1st Edition
Hospital Quality Implementing, Managing, and Sustaining an Effective Quality Management System
In healthcare, quality management refers to the administration of systems design, policies, and processes that minimize, if not eliminate, harm while optimizing patient care and outcomes. Whether you are a hospital with 1,000 beds or 25, the fact remain that every hospital must navigate and manage the many complexities associated with a quality management system.
Why is quality management important in healthcare? There are numerous reasons why it is important to improve quality of healthcare, including enhancing the accountability of health practitioners and managers, resource efficiency, identifying, and minimizing medical errors while maximizing the use of effective care and improving outcomes, and aligning care to what users and patients want in addition to what they need.
Hospital Quality: Implementing, Managing, and Sustaining an Effective Quality Management System demonstrates a practical approach to managing and improving quality. Whether you agree with the premise that these activities are complex, this book will outline a standardized approach that any organization can adopt to meet their needs while accommodating the foundational concepts of quality improvement by accreditation agencies. It also outlines how to set-up and manage a quality management program as a part of continuous process improvement initiative, as well as the purpose and managing of a patient safety organization.
The purpose of this book is twofold. If you’re a senior healthcare manager or director tasked with setting up a quality management system, this book will provide tools and techniques you can immediately apply. If you’re a healthcare professional preparing for the CPHQ certification exam, this book will take you beyond study guides by explaining what you need to know and the why behind each concept.
Acknowledgements
Introduction
Chapter 1: An Introduction to Quality
Defining Quality
Examples of Quality
Quality Culture
Cost of Poor Quality
Summary
Chapter 2: Quality Regulation and Benchmarking
Regulation
Centers for Medicare and Medicaid Services (CMS)
CMS 5-Star Rankings
QualityNet/HARP
Other Benchmarking Agencies
Other Regulations Important to Quality Departments
Health Insurance Portability and Accountability Act (HIPAA)
Clinical Laboratory Improvement Amendments (CLIA)
Summary
Chapter 3: Managing Quality
The Original Mission
The ”Quality Director” as defined by Job Descriptions
The Paradigm of Managing Healthcare Quality
Quality Governance Structure
The Quality Committee
The Medical Executive Committee (MEC)
The Governing Board
Summary
Chapter 4: Quality Measurement and Analytics
Basics of Quality Measurement
Quality Measurement and Analytics
SMART Goals
In-Process versus Outcome Measures
Trending Data
Control Charts
Pareto Chart
Cascade Measures
The Quality Oversight Scorecard
Updating the Quality Oversight Scorecard
Summary
Chapter 5: Quality Improvement
Process Improvement Techniques
Change Management
Summary
Chapter 6: Quality Training
Role of the Quality Professional in Training
Employee Engagement
Catch Ball Sessions
Standard Work
Training Within Industry
Summary
Chapter 7: Project Management
Project Management in Quality
Action Item Tracking Tool
Action Item Standard Work
Summary
Chapter 8: Accreditation
Role of the Quality Professional in Accreditation
Managing the Activities of the Accreditation Agency
Manage Survey Action Plans
Survey Readiness and Preparation
Example Case Study
Summary
Chapter 9: Sustaining Quality
Role of the Quality Professional in Sustaining Quality
Daily Operations
Standard Work for the Quality Professional
Summary
Chapter 10: The Quality Plan
Components of the Quality plan
Summary
Chapter 11: External Reporting
National Healthcare Safety Network (NHSN)
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
QualityNet/HARP (CMS) Portal
Using Vendors for QualityNet Data
Updating Information In QualityNet
COVID-19 Reporting
Summary
Chapter 12: Patient Safety Organization, Quality Incidents, and Mortality Reviews
Patient Safety Organization (PSO)
Quality Incident Events
Quality Incident Summary
Mortality Reviews
Summary
Chapter 13: Managing Hospital Acquired Conditions (HAC) and Harms
Role of the Quality Professional in HACs and Harms
Summary
Chapter 14: Managing the Quality Team
Developing The Quality Team
One-On-One Meetings
Huddle Meetings
Calendar for Reporting
Support, Support, Support
Summary
Chapter 15: Summary – Bringing it all Together
Quality Professional Next Steps
Example Scenario
Summary
Appendix:
Chapter 2 Appendix: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Questions
Chapter 4 Appendix: Obtaining Standard Deviation in MS Excel
Chapter 8 Appendix: Job Descriptions for Survey Readiness
Committee Charter Example
Chapter 10 Appendix: Example Quality Improvement Plan
Chapter 12 Appendix: Patient Safety Organization Confidentiality Agreement
Quality Incident Comparison Checklist
Mortality Review Forms
Glossary of Acronyms
Biography
Doug Johnson has been in healthcare over 30 years. He is a Registered Nurse, Certified Professional In Healthcare Quality, Lean Six Sigma Black Belt and earned his BSN with summa cum laude honors. His healthcare career began in patient transport and has progressed over numerous areas including the cardiovascular lab, health plan operations, emergency department, operating departments, nursing units, urgent care, billing processes, electronic medical records, patient-throughput, regulatory and accreditation requirements, quality, database management, data analytics and software development.
Doug has outstanding interpretive skills in quantitative and qualitative analyses, identifying root causes of poor process control and inefficiencies. His vast experience in the multifaceted business of healthcare has equipped him to design, improve and provide sustainable solutions in all areas of healthcare operations.
His company, DcJ Solutions (www.Innovate2Accelerate.com) offers quality management consulting and training through proven tools and techniques to allow your organization to implement, manage, and sustain a quality management program using existing and permanent staff. He developed a team of experts both in healthcare operations and information technology design. By combining the skills of healthcare operations, process improvement and technology, this team is well aligned to create meaningful solutions for healthcare organizations.
"The moral responsibility to provide high quality care in an increasingly complex healthcare industry challenges the best healthcare organizations. Fierce competition for resources and the multidisciplinary nature of healthcare can leave organizations less focused and structured than needed to achieve their quality goals. The Hospital Quality Book is a fantastic resource for providing a practical and straightforward path to attain quality objectives. Douglas C. Johnson captures his decades of learning during his practice as a system, process, and quality professional. It is truly scalable to each organization’s current capabilities and can be used to stand up an entirely new program or as a reference to assist established programs in accelerating performance."
Troy Greer, FACHE, MBA, MSHA
CEO, Boone Health, Columbia, MO
