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Performance improvement: the new quality paradigm; why the old quality-assurance approach is no longer adequate, and what to do about it. (Feature Article).

Quality assurance (QA) programs have had their place and time in the evolution of quality management. However, in today's environment, quality assurance can actually have negative impacts on the organization.

Quality assurance embodies an old management culture promoting competition instead of cooperation and collaboration, along with short-term planning and beliefs that people will never change or that "everyone needs to change but me." The primary focus of QA--to ensure employee compliance with standards--creates a culture of fear and blame. The employee is the target for corrective action rather than giving priority to evaluation of the process or the system. The tendency to hide or ignore problems becomes more enticing than the possibility of facing disciplinary action.

Quality-assurance reports often present data as a "one-point-in-time" reference instead of evaluating data over time and comparing them to benchmarks in the industry. A typical QA report for the Quality Indicator might read as follows:

This month we had 10 indicators that were flagged. Charts were reviewed on all 10, and staff were reminded to develop care plans on each of the resident issues. Plan is to continue to monitor. Staff has been advised that disciplinary action will be applied if compliance is not met.


This month weight loss was flagged at an overall 65%, while the state showed 32%. We are double the state average. This is a sentinel event and needs to be carefully monitored. The dietitians have been tasked to monitor every resident's weight and report all weight losses to the administration on a weekly basis, Continue to monitor.

While these examples might seem extreme, they make the point that the data collected are evaluated only for the current month. The data provide no real analysis, comparison, or evaluation of cause and effect or whether, in fact, there is a problem. Certainly, the real problem has not been identified. The bandaids put into effect will return to haunt the facility upon survey, for it is then that the real overall picture could come to light.

A solid connection to the overall organizational strategic plan is absent in QA programs. The QA program is often developed without a sense of the mission and vision of the organization. Often the program is created without developing clear guidelines or a process. As many QA directors describe it, "It seems as though we are separate from the organization. No one understands what we are about, and they hate to see us coming." The leadership might not even have developed a strategic plan. If a strategic plan does exist, it possibly sits on the shelf waiting for the next update.

The New Paradigm

Performance assessment and improvement is an approach to evaluating the overall effectiveness of an organization's major functions. Different than QA, it is an approach driven by the leadership. The leaders form a steering council where ongoing strategic planning is conducted in at least weekly meetings. The director of performance improvement, in order to move the process along and create team decisions, facilitates the meeting. To evaluate the various functions of the organization, the leadership charters various teams, quality-management boards, or committees to assist with assessing the organization and making recommendations for improvement. As seen from the accompanying example (see "The performance-improvement approach," below), each team, including the steering council, operates from a strategic plan and a measurement plan. Plans and measures of performance are clearly defined. Reports consist of analysis of the data that have been collected over time, along with specific conclusions and recommendatio ns for improvement. Data are graphically displayed as histograms, Pareto charts, run charts, control charts, and other tools for an enhanced view of the bigger picture.

Data are compared internally, over time, and externally for more in-depth examination. Examples of measures may include deaths, infection rates, adverse drug reactions, customer satisfaction survey results, staff satisfaction results, medical record deficiency and delinquency rates, measurements from the 24 Quality Indicators, transfers to hospital, admissions, and more, as prioritized by leadership. These measures can also play a vital role in a competition analysis when compared to those of other facilities.

All levels of staff are involved and are members of the various teams. If leadership agrees, middle management and other staff levels can be part of the steering council, whether to sit in open meetings or to serve as permanent members. Some organizations ask residents or patients to be on the steering council to keep them in tune with what the customers want and need. This promotes a sense of ownership, participation, and understanding among all involved.

This proactive, long-term planning minimizes the need for crisis management. Knowing the real problems and providing corrective action before facing a survey prevents unexpected deficiencies. Comparatively, performance-improvement methodologies and management approaches offer the organization a greater chance to succeed and be recognized as a benchmark in the industry.

The following scenario will help to demonstrate the differences in approach:

On Friday at about 11:30 p.m., a weak cry could be heard from Room 202. It was Mrs. J. Doe. She was found on the floor, apparently after another fall. She often tries to get out of bed at night on her own instead of using her call light to ask for help, even though the nursing staff has instructed her many times to use the call light.

The quality-assurance approach. In the above scenario, the usual medical and nursing protocols and assessments were carried out and risk-management screens completed. Proper notifications to management were made. The nurse on duty reminded the only night-shift CAN that more frequent rounds were needed for Mrs. Doe because she had fallen several times previously. The supervisor on duty ensured that all paperwork was completed and forwarded appropriately. In the Monday morning meeting with the administrator and the director of nursing, all falls were discussed and guidance provided.

At the Quality Council meeting later that month, a falls report was given, stating that there had been 15 falls that month, compared to only 3 last month. Most of the falls had occurred at night. Recommendations were made to reeducate the staff on fall prevention and that all clinical staff would be required to attend this class by the end of the following month. Failure to do so would result in disciplinary action. It was suggested that the night shift make additional rounds to ask residents if they needed help. "Continue to monitor" was the final solution.

The performance-improvement approach. As with the QA approach, the usual medical and nursing protocols and assessments were carried out, risk-management screens completed, and proper notifications to management made. But in light of Mrs. J. Doe's history of falls, the staff had already met to review and discuss a plan of care; this included taking her to the bathroom prior to bedtime, performing frequent rounds, ensuring the call light button was within her reach and placing her in a room closer to the nursing station for better observation. The supervisor on duty ensured that all paperwork was completed and forwarded appropriately. In the Monday morning meeting with the administrator and the director of nursing, all resident falls were discussed.

A risk-management report was provided at the monthly meeting of the Care and Treatment Quality Management Board, a team that meets regularly to evaluate resident care. Fall prevention, having been prioritized as a major and key success factor for this facility, was one of the measures of performance on the risk-management report.

It was found that falls had steadily increased over the previous six months; they were also 40% higher than last year's data for the same time period. Most of the falls occurred at night between the hours of 10:30 p.m. and 4:00 a.m. There was an even distribution of falls among the units. Injuries as a result of falls remained at a consistent 1%. The most significant injury was a bruise, which required no treatment. From the data, there was no clear understanding of probable causes. The recommendation was to initiate a process-improvement team to further evaluate the situation for cause and effect and offer recommendations for long-term solutions to the Care and Treatment Quality Management Board.

The Quality Management Board reported the data and the conclusions to the Executive Steering Council, made up of the senior management of the organization. Recognizing that the falls issue was a systemic problem and not a people problem, the Council approved creation of the process-improvement team. A statement of work (or "opportunity statement") was developed so that the process team could focus on clear guidelines and time frames.

The process team met frequently to problem solve, as requested. The team used a flowchart to depict the current caregiving process, which illustrated where the process was breaking down. After the problems were identified, the team developed a fishbone analysis (or cause-and-effect diagram) to analyze why these falls were occurring. The team members felt confident in identifying the root causes because they had no fear of management reprisals.

The team was able to demonstrate that the most common causes were usually related to the four Ms: manpower, money, methods, and materials. These included, more specifically, problems with education of staff, staffing, management style, policy and procedure, equipment, and other factors. The team researched benchmarks in the profession, described several creative preventive measures and developed a solution matrix and a plan of action. Solutions proposed by the team included:

* Perform an organization-wide falls risk assessment to critically evaluate for proper lighting; handrail placement and integrity; and presence of trip hazards, such as throw rugs, uneven steps, slippery areas, and other hazards.

* Develop and implement a falls assessment tool to more effectively identify residents at various risk levels (high, medium, low) for falls.

* Identify each resident's specific personal risk and develop and communicate the appropriate care plan with the interdisciplinary team. Include the physician in the process. For example: Residents with visual impairments may need visual examinations and a modified environment; residents may need a change in medication regimen if they're on sedatives or balance-altering drugs; and vitamin D and calcium supplements might require consideration to reduce the possibility of fractures from falls.

* Enhance the current resident exercise program to improve balance and coordination.

* Provide residents with special footwear to decrease the chance of slipping.

When the plan was approved by the Quality Management Board and the Executive Steering Council, they made sure that the staff was educated on the new methodologies. Continued measurement of the data showed significant decreases in the falls rate each month. It was no surprise, therefore, when the Quality Management Board and the Executive Steering Council acknowledged the process team and the staff with a special award ceremony at the next general staff meeting.

Suggested Reading

Greeley HP, Cofer JI. Quality Improvement Techniques for Long Term Care: A Handbook. Marblehead, MA: Opus Communications, 1993.

Joint Commission. The 2002-2003 Comprehensive Accreditation Manual for Long Term Care (CAMLTC). Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 2002.

Joint Commission. The Measurement Mandate: On the Road to Performance Improvement in Healthcare. Oakbrook Terrace, IL: Joint Commission on Accreditation of Health-care Organizations, 1993.

Pyzdek T. The Handbook for Quality Management: A Complete Guide to Quality Management. Tucson, AZ: QA Publishing, LLC, 2000.

Joy Karanick, RN, BSN, MSM, CPHQ, CALA, is program director for the Adult Homes and Home Care division in the New York State Department of Health. For further information, phone (732) 740-4153. To comment, send e-mail to
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Author:Karanick, Joy
Publication:Nursing Homes
Geographic Code:1USA
Date:Jan 1, 2003
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