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An emergency department perspective.

14 High patient volumes requiring rapid turn around times, critical decision making processes, and a necessity for establishing an accurate working diagnosis are a few of the many challenges in hospital emergency departments. Quality management,(l) rather than quality assurance, most accurately describes how activities in the emergency department should be monitored to meet these challenges. Already an important factor in manufacturing and service industries across the United States, quality management will become the essential driving force in the health care industry. To survive in the'90s, the emergency department must include in its goals the development of plans and processes that meet the challenge of the ED environment and that focus on customer satisfaction.

It is predicted that the acute care hospital as we know it will not exist in the future. A large segment of inpatient care will shift to alternative delivery methods, such as those provided in outpatient settings.1 Several quality variables are unique to the outpatient setting(3):

* Large patient volumes make 100 percent

monitoring impractical.

* Highly variable treatment-to-discharge

turnaround times (from minutes to hours)

make concurrent review difficult.

* The linkage between process and outcome

is frequently difficult to define.

* Follow-up procedures are laborious and

may become unmanageable.

* Outpatient care may be highly subjective

because it depends on a working

diagnosis. The emergency department has the same quality variables as any other outpatient setting.1 The majority of patients are discharged home and are not held captive for observation, and the emergency department faces the same limitation in process monitoring as in any outpatient setting. In addition, the ED must deal with three of its own quality variables:

Personnel turnover.

Interpersonal relationships.

Interface activities. Because of the scale of emergency departments, these factors present even greater challenges than would exist in the customary outpatient setting. Personnel turn over every 8-12 hours, which magnifies the lack of interpersonal relationships with patients. The emergency department is open 24 hours a day, so a dilemma develops in providing a standardized level of quality. The key element is establishing a shared mindset among all the department's physicians so some consensus can be achieved with respect to type and quality of treatment procedures. Additionally, the emergency department plays an important role as an interface between prehospital and inhospital care. The emergency department has existed in this complex environment of alternative delivery methods for many years and can serve as an example for an effective quality management program in the outpatient setting. Definition of Quality Quality has gone through a full circle. Assembly line production methods introduced inspection, with the emphasis on product uniformity.' Responsibility for quality control shifted from the individual to the inspector. As a result of the need to meet minimum standards, workers devised methods to get by, satisfying the inspectors rather than producing a superior product. The statistical quality control concept led to the responsibility for quality shifting to the manufacturing and engineering departments.(5) Control limits were set and control charts determined which production values fell within an acceptable range. Competition forced a change in attitude. Instead of the engineering department designing products that fit its definition of quality, consumers were demanding products that met their expectations. The Japanese understood the consumers'demands and began designing products that reflected and anticipated customers' needs and expectations. By adopting Deming's concepts,(6) the Japanese were able to move to total quality control TQC).

Using examples from the manufacturing and service industries, we have arrived at a working definition of quality in our emergency department. Quality is defined as "conformance to standards that meet or exceed customers' expectations." Our goal is to decrease customer complaints and eliminate waste and the need for rework or recall. The ultimate outcome will be meeting or exceeding customer expectations. Our goal is to place continuous quality improvement into the everyday processes of our quality management program.

Effective Quality

Management The traditional approach to monitoring activities in the emergency department has been to retrospectively review medical records to find cases that are not in conformance with some standard of care. By accepting the "bad apple" theory, a false sense of security is created. By simply removing or eliminating the individual responsible for the error, we do not solve the problem of disquality. The Japanese, through the TQC approach, have proved that the "bad apple" theory is inefficient and a formula for failure.(7) An effective quality management program requires inspections to be only part of a complete quality management control program.

The approach to quality management in our emergency department has several key factors in its success.

Commitment. Commitment, culture, and mindset are the foundation upon which the quality management program rests. The emergency department interacts with almost every facet of the hospital, providing a unique opportunity for interrelationships with other departments. However, these relationships cannot be successful without a commitment from the top down. Oral or written support alone is not sufficient. Commitment should be accomplished through resource allocations and through team participation on problem-solving committees working toward the same goals.(1) Development of quality management program goals and objectives for the emergency department through the organization's strategic plan provides the basic structure of the program. Team involvement. The team must be oriented to the goals of the program in order to formulate plans for improving the quality of care.1 However, team involvement does not occur automatically or overnight. We have started the process by instituting: * Education, including basic quality management

principles, a continuous improvement

model, and statistical quality

control methods for measurement. * Learning by participation, which requires

every staff member to rotate

through the reviewing and monitoring

activities. This encourages staff members

to become part of the quality management

team. We currently have two

teams applying quality management

principles and problem solving techniques. * Practicing the philosophy. The purpose

of quality management is not to

be punitive. The intent is to find remedies

do are focused on systemic changes

rather than recrimination for errors. Process improvement. The process of care in the emergency department starts when a patient seeks and receives medical care. It embodies the technical and interpersonal atuributes of the patient.(9) The cornerstone of process improvement involves 6.10: * Understanding how emergency department

services are delivered. * Relying on continuous improvement

in the process rather than a big bang

approach. * Realizing that process improvement

goes beyond finding the cause of the

problem and its correction; it is a method

of continuously looking at the process

and trying to find ways of doing it

better. Conformance to standards. Standards of performance and the ability to measure process performance are crucial to a quality management program." This involves setting up parameters of care based on objective criteria from the emergency medicine literature and designing a process for delivering the service. Each process or subprocess must have a detailed standard operating procedure based on the most efficient methodology for a needed service. By measuring performance through the outcome of each process, one can determine the extent to which the service conforms to the initial design. The focus is on constant efforts to reduce waste and achieve the desired outcome.(7)

Customer focus. The first step is to focus on identifying the customer. In the emergency department, there are external and internal customers. An example of external customers would be patients, the private physicians who send their patients to the emergency department, and third-party payers. An internal customer is a person at the next stage in the process of care delivery. The primary nurse who reassesses the patient is the triage nurse's internal customer. Similarly, the nurse in the inpatient nursing unit is an internal customer of the emergency department and the emergency department nurse. The next step is identifying customer needs and expectations, whether internal or external. When employees learn to deal with each other as customers and suppliers, they will be able to identify, correct, and prevent problems and create satisfied customers.(12)

The third step is measuring customer satisfaction through patient questionnaires and by receiving complaints. One of the most effective ways to gain a competitive advantage is to systematically pay attention to customer complaints about services.(13 Another area that has received very little attention in the customer focus is competitive benchmarking of the emergency department. (13) One needs to find the reason customers choose one emergency department over another. This concept is critical in understanding the attributes that add value to the service. What is the role of the staff in the success of the department? The patient measures ED performance primarily by speed of service; technical training and expertise are assumed. In a competitive setting, the emergency department must differentiate itself through features that are secondary characteristics of the services provided. This involves understanding the interpersonal relationship between staff and patients, understanding the communication processes, and meeting the secondary needs of patients and their families. Providing an excellent customer service entails active involvement in the process at all levels and is not something a department or an organization can enforce.

Continuous improvement is a philosophy based on the understanding that standards are constantly evolving. It is a relentless pursuit of improvement in the delivery of value to the customer.(14) It provides the mechanism to reduce total variations associated with a patients' ED visit. The patient evaluates the outcome of a visit on the basis of an aggregate reaction to the care received and of perceived variation in care. By applying the methods of continuous improvement, variations are identified and reduced and efforts are focused on reducing waste and ultimately providing a service with zero defects.' C3

References 1. Couch, J. Medical Quality Management for Physician Executives in the 1990s: The Essentials of Medical Quality Management, Preparing for the Joint Commission's New initiatives, and The Era of Medical Care Value Purchasing. Tampa, Fla.: American College of Physician Executives, 1988, 1988, and 1989. 2. Goldsmith, J. A Radical Prescription for Hospitals.' Harvard Business Review 67(3):10411, May-June 1989. 3. Tyler, R. Quality Assurance in the Ambulatory Care Setting.' Physician Executive 15(6):17-20, Nov.-Dec. 1989. 4. Mayer, T. Emergency Medicine Clinics of North America.' Practice Management and Administration 5(l):103-17, Feb. 1987. 5. Garvin, D. Managing Quality., The Strategic and Competitive Edge. Now York City, N.Y.: The Free Press, 1988. 6. Deming, W., Out of the Crisis. Cambridge, Mass.: MIT, 1986. 7. Berwick, D. Continuous Improvement as an ideal in Health Care.' Now England Journal of Medicine 320(l):53-56, Jan. 5, 1989. 8. Perrin, R., Making Quality a Priority." Hospital Material Management Quarterly 9(4):1-10, May 1988. 9. Donabedian, A., The Quality of Care, How Can It Be Assessed?' JAMA 260(12):1743-8, Sept. 23/30,1988. 10. Grayson, J., and O'Dell, C. American Business: A Two-Minute Warning. New York City, N.Y.: The Free Press, 1988. 11. Juran, M. Juran on Leadership for Quality: An Executive Handbook. New York City, N.Y.: The Free Press, 1989. 12. Tackett, S. Ouality Assurance versus OP(4)--The Missing Link.' Journal of Quality Assurance 11(3):8-11,36, June-July 1989. 13. Loewe, D., Ouality Management at Weyerhaeuser.' Management Accounting 71(2):36-41, Aug. 1989. 14. Turney, P., and Anderson, B. Accounting for Continuous Improvement.' Sloan Management Review 30(2):37-47, Winter 1989.
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Title Annotation:medical quality management, part 1
Author:Dagher, Michel
Publication:Physician Executive
Date:Nov 1, 1990
Words:1875
Previous Article:Persuasion strategies for physician executives.
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