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Integrating CQI and QA.

Merging the hospital's quality assessment methods with continuous quality improvement strategies takes time, patience, and team effort, but the results are worth it.

THE DAY OUR HOSPITAL began implementing W. Edwards Deming's approach to continuous quality improvement (CQI)|1~ in 1988, most of us were enthusiastic, although a few skeptics figured that CQI was just another management fad destined to fall quickly by the wayside.

Five years into the process, we're still enthusiastic about what we've accomplished and where we're headed, but our optimism is tempered by frustration over how long it's taking for our ways--and thinking--to change.

* Two directions at once. Making CQI an integral part of what we do requires a change in the way we think as well as manage processes and variation. Such changes take time, perhaps 10 years or more.

In addition, in our hospital the complete quality assessment (QA, our preferred term for quality assurance) structure has been maintained while a separate CQI structure has grown up. Consequently, there are two different sets of reports and reporting pathways.

* Combining the two. The health care professionals who are involved in both QA and CQI at our 750-bed proprietary hospital in Wichita, Kan., have been actively looking for ways to integrate the two systems. We can't just drop QA. We are all interested in improving quality, which inherently requires some assessment of it.

In late 1990, the ancillary-service QA committee that I chaired decided to begin looking for a more unified approach. At this writing, 3 years have passed and the process is, by no means, complete. But while the total integration of QA and CQI remains years away, we have made headway.

This article is a progress report that you might find useful in your own efforts to reconcile different approaches to quality. Our steps to date have included education, changing our QA plan, implementing our "QA and I" plan, and establishing the CQI team process.

* Education. The push for CQI came from our hospital administration, which began an institution-wide effort to educate all department directors and, eventually, all first-line supervisors. The learning focused on helping us begin to change our ways of thinking.

We learned that nothing we do is worthwhile if it doesn't have a customer focus. We learned that we need to improve systems and processes, not focus blame on people. And we have well-developed skills for analyzing data and understanding process variation.

In some cases, it took a long time just to agree on who our customers were. Then it was hard to accept that we needed to survey them to find out what quality characteristics they think important (we were sure that we already knew). * The "how" of a problem. Process thinking, a basic tenet of CQI, requires that we examine the ways we do those things that lead to a problem so that we learn how to improve the process itself. That makes good performance easier for people to accomplish.

Process thinking is difficult because all people have a tendency to think that, at the root of every problem, there's a person in error. We like to believe that if the offending person can mend his or her ways the problem will go away. Most employees, however, want to do a good job; it's just that many of the processes by which they work erect barriers to success.

The techniques|1-3~ we studied include:

* Flow charting processes

* Organizing data into run charts

* Calculating upper and lower control limits

* Constructing Pareto charts, fishbone (cause and effect) diagrams, and group facilitation techniques

* Changing our QA plan. Once most of our hospital-wide supervisory staff was educated in CQI, one of the first steps we felt we needed to undertake was to convert our laboratory QA plan into a "QA and I" (quality assessment and improvement) plan. We did this to reflect the new emphasis on the improvement component. Then we made certain that our stated objectives included our aim to improve as well as to assess quality.

For the first time, we identified our customers explicitly in our plan. We then examined our monitors; we assured that there was at least one for each customer group as well as one for each key process. We decided that we would interpret JCAHO's somewhat vague "important aspects of care" as being key processes. Furthermore, we would select one or more indicators to monitor for each key process.

Next, we used a fishbone diagram to show the cause and effect relationship between the key processes and the principal laboratory objective. That goal is to provide accurate and timely information that assists the physician in the diagnosis of disease or the monitoring of treatment. We delineated the indicators used to monitor those key processes.

* The "QA and I" plan. As the implementation of our new plan unfolded, we made several changes meant to reflect our increasing emphasis on improvement:

* If we continue to surpass our threshold for evaluation on a given monitor, we increase that threshold and look for ways to improve the process further.

* When possible, we use our new statistical analysis tools on our data. Among the tools are plotting the data on run charts, calculating upper and lower control limits, and looking at the charts to determine both special cause and common cause variation and the management action to take.

* While any monitor can be improved, one that exceeds the threshold for evaluation indicates a needed improvement. When a monitor reveals such an opportunity to improve the quality of service, we establish the aim of the improvement and then decide if a CQI team is needed. If a team is called for, we use several models to conduct the team process.

* The QI team process. One quality improvement model developed at our facility in 1991 includes the following steps:

Charter the team. The person who starts the team sets the goal and determines--insofar as possible--the members. They must be knowledgeable about the system, the process, and the product being improved.

Once the team is formed, additional team members might be suggested. Some persons who are involved only in parts of the process need not be full members; they can be called upon as needed.

Delineate current knowledge. How does the process work now? It is often necessary to reiterate who the customers of the process are and what their quality characteristics are. (Hopefully, these characteristics comprise some of the QA monitors.)

Current knowledge of a process may be flowcharted to facilitate understanding. Are there any obvious improvements that could be tried on a small scale? If so, execute them. Then look at current knowledge again.

Gain knowledge. Having identified the customer's quality needs, decide which parts of the process have the biggest impact on those quality characteristics. If QA monitor data doesn't give you enough information about the process to be improved, more may need to be collected. Decide what change will be tried first. Start the improvement cycle. Remember the initials PDCA (plan, do, check, act). Once the improvement has been decided upon, plan what it is that you need to do to implement the change. If possible, develop and test the change on a small scale. Decide how you will know that the change has improved the process. Then act on your plans and check for signs of improvement.

* Making it work. The key to making this model work is finding obvious improvement early in the process. Don't wait until you've flowcharted the entire process to make changes. So doing will make everyone frustrated that so much time was spent before improvements were seen. If knowledge of the process is sketchy, additional team members with the necessary information may be required to avoid making changes that do not improve your procedures.

Another CQI team process model that we frequently use was developed by Tom Nolan (Associates in Process Improvement, Silver Spring, Md.). This model involves asking three questions:

* What exactly are we trying to accomplish? * How will we know that a change is an improvement? * What changes can we make that will result in improvement? This three-part model avoids frustration by guiding the team more quickly to improvements in the process. The model also is easily adaptable to individuals who are making improvements in their daily work. CQI readily becomes a way of thinking and working, not just a team process.

* Difficulties. As we work to integrate continuous quality improvement, not only into QA but into all that we do, we find ourselves frustrated by certain barriers:

* It takes a long time to educate everyone. If the techniques aren't quickly used, they're forgotten.

* It's hard to change from people thinking to process thinking. Even our most accomplished CQIers find themselves apologizing for using old-way thinking at times.

* The CQI team process takes too long. We have been able to minimize the impact of this problem by making improvements as soon as possible, as advised above. Overall, we have realized that lots of good comes from having the group look at the process as a whole instead of just trying to fix individual problem areas. As long as the facilitator keeps the team on track, the time invested can be worthwhile, both in terms of saved resources (avoiding rework, for example) and increased quality.

* It is difficult to integrate reporting structures. While our ultimate goal is to have a single reporting structure in place for both CQI team progress reports and QA monitor results, we haven't been able to accomplish it yet.

Currently, our CQI team reports go through the line officers to the CEO, while our QA reports go through hospital and medical QA committees to the board of directors (with the support of the quality assessment department). Although we're frustrated that we haven't been able to unify the systems yet, we are confident in our ability to get there eventually.

We also know that doing CQI doesn't mean we can eliminate other systems. Our most recent JCAHO inspectors were extremely clear on that point. We still must have QA monitors and we must find opportunities to improve care using them. In our opinion, CQI works nicely in the planning of these improvements.

* Commitment needed. Leadership must be totally dedicated to CQI. While our top administration has been fully committed to the program for more than 5 years, management systems in the hospital still frequently rely on mistake tracking, people checking, and target numbers. Old ways die hard.

Discouragement may set in because implementing CQI takes more time than we think it should. We give each other pep talks and keep in mind that what we're doing is important and that our goal is a long-term one.

* Summarizing successes. Where do we go from here?

We see CQI not just as something that we must integrate into QA, but as a natural part of everything that we do. Figure 2 shows the different places that we see CQI fitting into the scheme of things in the clinical laboratory.

We have also begun summarizing all improvements made in the department during a year on one form. We keep this record regardless of whether the improvement was generated from the QA system, the normal management process, a problem log, or a CQI team. On it we note what was improved, what was changed, and what was the impact.

* Keep on improving. Our needs for the future? We need more education and involvement of the bench-level technologists. We also need new reporting structures for our reports.

We require individuals--not just teams--to focus on making improvements. And we need to stress more interdepartmental, "patient-wide" processes to monitor. Beyond these few needs, our goal is simple: to keep on improving.


1. Walton M. The Deming Management Method. New York, NY: Dodd, Mead; 1986.

2. Wheeler DJ, Chambers DS. Understanding Statistical Process Control. Knoxville, Tenn: Statistical Process Controls; 1986.

3. Wadsworth HM, Stephens KS, Godfrey AB. Modern Methods of Quality Control and Improvements. New York, NY: John Wiley and Sons; 1986.

Mary Jane Wooten, M.B.A., MT(ASCP)SBB is special projects technologist in the pathology department of HCA Wesly Medical Center, Wichita, Kan.
COPYRIGHT 1994 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1994 Gale, Cengage Learning. All rights reserved.

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Title Annotation:continuous quality improvement; complete quality assessment
Author:Wooten, Mary Jane
Publication:Medical Laboratory Observer
Date:Jan 1, 1994
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