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Hospitals' newest challenge: designing in quality.

If you consider every work activity to be a "process," you can begin to see that, in order to do that work, workers need a number of resources, including some combination of equipment, supplies, buildings, and, most important, people with special skills (figure 1. page 27). When people do whatever they do with and to these resources, they are performing the process. The result of a manufacturing operation is an identifiable product, a tangible thing. In health care, the product may be a repaired bone, someone's improved health, or the delivery of a healthy baby. It may be the completed transfer of health information to a patient or family member, the results of a test or procedure, the completion of a medical record, or the completion of a report (figure 2, page 27).

What makes health care more challenging is that all these processes are being done to or for real people. Each patient enters the health care arena with a personal set of fears about and expectations for the entire process. Each patient enters with a given condition of health that may help or hinder healing. In addition, each patient also has a given mental state and support network of friends and family who may contribute to or get in the way of recovery.

Retrospective Review

So how do we know if our resources, processes, and patient outcomes are as good as we can make them? In the early years of clinical quality measurement and review, health care experts focused primarily on retrospective review of key clinical practice parameters and quality indicators. Clinical practice parameters focused on such occurrences as whether a patient needed to have a procedure redone within a certain period or whether further intervention of any kind was necessary. Key quality indicators were also counted and reviewed. They included measurable circumstances, such as infection rates, morbidity, and case cost by diagnostic group.

If clinical practice parameters and quality indicators were good, it was assumed that the patient had received high-quality care. The improvement process involved medical staff review of selected patient charts and data from specific indicators. If outliers were discovered, they typically became the subject of further review. These reviews sometimes involved team brainstorming to determine methods for improvement. Occasionally, they were disciplinary in nature, seeking to punish the "doer" rather than to find common causes for the problems indicated by the data.

Critical Pathways

Next, health care professionals began to focus on the condition of the patient at the onset of the process and to review methods for moving the patient through the maze of processes designed to improve his or her health. The concept of critical pathways helped us standardize our many processes by defining each of the steps, providing the expected timing for each step, and giving the anticipated result of each process (figure 3, page 28). This helped to move the patient through the system more efficiently, because planning was simplified, steps were not overlooked, the process became more routine and needed fewer approvals, and the entire process could be shared with the patient, who could take an active role in his or her recovery. The improvement process involved comparing the actual patient movement through the pathways and checking the results of this care. Then team members brainstormed to develop methods for improving the process.

Building Quality In

As a part of this review, thanks to the influence of continuous quality improvement (CQI), we began to focus on building quality into each step. In recent years, CQI has caused us to critically review each of these areas:

Quality Resources

* We have to have high-quality equipment. If we do not, what will it take to have it? How do we establish priorities among the many pieces of equipment that we believe are necessary?

* We must have high-quality buildings and surroundings. If we do not, what is needed?

* We need high-quality supplies. What supplies would be better than those we have now? What specifications are important for our supplies? How can we be sure that we're getting the specifications we demand?

* We have to have high-quality people. If we do not, what education or training do they need so that they can become high-quality staff members? How can we do a better job of treating them with respect and of communicating honestly with them? Examining the issue of quality resources leads to discussions about needing good hiring, orientation, and training practices; being clear about our values and job requirements; and treating people with the dignity they deserve.

Quality Processes

* The steps have to work. Which steps are superfluous? Which steps should be revised?

* We have to know who the customer is. Who gets the results of our work? How does our work affect that individual or group?

* We have to understand the customer's needs and expectations. What does the recipient of our work need from us? What would that individual or group really like from us?

* We have to follow the appropriate steps and specifications. What must be done to meet specifications and requirements?

* We have to deliver what we say we will deliver within the predetermined time. How do we measure our accuracy and timeliness? What do we do when we are not meeting these goals?

Quality Product or Service

* The customer must perceive that care or treatment is satisfactory. Do we ask the customer for his or her perceptions and suggestions? What do we do with the results of this input?

* Care or treatment must be the best anyone could possibly give that patient. How are we doing clinically? Would other health care professionals rate our care or treatment with the highest possible marks?

Quality Outcome

* We have to offer the patient the best overall quality of life that can be expected over the long run. Given several alternatives, did we provide the best possible procedure for the patient?

* We have to do this at the most reasonable cost. Did we provide the most cost-effective procedure?

If an individual walked in the door of a hospital or clinic and said, "My heart doesn't work; please fix it," we used to focus just on process. Now we're asking, "What process did we use to fix the problem? Could we have used a different and better process to get to the same excellent, or perhaps even better, outcome while spending fewer resources?

Outcome Studies

Now, in the newest evolution of the clinical quality improvement process, health care providers are using outcome tools and methods to review long-term patient outcomes spread over large patient populations to determine whether selected critical pathways are better than others over the coming months and years of patients' lives and if the procedures or services performed are worthwhile (figure 4, left). This improvement process involves patient surveys made as much as six months to a year after patients are treated to determine whether the patient population is most likely to have the best overall outcome as a result of one treatment plan over others.

These newer reviews also take into account the long-term costs of various treatment modalities. Which is the most cost-effective in terms of initial cost, cost of follow-up care, the necessity for future adjustments, and the projected lifetime of the treatment? It should be noted that CQI does not replace any of the previously mentioned methods for ensuring that a patient receives the best possible care. However, CQI may provide the best method for integrating these various medical staff, nursing, and other quality assurance initiatives into one unified organizational management system.


Retrospective review was a good beginning. Critical pathways offered an excellent next step. Now we are beginning to build quality in at the beginning and to learn more about the outcomes of our efforts. When, as health care organizations, we make every possible effort to maintain quality in our resources, processes, and outcome, we will deliver high-quality products and services.

John G. Reiling, MHA, MBA, is Principal in Charge of Health Care Services, Larson, Allen, Weishair, and Co., and Director, MBA in Medical Group Management, Graduate School of Business, University of St. Thomas, Minneapolis, Minn., and Loretta J. Baehr, MHA, MBA, is Administrative Fellow, Novus Health Group, Inc., Appleton, Wis.
COPYRIGHT 1994 American College of Physician Executives
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Author:Baehr, Loretta J.
Publication:Physician Executive
Date:Dec 1, 1994
Previous Article:The late Dr. Mason.
Next Article:A study of clinical guidelines.

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