and more efficient care for nursing home residents -- and satisfying OBRA requirements -- in the 1990s and beyond.

The essence of quality improvement is a focus on satisfying the needs of customers. As W. Edwards Deming, whose concepts of quality improvements helped revolutionize Jamaese industry, wrote, "quality has no meaning except as it is defined by the desires and needs of the customer." Customers can be both internal (e.g., other staff members) and external (ranging from suppliers to residents).

What exactly is "quality improvement?" Quality improvement means:

-- creating a customer-focused, quality-driven work environment fueled by leadership commitment;

-- systematically identifying processes that are critical to meeting customer needs and expectations;

-- using statistical tools to describe, measure and continuously improve the efficiency and effectiveness of these key processes.

Quality improvement stresses that most problems in delivering quality service are systemic, not individual; that interdepartmental teamwork is essential to solving systemic problems; that the employees who do the work must be empowered to help develop improvements that will help them do a better job -- and that they want to do a better job; and that problems can best be solved through the collection and use of objective data. Quality improvement seeks to measure and upgrade an organization's actual performance of its various activities, rather than simply measuring whether the organization has the capability of carrying out those activities.

The practice of quality improvement is an evolutionary advance over "quality assurance" (QA), which in recent years has been the mainstay of many health organizations' quality-related efforts. Adopting a QI approach does not mean throwing out QA activities entirely; rather, it builds on QA's strengths (such as emphasis on collecting data and developing performance indicators) and avoids QA's weaknesses. For example, QA (and most other methods of evaluation, such as auditing and peer review) often seems to focus on assigning blame to an individual when something goes wrong, an approach that does little to encourage employees to cooperate in efforts to examine problem areas. QI emphasizes that processes determine outcomes and that analysis and improvement of processes are the basis for increasing quality. QA often isolates quality activities in separate departments; QI, by contrast, recognizes that most aspects of patient care, from passing medication to delivering good nutrition, really involve personnel from different departments. QA primarily highlights problems after they occur; QI stresses revising processes to upgrade the daily level of performance to help prevent problems before they occur.

A QI approach, reduced to its most basic elements, includes a commitment to make ongoing improvements; the hands-on involvement of management; the use of interdepartmental teams to analyze problems, organize data collection, and develop solutions; and the inclusion of all levels of employees in the process.

At Villa Clement, the first element of success through a quality improvement approach was a commitment by top management to improving key systems -- in this case, food distribution -- and a commitment to involve all relevant staff. A team that included dietary aides and cooks, as well as mangers, reviewed the food system, crossing departmental lines to consult with nursing staff. Tutored by a staff member who had training in quality improvement techniques, the team applied QI "tools" to the problem: they met to discuss the problem ("brainstorming"); they drew visual maps showing the many steps in the distribution system ("flow charts") to help understand the system; they identified measures of performance ("indicators") and collected data on those measures (for example, how long it took to deliver food to residents and the different steps involved).

They evaluated their data, developed recommendations, and reported them to a quality steering committee composed of executive-level staff. That committee agreed with most of the team's recommendations and initiated their implementation. The team was then recognized for their work at an all-staff reception.

Joan Carlson, Villa Clement president, comments, "It's usually the process that's the problem, not the people. QA tends to point fingers and tends to look at outliers, not at common problems." QI, she notes, stresses the importance of teamwork involving employees throughout the organization. At Villa Clement this approach has helped solve problems in laundry delivery and work order processing, as well as in food distribution. Carlson is working on setting up additional teams in other areas. Commenting that not only is quality improved, but in addition "the sense of ownership and enthusiasm of people on those teams is wonderful to behold."

Sara Sinclair, RN, administrator of Sunshine Terrace in Logan, Utah, also finds that the benefits of a QI approach include a healthier organization as well as improved care for residents and their families. Sunshine Terrace experimented with various QI techniques, such as family satisfaction surveys and staff quality circles, for several years before implementing a comprehensive team-based QI program. QI's stress on interdisciplinary teams is particularly appropriate in nursing facilities, where, as Sinclair notes, "Almost everything goes across disciplinary lines."

Sinclair has directed the development of a series of QI teams to begin collecting and analyzing data on everything from family satisfaction to infection control, pressure sores, lost items, and other crucial areas. Given her previous experience with QI, she expects that "given time, this is going to build a stronger team and promote retention of employees," while improving the quality of care delivered by Sunshine Terrace.

Sinclair recommends starting on a small scale (perhaps identifying a single problem and forming one team to address it), rather than suddenly attempting a complete reorganization on the QI model. Implementing QI takes practice, and Sinclair does not expect instant success: "We are feeling our way, and we are learning every day." She has learned, she says, to stress the importance of taking action to make improvements and documenting the change, which she calls "closing the loop." She also says, "Don't let data petrify you. We went through that. I'm a nurse, not a statistician." Indeed, QI does not require computerization or a degree in statistics, and data collected under existing QA programs can often be used in QI efforts.

Practicing quality improvement not only has the potential to meet resident needs and improve a facility's internal functioning, it is virtually tailor-made to help nursing homes meet OBRA requirements. OBRA is remarkably progressive (from a quality improvement standpoint) in stressing evaluation primarily on the basis of actual performance -- a key emphasis of QI -- rather than simply addressing whether a facility has the capability to carry out certain functions.

OBRA surveys on quality of life, quality of care, and residents' rights issues, and an organization-wide QI program can be based around the priority areas set by OBRA. QI teams can be formed to continually monitor, evaluate, and make recommendations for improvement in key areas.

To a large extent what is required to implement QI is training of staff (including managers and physicians) in the philosophy and techniques of the system, a commitment by management to lead -- and be personally involved in -- organization-wide change that includes the empowerment of their employees, and the understanding that an investment of time to refine QI methods -- and to make mistakes -- will be required. QI does not guarantee dramatic financial savings (though they can occur, as at Villa Clement), and it is not an overnight road to success, but it is a proven method that can help long-term care facilities improve patient care and meet regulatory requirements.

Mary Tellis-Nayak is Director of Long-Term Care Accreditation Services for the Joint Commission on Accreditation of Healthcare Organizations, and Gary Snyderman is a writer on the JCAHO staff.