Peer Review Please respond to the following discussion topic and submit to the discussion forum as a single post. Your initial post should be a minimum of 150 words in length. Then, make at least two

CHAPTER 13

Improving Performance and Controlling the Critical Cycle

CHAPTER OBJECTIVES

• Define the management functions of quality improvement and controlling.

• Introduce the concept of the search for excellence and examine its relationship to the function of controlling.

• Relate controlling to directing in an essential cycle that affords ongoing attention to follow-up and correction.

• Introduce the concept of benchmarking and describe its place in the management process.

• Describe selected techniques for improving quality.

• Enumerate the essential characteristics of adequate controls, and introduce some commonly used tools of control.

QUALITY, EXCELLENCE, AND CONTINUOUS PERFORMANCE IMPROVEMENT

Headlines and key phrases that reflect a deeper organizational commitment to quality include the following:

• Committed to Excellence

• Your Safety Comes First

• The 30-Minutes-or-Less ER Service Pledge

• Memorial Nursing Care Facility Granted 5-Star Rating

These are a sign of the continuing search for excellence and the striving for perfection, creating a climate of continuous improvement. Also, these phrases and similar ones reflect the overall theme of performance improvement initiatives associated with the management functions of quality improvement and controlling. The search for excellence flows from the healthcare organization’s fundamental vision and purpose: the timely and thorough care of the patient. Its values of stewardship and integrity further infuse the organization with energy directed toward continuous quality improvement (CQI). Effective managers engage in this pervasive process of continuous performance improvement.

What other factors occasion the emphasis on quality? There are several—some positive, some challenging. The fundamental commitment to excellence includes full compliance with the applicable laws, regulations, and standards. Thus, any area with less-than-full compliance receives review and corrective action to achieve that basic goal. The response to major legislation or regulation (e.g., Health Insurance Portability and Accountability Act [HIPAA], Affordable Care Act, electronic health record [EHR] mandates, Recovery Audit Contractor [RAC] programs, Program Effectiveness Review) brings renewed attention to the systems and functions affected by these mandates. When management chooses to make a major systems change (e.g., complete automation of information system, adoption of advanced technology), new concerns arise; in these examples, the related issues of identity theft, date security, and antihacking measures become the focus of quality review. During any major changeover in a system (e.g., migration from hard copy to EHRs; a shift from one coding system to a newly required one), the manager must attend to the issues associated with phasing out legacy systems.

Topics relating to patient care studies reflect new concerns and therefore special studies about these topics. By way of example, note the increased attention paid to sports-related injuries (e.g., concussions, hand or knee injuries) in professional and high school athletes. Another aspect of quality improvement studies relating to patient care is reflected in the emphasis on outcomes and predictive analysis. Or an external event (e.g., a superstorm, a pandemic) might result in a review of the disaster response findings: what went well; what needs upgrading? Finally, negative publicity about a particular issue (e.g., rising infection rate, a scandal arising from employee behavior, an accident resulting in improper disposal of medical records) may require the management team to prepare a proactive response, including a renewed commitment to quality.

Just as there is negative publicity from time to time, there is also the opportunity for sharing positive accomplishments with the internal and external communities. For example, public relations releases feature the achievement of a five-star rating, the (n) number of days without accidents, excellence awards by specialty groups for certain diagnostic categories (e.g., cancer, stroke, neonatal care), peer-reviewed score for hospital safety, and ranking in top 25 hospitals nationally in supply-chain management. All of these issues reflect managers’ concerns about maintaining quality in every aspect of organizational life.

This continuing search for excellence has a long and varied history. A review of this history provides managers with a framework within which to consider effective approaches to CQI.

THE SEARCH FOR EXCELLENCE: A LONG AND VARIED HISTORY

Emerging with a vengeance in the late 1980s, quality became the most fashionable business term of the 1990s, just as the term excellence had dominated much of the 1980s. The total quality management (TQM) movement and the earlier excellence movement had somewhat different origins, but so far the results of the quality movement have been much the same as the visible results of the excellence movement, although more widespread. In each instance, a basically sound, well-intentioned philosophy has been adopted, promoted, and implemented with extremely mixed results.

Many of the organizations that attempted to adopt dedication to excellence as a guiding philosophy ran into the same problem that has stymied many otherwise effective organizations: how to instill a philosophy in people so that it will cause them to behave in the desired manner.

Between the philosophy, which may initially be accepted by a few members of top management, and the actual practice, which involves many employees living out the philosophy, lies a matter of process. There has to be some process available to successfully transfer the philosophy from the few to the many.

A great many people never see past the process and are thus unable to truly adopt the philosophy. They simply go through the motions, appearing to do what they perceive top management wants them to do. Invariably, when a philosophy is proceduralized—that is, when a process is superimposed on something as ethereal as a concept, idea, or belief—something essential is lost. Those who simply adopt the process as part of the job without buying into the philosophy will not truly reflect the philosophy in their behavior.

When a philosophy of management is overproceduralized, overpromoted, overpublicized, and overpraised, it becomes a fad. It becomes fashionable for its own sake. It was in this manner that excellence essentially went down the same path traveled years earlier by management by objectives. We have reason to wonder, therefore, whether the quality movement will prevail or devolve into just another fad, the current “flavor of the month” destined to go the way of management by objectives, quality circles, excellence, and others.

Quality Control, Quality Assurance, and Quality Management

For years, many of the manufacturing and service industries had what was referred to as quality control. Quality control ordinarily concentrated on finding defects, rejecting defective products, and providing information with which to alter processes so they would produce fewer defects.

Healthcare organizations had what they called quality assurance. It consisted largely of record scrutiny during which errors consisting of departures from some dictated standard were counted, providing information that subsequently directed which steps would be taken to reduce the frequency of recurrence of the same kinds of errors.

In addition to correcting the processes that produced the errors, both quality control and quality assurance were often responsible for instituting more frequent quality checkpoints so that errors might be caught earlier. The most important similarity between quality control and quality assurance, however, was that both focused primarily on finding errors after the fact. Both were, and yet remain, retrospective processes.

During the 1980s, using philosophical grounding and methods exported from the United States to Japan decades earlier and later brought back as “new, revolutionary management techniques,” the emphasis on quality began to shift from catching errors before they went out the door to avoiding errors in the first place. Thus we have the basis of the quality movement embodied today in labels such as TQM, CQI, and performance improvement initiatives.

Old Friends in New Clothes?

Many of the tools and techniques included under the performance improvement umbrella should look familiar to some people who have been in the workforce for a few years. Many of the “current” tools and techniques have been around for a considerable amount of time—some for decades. They have been resurrected, revitalized (especially through computer technology), and in some instances renamed. For example, a number of TQM-implementation case histories mention the acronym TOPS, standing for team-oriented problem solving. As the name suggests, workers who have concerns with various aspects of particular problems approach problem solving as a team, with a common goal and purpose. These problem-solving teams espoused under TQM look, sound, and function the same as quality circles promoted during the brief popularity of “Japanese management.”

Also essentially renaming quality circles are other TOPS look-alikes such as self-directed work teams and team-oriented process improvement. These particular labels are but two of several similar designations that have emerged as representing a significant part of the path to CQI.

Quality circles were themselves nothing new when they were so named. In years past, many work organizations used what they called work simplification project teams, in function and intent essentially identical to quality circles and the problem-solving teams of TQM. Written about in the 1950s and earlier, work simplification teams found their way into hospital methods improvement work as early as 1956.1

Even many of the specific tools used by today’s performance improvement problem solvers go back 50, 60, or as far as 70 years. Industrial engineering techniques already existing for decades scored a number of modest, if not long-lasting, successes when implemented in hospitals from the second half of the 1960s to the mid-1970s. Renamed management engineering—probably because of a general aversion in health care to anything perceived as “industrial”—they have nevertheless fallen short of their potential value in health care. Yet, there is a return to these practices (process flow, control charts, and cause-and-effect diagrams, for instance) as part of today’s performance improvement programs.

The Common Driving Force

Regardless of how many previously popular techniques are returned to the spotlight or how many genuinely new features are added, there remains one ingredient that is fully as essential to performance improvement as it has been to any other approach by any other name. That crucial ingredient is top management commitment. Its importance should come as no surprise. Top management commitment to new ideas and approaches has been a prerequisite to complete success for as long as organized enterprise has existed. Without sufficient top management commitment, most organized endeavors are destined to, at best, generate results that fall short of intentions, or, at worst, fail altogether and cause harmful results or leave residual damage.

One cannot imagine any rational top manager openly avowing opposition to the principles of quality improvement. Ask any top manager whose organization has espoused performance improvement or TQM initiatives if he or she is truly committed to it—or, for that matter, ask any top manager at all if quality, period, is a personal commitment; surely each will state unwavering commitment. We know that many such endeavors fail because of insufficient top management commitment, but because almost all managers will voice commitment there is but one conclusion to be drawn: top management commitment is a matter of degree, and the degree of commitment is critical.

None of today’s total quality programs will work as intended unless top management is actually involved and actively promoting the concept. Superficial commitment at the top results in similarly weak commitment at lower organizational levels. Beware of skyrocket commitment of the top manager who gets all fired up over performance improvement initiatives; distributes information to everyone; creates a steering committee, advisory committee, or other body; and chairs the first meeting or two or three—but then starts missing meetings because of “pressing business” and soon transfers the guiding role to subordinates.

A total quality program also will not work if managers, especially first-line supervisors, will not let go and truly delegate to employees. This means not simply giving employees the responsibility for doing different tasks or determining more efficient methods; it means also giving them the authority to make the decisions to implement their own findings. Furthermore, letting go means accepting what employees decide and living with it.

Letting go as just described is difficult for the majority of managers. A great many managers, far more than would be able to see it in themselves, possess a recognizable streak of authoritarianism. On reflection, the reasons for a fairly strong presence of residual authoritarianism are understandable. Modern management—true, open participative management—is a phenomenon of the past two or three decades. Although the spread of participative management has been steady, it has also been gradual; there remain many areas of organized activity in which employees have yet to experience any management style other than straightforward “bossism.”

Managers learn about management mostly from other managers, and especially from those organizational superiors who, for good or ill, were by virtue of their positions role models for those persons newer to management. At one time, virtually all management everywhere was authoritarian; even now, management that is at least partly authoritarian predominates. Most management role models thus convey at least a modicum of authoritarianism. Subtle proof of the existence of the authoritarian streak can be experienced by the manager who might ponder his or her reaction to being pushed abruptly into a fully participative management situation. The manager may feel that participative management exhibits weakness and that delegating decision-making authority to subordinates is somehow abrogating his or her responsibility.

Managers also have trouble letting go and adjusting to a truly participative environment because, for the most part, TQM runs contrary to classical organizational theory and old notions about how a work group is to be managed. Classical theory stresses structure, lines of authority, and the chain of command, and it suggests that as far as each level is concerned, someone just above it is in charge. In classical organizational theory, one works for the manager; in contrast, in a truly participative environment, one works with the manager.

It remains clear, however, that changes in management style and approach may have to occur for a quality management program to be successful. In most instances the manager will need to shift from being the boss—from planning, telling, and instructing—to being the leader of a team—to counseling, teaching, coaching, and facilitating.

Management’s commitment, then, can be seen as a total commitment not only to participative management and employee empowerment but also to intradepartmental and interdepartmental teamwork and improved communication throughout the organization.

Will Total Quality Management Prevail?

The answer to this question is yes: the focus on quality is a mandate flowing from the very purpose of the healthcare organization. However, its forms and approaches will vary from time to time. TQM has every chance of working where previous and perhaps partial efforts undertaken under other names have failed. There is a great deal going on with performance improvement initiatives. Activity undertaken in the name of quality improvement has become so widespread that the impression that “everyone is doing it” places considerable pressure on the supposed few who have yet to commit to true quality improvement.

In the healthcare setting, quality improvement has become the norm. It flows from the organization’s overall vision: quality patient care, with emphasis on timely, effective care given in a climate of safety. The Joint Commission as well as state and federal regulatory bodies mandate performance monitoring and improvement. Examples include the Centers for Medicare and Medicaid Services (CMS) quality of care initiatives for hospitals and other healthcare facilities; the American Recovery and Reinvestment Act (ARRA)/Health Information Technology for Economic and Clinical Health Act (HITECH), which gives additional mandates concerning the protection of patients’ privacy; and the Federal Trade Commission and its regulations concerning medical identity theft prevention. In addition, Congress passed the Patient Safety and Quality Improvement Act of 2005 (“Patient Safety Act”). The Joint Commission reflects this mandate in its standards for patient safety. The Institute for Healthcare Improvement launched the “100,000 Lives Campaign” concerning patient safety, which has since been expanded to the “Five Million Lives” campaign. Quality, excellence, and continuous improvement have become the permanent underlying themes in the healthcare setting.

Performance Improvement Focus

Studies relating to performance improvement generally fall into one of seven categories:

1. Mandates resulting from laws, regulations, and standards. Within these laws and regulations there are specific target areas requiring attention—for example, the payment-error review requirements of the CMS, which includes a user’s guide indicating the type of quality study needed to satisfy the review of payments. Topics for study include same-day surgery discharges, septicemia, simple pneumonia, and chronic obstructive pulmonary disease. Also, any topic reflected in the Plan of Correction for licensure or accreditation would receive particular focus. Many of the mandates have been noted in earlier discussions (see Chapters One, Two, and Five) and in the opening discussions in this chapter. Recall the guidelines provided in Chapter 6 under the consultant report that uses a priority system of action.

2. CQI, focusing on maintaining the quality of standard operations—for example, the quality of medical transcription, detection of fraudulent line counting, completeness of documentation, and spoliation of medical evidence in documentation. These studies become routine and frequent (e.g., monthly).

3. Periodic studies, stemming from external requirements as well as internal commitment to excellence—for example, an accrediting agency’s quarterly reports or the state agency’s annual licensure survey.

4. Adoption of a new process or approach, focusing on the “debugging” of such undertakings and eventually moving it into routine practice. Examples include “dry runs” using the tracer methodology advocated by The Joint Commission, following the course of care and services the patient received during the course of hospitalization, with real-time review involving several departments. Quality review protocols would be used in a major project such as the overhaul of the master patient index, culling out duplicate numbers, and consolidating the related medical record documents. Once the solution has been found to this problem, the topic becomes one of routine focus.

5. Critical areas of interest stemming from internal or external concerns. From time to time, an issue demands intense review. Examples include:

a. Patient safety. Although this has been an area of focus of risk management for many years, fresh impetus has been given to this topic, as noted earlier. The Patient Safety Act, The Joint Commission standards, internal malpractice-related reviews, infection control concerns—all of these have led to renewed interest in studies such as those focusing on wrong-site surgery, medication errors, “read back” requirements, and any of the sentinel events emphasized by The Joint Commission in its adverse patient occurrences topics. The ECRI Institute (formerly the Emergency Care Research Institute) continues to develop patient safety–quality improvement programs to support risk management activities.

b. The revenue cycle. Efforts in improving both the timeliness and the accuracy of billing, along with the prevention of fraud, is a multidepartment effort including the physicians, the admitting department, the emergency service, the finance office, and health information management. Studies typically include such topics as:

○ Tracking the time elapsed from the time of clinical events through the final payment of a bill.

○ Analysis of billing rejections along with comprehensive error rate testing as it relates to accuracy in payment.

○ Selection of high-priority coding and billing (e.g., a $200,000 inpatient bill versus a $500 clinic visit). All are important, but priority effort devoted to rapid, high-revenue return is sometimes indicated.

○ Comparison of present organizational practices to the planned reviews announced by the Office of Inspector General and its efforts at fraud control, with emphasis on the RAC program requirements (e.g., specific attention to coding regarding present-on-admission and hospital-acquired conditions).

c. Disaster and emergency preparedness. A major catastrophe (e.g., hurricane, tornado, blizzard, fire) brings renewed attention to this aspect of organizational plans. The after-action reports, with lessons learned noted, provide the management team with valuable focus points. In addition to overall preparedness as reflected in the disaster/emergency plan, topics of study could include:

○ Aspects of the business continuity plan for patient care and financial records

○ Compliance with the HIPAA/Department of Health and Human Services (DHHS) guidelines for release of information about the aged and persons with disabilities during a disaster event

○ The proper use of the condition modifiers in coding and billing relating to catastrophic or disaster-related events

d. Patient privacy and medical identity theft. HIPAA, ARRA, and HITECH legislation mandate a variety of security compliance assessments, prevention of breach analysis studies, and development of practices to prevent and mitigate compromises of patient privacy. The increased use of smart phones, laptop computers, and other devices that are often used off site (such as by home care personnel) is an area needing particular attention when these devices are lost or stolen. When equipment is leased, or recycled, these items must be securely “scrubbed” of confidential data. The Federal Trade Commission has promulgated regulations (the “red flag” rules) focusing on the detection, prevention, and mitigation of the effects of medical identity theft. Regular auditing of workers’ access rights and their history of access/attempted access to health record information is another area of monitoring.

e. Patterns of care. Various federal and state government initiatives include provisions concerning the reduction of rates for preventable readmission. The frequency and causes of readmission are aspects of this mandate. Related topics include transition from acute to post-acute care and observation unit utilization. Such initiatives also includes requirements to monitor and report elder abuse, making this a topic ripe for fresh scrutiny. Another area of focus deals with evidence-based evaluation and treatment standards such as those promulgated by the American College of Surgeons Commission on Cancer or those included in the federal comparative effectiveness reviews.

6. Patient satisfaction studies. Questionnaires (using a mix of anonymous and identifiable responses) provide feedback about the effectiveness of quality initiatives as well as processes in need of improvement. The incidents may describe seemingly small concerns, but from the client’s perspective, these are the tangible effects of practices. The care per se may have been excellent, but the related processes might cause discomfort, anger, or confusion. Examples include not being able to easily access health record information because of HIPAA rules but being asked over and over to state one’s date of birth within earshot of other patients, giving an overseas 14-digit telephone number of the next-of-kin/power-of-attorney (POA) holder to registration personnel only to be told that phone number field is limited to 10 digits, difficult-to-read/use computers for self–check in, and no weekend or holiday campus transportation to remote parking sites.

7. Employee satisfaction studies. As with patient satisfaction studies, these questionnaires and interviews provide information to assist managers in maintaining a culture of excellence. Topics include general working conditions (noise levels, temperature, proper equipment in good working order) and related concerns such as safety, parking, lack of flexibility in working hours, lack of adequate training and therefore promotion opportunities, and lack of easy-to-contact “help desk” for computer support. An analysis of grievance issues provides another source of information about topics of concern.

There are many resources available to the manager for carrying out performance improvement studies. Examples include American Health Information Management Association (AHIMA)’s Information Governance Principles for Healthcare, National Hospice and Palliative Care performance outcomes and measures, Medicare’s allowable/nonallowable cost compliance checklist, and Healthcare Effectiveness Data and Information Set performance measures and quality improvement core set for cultural and linguistic services. See also the interpretive guidelines of federal and state regulations.

Managers of each department develop and carry out such studies within their immediate organizational jurisdiction; they also partner with other units in the organization through committees, teams, and special projects to achieve the goals relating to organizational excellence. The management function of controlling is the traditional term associated with these detailed processes.

THE MANAGEMENT FUNCTION OF CONTROLLING

Controlling is the management function by which performance is measured and corrective action is taken to ensure the accomplishment of organizational goals. Performance improvement, continuous quality efforts, TQM—all of these initiatives make up the controlling function. It is an oversight operation in management, although the manager seeks to create a positive climate so that the process of control is accepted as part of routine activity. Controlling is also a forward-looking process in that the manager seeks to anticipate deviation and prevent it. It is an overarching activity, involving all the functions of management.

The manager initiates the control function during the planning phase, when possible deviation is anticipated and policies are developed to help ensure uniformity of practice. Goals and objectives include quality measures. During the organizing phase, a manager may consciously introduce the “deadly parallel” arrangement as a control factor. Job descriptions include reference to maintaining excellence through performance of duties. Training and retraining programs are provided in order to prevent poor performance. Motivation, reduction of conflict, and the promotion of team effort support quality initiatives. Two styles of leadership are necessarily blended in this function:

• Close supervision and a tight leadership style reflect an aspect of control. Through rewards and positive sanctions, the manager seeks to motivate workers to conform, thereby limiting the amount of control that must be imposed. Finally, the manager develops specific control tools, such as inspections, visible control charts, work counts, special reports, and audits.

• Participative management/leadership style, with wide participation in the quality cycle, is the generally accepted principle in performance improvement initiatives.

Does this comprehensive focus on quality consume all or most of the manager’s time? No, not necessarily—studies and oversight processes can be combined, efficiently scheduled, and carried out by designated individuals, teams, and committees. For example, when budget preparation is undertaken, a review of just-in-time inventory practices could be an adjunct activity. When a project to clean up and consolidate the master patient index is implemented (including timely and accurate updates of identifying information), a related study might focus on registration processes regarding unconscious patients or trauma and emergency admissions. A comprehensive study of clinic appointments might include the reasons for “no shows,” cancellations, late arrivals, and those who “leave without being seen.” A review of related support systems such as on-campus and other transportation issues would contribute to the comprehensiveness of the study. Elderly patients who depend on community-based driver services might silently resist certain follow-up appointments because of timing. A simple entry into their care plan to indicate preferred appointment time (and clinic location on multisite campuses) easily eliminates this concern.

A manager might focus on one system at a time through a comprehensive review, including the positive and negative results of work productivity, error types and rates, HIPAA compliance, standards of conduct annual briefing, safety of equipment, worker safety, employee satisfaction survey, turnover rates, and overall process and methods improvement.

A study relating to payment denials logically includes a review of coding accuracy, completeness, and timeliness; this, in turn, relates to the quality of data entries, studied routinely in records review. Some additional data mining relating to patterns of denial would usually lead to the identification of problem areas.

When Improvements Fail

Using the results of the feedback step in controlling, the manager assesses the results of the planned improvement, noting immediate results along with the long-term effects. If the effects are starkly negative, spontaneous feedback may occur, requiring the manager to reassess the change. Two caveats are in order:

1. The manager must respond to the feedback, making the necessary adjustments or providing clients with assistance in adjusting to the changes.

2. The manager must be willing to abandon a change when the data indicate clearly that the new, hoped-for improvement has not come to pass.

Consider these examples:

Situation One: A university decreases resources for part-time and evening students in favor of full-time students. The new goal is to eliminate the longer cycle of degree completion (average of 6 years) in favor of the traditional 4-year cycle.

Outcome: The university had as its founding mission the education of part-time and evening students. Full-time, day students are the secondary clients. The primary endowment funds are restricted for use with the part-time and evening programs and cannot be distributed without a return to original mission of emphasizing part-time and evening students.

Situation Two: An acute care hospital has undergone renovations of three inpatient care units. One of the goals was making the environment “softer” and less clinical. The color scheme was changed to reflect this goal. The typical red crash cart was given a new look, including removal of the red color, and the equipment, including the crash cart, was placed inside closeted areas or behind screens.

Outcome: The crash carts were difficult to find in an emergency when personnel from other units were deployed. The standard routine—color and location of crash carts—was disrupted, leading to delays in their use at critical times.

Situation Three: A continuing care facility streamlined various services, including maintenance, transportation, and reception. All maintenance personnel were reassigned to one central location, and all requests were processed through an online/telephone commercial clearinghouse service. Also, transportation was centralized, with bus-stop style pickup and drop off replacing door-to-door service on campus. Transportation to the local hospital and clinics was changed to a 2-hour shuttle service.

Outcome: Response time for maintenance requests dropped from 2 hours to 2 days. Transportation shuttle to hospital and clinics resulted in early arrival of patients (usually about 1 hour ahead of schedule), thus crowding the clinic waiting areas; return pickup was delayed on average by approximately 2 hours, again causing crowding of clinic waiting areas. Patients/residents evidenced higher rates of anxiety because of the waiting time. This population of frail elderly also had an increase of falls on wet or snow-covered sidewalks at the pickup points.

The unintended consequences of hoped-for improvements in efficiency and cost savings outweighed any positive benefits. Managers reworked their plans, thus removing the negative outcomes.

Participants in the Planning Process

The governing board’s commitment to excellence, stated in the vision or mission statement and overall organizational goals, is the starting point for such initiatives. Relying on both external benchmarks and internal assessments, the board takes the lead in CQI. The chief compliance officer, at the executive level, often takes the lead in these matters.

Process improvements and routine quality control initiatives are the purview of the line managers who are involved in day-to-day operations. These managers do not work in isolation but rather partner with other stakeholders and superusers. Physician satisfaction surveys as part of the annual strategic plan review are one major source of input. The findings can be used to set priorities and outline strategic initiatives to improve the working environment (e.g., space allocation, renovations) and systems improvements (e.g., upgrading technologies).

Quality improvement teams and committees are yet another common approach: patient care providers and support department managers cooperate in a variety of reviews such as patient safety and risk management, infection control, and medication error prevention. Employee involvement through quality circles is a long-standing feature of performance improvement. These workers, close to the daily routines, provide important insight and feedback to operational managers.

Clients are included in quality improvement initiatives. Patient satisfaction questionnaires are used routinely to capture information about wait times and adequacy of information provided about such delays. Privacy considerations, intake processing procedures, and related aspects of admission are commonly included in such questionnaires.

The Basic Control Process

The control process involves three cyclic phases: establishing standards, measuring performance, and correcting deviations. In the first step, the specific units of measure that delineate acceptable work are determined. Basic standards may be stated as staff hours allowed per activity, speed and time limits, quantity that must be produced, and number of errors or rejects permitted. The second step in the control process, measuring performance, involves comparing the work (i.e., the goods produced or the service provided) against the standard. Employee evaluation is one aspect of this measurement. In manufacturing, inspection of goods is a routine part of this process; studies of client satisfaction are key elements when services are involved. Finally, if necessary, remedial action is taken, including retraining employees, repairing equipment, or changing the quality of the raw materials used in a manufacturing process.

Characteristics of Adequate Controls

Several features are necessary to ensure the adequacy of control processes and tools:

• Timeliness. The control device should reflect deviations from the standard promptly, at an early stage, so there is only a small time lag between detection and the beginning of corrective action.

Example: Patients with chronic conditions have repeat visits; a coding-billing error, with resulting denial of payment, should be addressed immediately so that the same denials do not recur.

Example: Frail, elderly residents of a skilled care center need regular update of POA and next-of-kin notifications when these individuals are, themselves, frail and elderly.

Example: A required change in billing systems, with a related change in coding systems, has a deadline for claims submissions under the old coding system. Failure to meet the deadline will mean no claims payment. Any problems in denials and related appeals needs to be monitored throughout the changeover, with rapid feedback and correction processes in place.

• Economy. If possible, control devices should involve routine, normal processes rather than special inspection routines at additional expense. The control devices must be worth their cost.

• Comprehensiveness. The controls should be directed at the basic phases of the work in addition to later levels or steps in the process; for example, a defective part is best inspected and eliminated before it has been assembled with other parts. Furthermore, the controls need to include focus on workers, equipment, and processes.

• Specificity and appropriateness. The control process should reflect the nature of the activity. Proper laboratory inspection methods, for example, differ from the financial audit and machine inspection processes.

The setting itself should be taken into account when developing controls. For example, a rural critical access hospital needs to monitor its billing and payment systems to reflect services provided via telehealth and distant-site practitioners. The pattern of usage of swing beds is another area of study. Studies relating to unnecessary medication, along with positive outcome measures for behavioral interventions are topics for continuing review.

• Objectivity. The processes should be grounded in fact, and standards should be known and verifiable. External reviewers and auditors should augment line managers’ observations.

• Responsibility. Controls should reflect the authority–responsibility pattern. As far as possible, the worker and the immediate supervisor should be involved in the monitoring and correction process.

• Understandability. Control devices, charts, graphs, and reports that are complicated or cumbersome will not be readily used.

Types of Standards

Standards may be of a physical nature, in terms of both quantity and quality (e.g., the number of charts processed according to the required regulations). Such standards make it easier to develop inspection processes because such information can be recorded relatively simply on visible control charts, work logs, and similar tools. Standards may also be set in terms of cost; a monetary value is attached to an operation or to the delivery of a service (e.g., the cost per square foot per employee, the cost per patient per visit, or the cost per object in a factory). Occasionally, the standard is expressed somewhat intangibly, such as the success of a volunteer drive, competence or loyalty in an employee, or ability in a trainee. Whenever possible, however, a quantifiable factor should be introduced. For example, behavioral objectives could be developed for each level of trainee functioning.

The Intangible Nature of Service

Healthcare organizations face a special difficulty in that their primary activities are services, which do not always lend themselves to quantifiable measurement. Furthermore, it is difficult to monitor the delivery of a service because of its dynamic nature. Patient privacy is a major consideration. Another dilemma stems from attempts to delineate services in terms of cost; many services must remain available even if the patient census has dropped during a given period. For example, an emergency service must have adequate coverage no matter how many patients come for service at a particular time.

Selected Strategies

Traditional approaches to developing control processes may be further refined through the use of additional strategies and methods. Examples include:

• The Six Sigma approach to TQM and continuous performance improvement, which is based on statistical analysis of variations in performance measures. Sigma, the Greek symbol, is used in statistics to measure variation (standard deviation) from the mean. In the Six Sigma approach, process improvement teams seek to minimize variation from the desired norm. The target is six sigma (99.999%) or less of variation from this desired level of performance. The emphasis is on prevention of error, reduction of variation, zero defects, and continuously increasing customer satisfaction.

This management strategy, applying proven management principles, was widely used in the 1990s and continues to be implemented. Managers acquire certification in the principles and practices of lean enterprises, streamlining processes, reengineering total systems, and focusing on cost reductions, while at the same time increasing productivity and quality: these are characteristics of Six Sigma. Measurement and statistical analysis are central. The ongoing analysis focuses on process variation and then rapid response to correct undesirable variations.

• Root cause analysis. The emphasis in this approach is the search for fundamental cause of problems rather than only treating the symptoms. Developing the in-depth review of a situation requires thoroughness. It often involves working with other departments because of the interconnectedness of both problem and cause.

• Waterfall or cascading impact review. The emphasis is early detection and correction so that one error is not repeated and compounded throughout the system. For example, an error made during the intake/registration process, if not detected and corrected, may remain dormant, surfacing later as a compound problem (e.g., duplicate numbers; misidentification of patients, with resulting errors in care).

• Rapid improvement cycle. The emphasis is short implementation time (e.g., a few months), with continual improvements made during the same time period. The federal Health Resources and Services Administration has guidelines and examples of such processes for the healthcare setting.

• Dashboard reporting. The emphasis is timely, concise data capture, along with real-time updates. Such reporting is especially useful in emergency situations (e.g., an unexpected weather-related emergency). Consider the situation of a large, acute care hospital, with multiple clinics; a once-in-a-century hailstorm developed in the early afternoon, around the time of shift change and at the height of outpatient clinic traffic. The storm damage occurred in a short outburst but with great intensity. Traffic came to a standstill; storm damage was extensive (cars, windshields, windows, signs). Management of the related disaster response was facilitated by the immediacy and accuracy of data.

Other examples of dashboard reporting include monitoring flu or pandemic cases or virus outbreaks (numbers, locations, patient population affected).

Healthcare organizations have a long history of monitoring performance and seeking continuous improvement. Risk management reviews, infection control monitoring, clinical audit studies, patient safety analysis, coding error rates, reducing accounts receivable delays, filing accuracy studies—all are examples of ongoing quality reviews that are suitable for these types of application. Projects relating to compliance measures mandated by licensure and accrediting agencies are yet another set of examples of continuous control and improvement. For example, the quality-of-life indicators associated with long-term care of the frail elderly or the core compliance areas of The Joint Commission provide ideas for topics of study. Coding–billing–documentation correlation in the revenue cycle is another suitable focus for studies. Dashboard reporting, with a focus on timely, concise summaries, is a useful method to combine financial and clinical information to foster rapid response to a problem area.

The various control charts presented in this chapter provide working tools for tracking data for such studies. By coupling the Six Sigma approach with the motivational aspect of appreciative inquiry, a manager helps foster a climate of success. This culture of celebrating success, giving it tangible expression in results-oriented projects, sets up a chain reaction in the organization, with each part of the system becoming fine-tuned and continuously improved. These approaches to quality reflect the fundamental values of the organization, spelled out in its vision and core values statement. CQI helps reduce cost, prevents errors, enhances the climate of patient safety and satisfaction, and fosters positive communication among the caregivers and support staff. (The motivational aspect of appreciative inquiry is discussed in Chapter 10.)

BENCHMARKING

Benchmarking is simply comparison of one’s own activity or results with the level of activity or results of another department or organization. This involves as a “benchmark” the experience of some other entity, the operating results of which appear to be reasonable or perhaps to represent a desirable target. Benchmarking frequently involves adopting various organizations’ best practices and comparing with their results in an effort to improve results in the benchmarking organization. Benchmarks may be derived internally from data obtained from peak performance analysis.

The present-day emphasis on benchmarking activities provides the manager with the impetus to develop standards of practice, deriving them from and comparing them with organizations having characteristics similar to one’s own.

Sources of Benchmarking Measures

Managers use benchmarking measures developed by external groups, develop measures unique to their organizations, or combine external and internal sources for comparison. Examples of external sources include those taken from federal agencies, national associations, and specialty groups—for example, the core performance measures or the patient safety practices of The Joint Commission, the ECRI Institute’s guidelines for emergency care, and the American Society for Testing and Materials and its standards for medical transcription quality programs. National associations of the various credentialed practitioners offer benchmarking studies appropriate to given fields of practice, such as AHIMA’s best practices model. Regional associations (such as a regional hospital group) have benchmarks custom-tailored to the particular characteristics of patient care in the geographic area.

Sample Benchmarking Studies: Health Information Management

The four studies profiled here reflect various aspects of benchmarking as found in typical health information management activities. Table 13–1 uses internal benchmarks and reflects issues of interest to medical staff review groups. Table 13–2 relates to personnel management, specifically turnover rate comparisons. Tables 13–3 and 13–4 focus on specific systems within the department. For the purposes of these studies, the data should be considered fictitious. The examples include both internal benchmark sources as well as external sources.

TOOLS OF CONTROL

Certain tools of control may be used in combination with the planning process. Management by objectives, the budget, and the Gantt chart are examples of tools used for both planning and controlling. Other techniques may also be used in planning workflow or assessing a proposed change in a plan or procedure. They may also be adapted for specific control use, such as when a flowchart is used to audit the way in which a task is actually being done as compared with the original plan. Some controls are directed at employee performance, such as the principle of requalification, whereby the employee is tested periodically to ensure quality standards are met. Specific, quantifiable output measures may be recorded and monitored through a variety of control charts. In addition to these specific tools, the manager exercises control through the assessment and limitation of conflict, through the communication process, and through active monitoring of employees. Specific tools of planning and control are dealt with here.

Gantt Chart

A visual control device, the Gantt chart was developed by Henry L. Gantt (1861–1919), one of the pioneers in scientific management. Sometimes referred to as a scheduling and progress chart, it emphasizes the work–time relationships necessary to meet some defined goal. The time needed for each activity is estimated, and a time value is assigned. This information is plotted on the chart. As the work progresses, entries are made to reflect the work completed. The chart focuses on the interrelationships among the phases of work within a given task. The Gantt chart may be used to reflect different aspects of the work:

• Machine or equipment scheduling (in this application it is also called a load chart)

• Overall production control

• Individual worker production

• Project management

Basic Components of Gantt Charts

Each Gantt chart contains the same basic components regardless of the application. The estimated time allotted for the work is plotted against a time scale that shows the appropriate time frame in days, weeks, or months, as well as calendar dates. The calendar legend may be placed at the top or bottom of the chart. As work progresses, items completed are entered and compared to those planned. In using the chart as a visual control tool, the manager uses shading or color coding to enter lines proportional in length to the percentage of work accomplished.

Standard Symbols

Standard symbols are used for plotting the Gantt chart:

1. The “opening angle” is entered under the date an operation is planned to start.

2. The “closing angle” is entered under the date the operation is planned to be completed.

3. A straight line joining the opening and closing angle shows the time span within which the operation is to be done.

4. A heavy line shows work completed. This progress line is usually proportional to the amount of work completed.

5. A check mark is placed at the date when the progress was posted and is entered on the time scale.

An additional entry may show cumulative work done as time progresses. Codes may be entered to show the reason for being off schedule, such as the following:

• W: worker unavailable due to illness or personal day

• M: lack of materials

• E: equipment breakdown

In constructing and reading any charts, codes should be used and interpreted consistently. Figure 13–1 portrays the Gantt chart for planning and controlling the filing backlog for laboratory reports in the remaining legacy hard-copy records. Figure 13–2 is a Gantt chart for evaluating new admissions.

FIGURE 13–1 Gantt Progress Chart—Filing Reports in Legacy Hard-Copy Files

FIGURE 13–2 Gantt Chart for Evaluating New Admissions

The Flowchart

The manager may use a flowchart to depict the chronological flow of work. A flowchart is a graphic representation of an ordered sequence of events, steps, or procedures that take place in a system. The following are various types of flowcharts:

• Procedure flowchart: a graphic depiction of the distribution and subsequent steps in processing work.

• Program block diagram: a detailed description of the steps that take place in computer routines. Specific operations and decisions, as well as their sequence in the program, are indicated.

• Logic diagram: a graphic representation of the data-processing logic.

• Two-dimensional flowchart: a depiction of complex workflow. This type of flowchart allows the procedures analyst to show a number of flows at the same time, such as a procedure that begins with a single action and branches out into several workflows.

• Systems flowchart: a display of the information flow throughout all parts of the system. These flowcharts may be task-oriented (i.e., emphasize work performed) or forms-oriented (i.e., depict the flow of documents through the functional structure).

Uses of the Flowchart

Flowcharting is associated with computerized data processing because of its emphasis on logical flow, but it is not restricted to program documentation. The flowchart may be used to advantage by any manager who must analyze, plan, and control workflow.

The flowchart may be used for both planning and controlling activities. As a planning tool, it may be used for the following purposes:

1. To develop a procedure. The chart forces the manager to think logically, because it reveals how one aspect of the task is linked to others, which areas of workflow must be made consistent, and where coordination mechanisms are needed.

2. To illustrate and emphasize key points in the written procedure. The flowchart may be used as companion documentation to the written procedure, because it provides an overall picture of the workflow in concise form. Key points in the workflow may be emphasized by color-coding critical decisions or actions.

3. To compare present and proposed procedures. A comparison of a flowchart for a proposed procedure with a flowchart for the existing procedure may show that there are as many, or more, delays in the proposed procedure.

It is less costly to assess the probable outcome of a procedure before it is implemented than to find that the procedure is not workable after it has been implemented.

As a control device, the flowchart may be used for these purposes:

1. To compare the actual workflow with that originally planned. For the charts to remain effective guides to actions, procedures must be updated and the workflow must be monitored for changes that occur imperceptibly. By developing a flowchart of a procedure as it is currently performed and comparing it with the original plan, the manager can see changes that have occurred in the workflow and may then decide whether to change the procedure so that it reflects existing practice or to enforce compliance with the original plan.

2. To audit the workflow. Every loop in a flowchart is a potential delay; the manager can pinpoint areas of delay, investigate the legitimacy of the delays, and determine how to shorten or eliminate them.

Flowchart Symbols

On a flowchart, each distinctive symbol stands for a certain kind of function, such as decision making, processing, or input–output. Symbols provide a shorthand method of describing the processes involved in the work. These symbols, which have become standardized in data processing, are used for flowcharts in connection with both computer programs and with noncomputerized systems analysis. Commonly accepted flowchart symbols are shown in Figure 13–3.

Support Documentation

Sometimes the flowchart is a companion document to a fully written procedure. When the flowchart depicts the overall systems flow or when the procedure has not yet been developed, support documentation is needed to complement the information on the chart. This documentation may be in the form of notes in the body of the flowchart or in the form of a narrative statement. Notes are brief, clarifying statements that supply information in conjunction with a process. They are keyed to their proper place in the chart by a number or a letter. Notes are placed in the side or bottom margins, where they will not interfere with the flowchart proper. A narrative statement covers assumptions, questions, and areas that need additional follow-up. A brief summary of the overall setting of the workflow may be included. Any special terms or abbreviations used are defined in this document.

FIGURE 13–3 Flowchart Symbols

Total Quality Management Display Charts

A manager may use modifications of the TQM charts associated with the Deming approach to management and the TQM movement in general. These data display charts are those traditionally associated with TQM processes. The examples given here reflect application to health information systems.

Run Chart

Purpose: to identify trends over time (e.g., number of requests for charts from off-site storage during fiscal year)

Display format: simple graph showing the element to be measured and the time period for the study

Histogram

Purpose: to measure the rate and frequency of occurrences to determine the usual, most predictable pattern when averaging is not a reliable indicator (e.g., response time for release of information requests; reimbursement denials by inpatient clinical specialty).

Display format: simple graph showing frequency distribution.

Scattergram

Purpose: to show the relationship between two variables or factors (e.g., number of “shadow charts” by clinical specialty).

Display format: simple graph.

Cause–Effect Chart (“Fishbone Diagram” or Ishikawa Diagram)

Purpose: identify a major problem and its associated cause. Causes are usually clustered by category: people, procedure, equipment, and policy (e.g., times unavailable for appointments in day clinics).

Display format: cluster diagram of causes, flowing toward the identified problem. Note: This chart is developed through team effort and it is displayed so that additions may be made as information becomes available.

Pareto Chart

Purpose: to determine priorities by comparing factors; to facilitate sorting the few critical elements from the less urgent (e.g., reasons for absenteeism)

Display format: bar graph displaying factors from highest to lowest ranking.

The foregoing and similar graphic displays of data may be incorporated into dashboard reporting systems that provide at-a-glance summaries of findings. They are simple, flexible, and informative methods for supplying support to decision makers in the organization. Chapter 5 includes additional discussion of control processes in the section on evaluating project implementation.

THE CRITICAL CYCLE

In the opening portion of the chapter, we stated that the control process involves three cyclic phases: establishing standards, measuring performance, and correcting deviations. Standards were addressed in the information about benchmarking, and the measurement of performance has consumed a great deal of the remainder of the chapter.

Taken together, all possible means of measuring performance—both those discussed in this chapter and others—will themselves do nothing to effect correction. Correction requires that someone take some positive steps based on what has been learned from the measurements. In other words, one may possess all possible control information, but this information means nothing unless something is done with it. Also, controlling cannot be accomplished without active directing, which is ultimately a part of all management processes.

There are actually two cycles involved in controlling. One is the cycle already cited: establishing standards, measuring performance, and correcting deviations. In this cycle, we continually address the adequacy of our standards as well as the reliability of our measurements as we continue to correct deviations. Neither standards nor measurements are ever considered carved in stone; these must always be reevaluated as the environment changes.

The other pertinent cycle is the directing-and-controlling cycle, or, as it may be referred to, the cycle of directing, coordinating, and controlling.

Rarely are plans and decisions of any consequence implemented exactly as intended in every respect. Recall the many examples of improvements that failed. Many changes, often from moment to moment, are required in pursuit of our objectives. In this cycle, progress is evaluated against objectives, intentions, or needs and adjustments—new decisions are made as we go along. Perhaps the terms most descriptive of the complete controlling function are follow-up and action. The follow-up provides information; this is the observation or measurement of performance. Again, however, all the information in the world is useless without action that translates it into correction. Continually observing how things are going as compared with how they should be going and making new decisions provides new direction to effect corrective action.

Controlling is, quite appropriately, quarterbacking—observing the conditions of the moment and adjusting actions based on current information. It is sometimes simple and sometimes complex, but it is always cyclic.

EXERCISE: CHOOSING AN ADEQUATE CONTROL MECHANISM—WHAT FITS BEST?

Refer to the chapter section titled “Characteristics of Adequate Controls.” For each of the tasks or circumstances described in this exercise, recommend a specific kind of control mechanism. Your selected mechanism should provide you with information on which you can base corrective actions as needed. In each case, state why you selected that particular mechanism, describe how it satisfies the characteristics of adequate controls, and state whether you believe there are one or two additional mechanisms that might work almost as well as your chosen mechanism.

• Display the status of the accomplishment of routine scheduled preventive maintenance activities by the plant engineering department.

• Track the number of repeat patient chart requests fulfilled beyond a stated 2-hour responsetime limit.

• Follow the processing of a letter of complaint from its initial receipt to the disposition of the problem.

• Track the timeliness of the clinical laboratory’s responses to STAT test requests.

• Track the department’s financial operating results as compared with the departmental budget.

• Report on employment turnover throughout the organization by quarter and by year.

EXERCISE: PROMOTING TOTAL QUALITY MANAGEMENT

You are a professional employed at a large urban medical center. You have been appointed to serve as a nonmanagerial member of a steering committee established to guide the implementation of TQM throughout the organization. The committee has been through a week of intensive education in TQM/performance improvement principles and has held the first two of an indefinite series of weekly meetings to pave the way for translating the TQM philosophy into practical actions that can be implemented at the medical center. You are encouraged by what you have learned and experienced during these first few weeks; however, you are also conscious of the organization’s past failures with management by objectives and quality circles, and you are aware of a fairly widespread tendency to regard such undertakings as dabbling in the latest management “flavor of the month.”

Your second steering committee ends late, leaving you only 2 minutes to get to your next commitment. As you leave the conference room and enter the hospital’s main corridor, a colleague, heading toward the same destination as you, falls into step beside you and asks: “What’s this total quality management all about? Looks to me like it’s the same stuff that’s been pushed at us in different wrappers several times over the years, and it’ll probably go the same way—nowhere. Just more fancy notebooks and reports that end up collecting dust. Why should we think this will be any less of a waste of time and resources?”

You have less than 2 minutes available while on the move to provide your colleague with a positive response in a few sentences. Write out your proposed response.

NOTE

1. H. B. Maynard, ed., Industrial Engineering Handbook, 2nd ed. (New York: McGraw Hill, 1963), section 10, 183–191.