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Control Systems: Quality Improvement and Community Healthcare Chapter Objectives After reading this chapter, you should be able to 1. Apply a quality improvement system to a healthcare organization. 2. Engage in effective community health management programs. 3. Implement methods to improve patient care over time. 14 © iStockphoto/Thinkstock Quality Improvement Programs and Tools Chapter 14 Throughout the business community in the United States, the past several decades have witnessed an increasing emphasis on quality. This trend also affects healthcare organizations. Consumers, patients, interest groups, and the government have all expressed interest in and concerns about quality in many walks of life. An interaction also exists between various sectors of the economy and the healthcare system. The connection between food production/consumption and health outcomes is one example of an increased emphasis on quality in two economic sectors—medical and nutrition/food. In 2004, independent filmmaker Morgan Spurlock released the documentary Supersize Me. Over a 30-day period in 2003, Spurlock dined only on foods served at McDonald’s restaurants. In an engaging, often funny, and poignant narrative, the movie displays the negative health effects associated with fast food. Spurlock begins the story as a reasonably healthy young man who starts to gain weight, faces a rising level of blood pressure, and suffers increased indicators of poor health. In an effort to stem the tide of criticism since the film, McDonald’s management team has taken numerous steps to change its menu to include more healthful foods. The organization also posts calorie figures and other information about its products in visible locations in all of its restaurants.

A second film, Food, Inc., directed by Robert Kenner, expands the indictment to the entire food production industry, includ - ing segments producing meats, grains, and vegetables. In the film, Kenner takes aim at the regulatory agencies that oversee food production in the United States. The film argues that current methods of food pro - duction result in unhealthy diets and are unsustainable both economically and envi - ronmentally, in part because they increase the costs associated with healthcare. In essence, better-quality food production can reduce not only costs but also the need for healthcare services.

This chapter examines the nature of qual - ity improvement programs and analyzes community healthcare efforts as part of an organization’s planning and control systems. The first section analyzes how healthcare managers design and apply quality improvement systems within their organizations. Next, community health management programs, including preven - tive healthcare, wellness, and diagnostic systems, are examined. Finally, additional health sys - tems, such as long-term care, ambulatory, and outpatient services, are described.

1 4 .1 Quality Improvement Programs and Tools The terms healthcare quality and quality improvement describe the efforts taken by managers to create and sustain the best possible healthcare organizations. The Institute of Medicine (IOM) defines healthcare quality as “the extent to which health services provided to individuals and patient populations improve desired health outcomes” (Committee on Quality of Health Care in America and Institute of Medicine, 2001). The approach includes increasing the likelihood of © iStockphoto/Thinkstock ▲ ▲ An increasing emphasis on the effects of food consumption on health outcomes has occurred over the past few decades. Quality Improvement Programs and Tools Chapter 14 desired health outcomes and using practices that are consistent with current professional knowl- edge (Committee on Quality of Health Care in America and Institute of Medicine, 2001). Table 14.1 identifies six aims of the IOM with regard to healthcare quality.

Table 14.1 Six aims of the Institute of Medicine Aim Description Safe Avoiding preventable injuries, reducing medical errors Effective Providing services based on scientific knowledge (clinical guidelines) Patient centered Care that is respectful and responsive to individuals Efficient Avoiding wasting time and other resources Timely Reducing wait times, improving the practice flow Equitable Consistent care regardless of patient characteristics and demographics Source: Committee on Quality of Health Care in America and Institute of Medicine, 2001. Reprinted with permission from the National Academies Press © 2001, National Academy of Sciences.

Quality is a multifaceted concept in healthcare. It consists of both subjective and objective data and factors, which can make it challenging to measure the degree of quality in an orga - nization. Several methods have been established to provide a means for measuring quality. For example, seven common measures of acute care hospital quality are (1) average cost per inpa - tient, (2) average length of stay, (3) 30-day readmission rates, (4) mortality rates, (5) provider and patient satisfaction surveys, (6) Joint Commission on Accreditation of Healthcare Organizations accreditation ratings, and (7) receipt of various quality awards. Once quality is measured, areas of improvement can be identified and actions taken.

According to Wiseman and Kaprielian (2005), “The terms quality improvement and perfor - mance improvement are sometimes used interchangeably.” Performance improvement is a positive change in the performance of a system. In healthcare, this term often refers to improve - ments in administrative systems. Quality improvement, on the other hand, refers to a positive change in the quality of a system, such as an improvement in the quality of healthcare provided by an organization. Quality improvement programs take advantage of statistical techniques, problem-solving tools, and empowered decision making (Wiseman and Kaprielian, 2005) and have originated from a variety of sources in both general industry and medical practice. The goals of a quality improvement system in the healthcare industry include providing the ability to assess an organization’s current situation and then prescribing methods to create continuous improve - ments over time.

The following models and tools are used to measure quality and to develop quality improvement systems. Each is described in more detail later in this section.

• Continuous quality improvement (CQI) • Total quality management (TQM) • Plan-do-study-act (PDSA)/Plan-do-check-act (PDCA)/Find-organize-clarify-understand- select (FOCUS) • Focus-analyze-develop-execute-evaluate (FADE) • Six sigma Quality Improvement Programs and Tools Chapter 14 Continuous Quality Improvement The U.S. Department of Health and Human Services defines continuous quality improvement (CQI) as an ongoing process “that employs rapid cycles of improvement” (Health Resources and Services Administration, n.d.) to a system. The CQI model is based on three dimensions for qual - ity of care: structure, process, and outcome.

Structure represents the characteristics of the place where care is delivered, such as the physical facility and equipment used. Human resource programs, such as staff training, are also part of the organization’s structural composition. Structural measures of quality include both individual and organizational actions that can improve the overall quality of a unit’s performance.

Process indicates whether effective medical practices are being followed. Process includes every action taken in a healthcare system, such as diagnosis, treatment, preventive care, and patient education, as well as the activities of and interactions with patients and their families.

An outcome is the effect of care on a patient’s health. Outcomes comprise the effects of a health - care organization on patients or the population of a service area. Variables include changes not only to health status, behavior, or knowledge but also to patient satisfaction and quality of life.

Although outcomes may be viewed as important indicators of quality, accurately measuring them can be difficult.

CQI relies on statistical process controls , which measure, track, and create responses designed to improve the quality of a specific process. These tools help healthcare managers understand sub - systems and uncover problems; however, the emphasis should be on future quality enhancements rather than being viewed as part of the controlling process.

When a healthcare activity requires improvement, the organization gathers a team of knowl - edgeable employees to research and document the steps in the process. Once effective measures have been identified, they can be improved upon, with the goal of preventing future failures.

Making such improvements involves setting goals, educating employees, and continually mea - suring results. The plan should be revised on the basis of the results. Table 14.2 provides examples of items that can be assessed using statistical techniques.

Table 14.2 Continuous quality improvement factors Structure ProcessOutcome Building or facility SafePatients treated Medical equipment EffectiveCost per care or per patient (efficiency) Financial resources Patient centeredClinical outcomes Human resources Hiring systems Training programs Timely Efficient EquitablePatient satisfaction Physician satisfaction (with employer organization) Public satisfaction (with healthcare organization) Quality Improvement Programs and Tools Chapter 14 Total Quality Management The concepts of CQI and total quality management (TQM) are closely related. Both models stress the importance of continuous improvement and the use of statistical techniques to identify areas of concern that may be improved. A series of innovators have contributed to the development of TQM programs.

Walter A. Shewart (1931) suggested that errors in production processes result from two sources.

Using the term variability to describe such errors, Shewart argued that the first source could not be controlled because the problems result from random causes. The first source, known as the common cause source of variability, originates from a random event, such as a fluctuation in the power supply to an operation, which cannot be addressed by a given company. The sec - ond source, termed a special cause , results from controllable factors, such as an incorrectly cali - brated machine or operator error. Such variations can be identified and improved for the future.

Reductions in variations lead to improvements in quality.

Many times, poor performance has been attributed to problems in the labor force. W. Edwards Deming (1986) argued, however, that employee-generated variations in quality constitute only a small percentage of the total. Deming maintained that a systematic and systemic approach to quality offers the greatest potential for reducing defects and improving performance. In Deming’s model, TQM encourages worker participation in creating change and reducing defects from sources other than humans. The classic Deming 14-point model emphasizes statistical analysis techniques combined with a change in managerial philosophy ( http://deming.org).

Joseph M. Juran (1970) introduced the concept that quality has a price, or “the cost of quality.” This idea shifts the focus from subjective evaluations of quality to a form that can be associated with a dollar amount. The idea of “fitness for use,” in which quality is defined as meeting the needs of customers, specifies the type of goal that organizations should seek. Juran’s approach involves quality planning, quality control, and quality improvement, all of which lead to a con- tinuous improvement approach (Juran, 1970).

Philip B. Crosby (1979) introduced the idea that “quality is free,” which suggests that the benefits resulting from quality improvement far outweigh the costs. Poor quality leads to wasted raw materials, reduced production efficiency, an increase in scraps not used, lost sales, and numerous other tangible and intangible costs to the organization. Quality improvements, by comparison, do not result in expenditures that exceed those costs. Crosby also promoted the concept of zero defects , which states that no level of defects should be considered acceptable.

TQM concepts have been applied to healthcare settings in a variety of ways. Hospital officials can seek to identify controllable and noncontrollable problems in the healthcare delivery and in administrative and support processes. In medical care, though there is a tendency to focus on human error, other sources should not be ignored. Concepts regarding employee empowerment and participation, along with an organizationwide emphasis on quality, have led to hospitals and other health organizations seeking documentation of quality through various standards, such as the Malcolm Baldrige National Quality Award. Hospital administrators using this perspective understand that the benefits of quality improvements far exceed costs, such as legal claims for malpractice, insurance premiums, and other measures designed to shield the organization from the effects of errors. Furthermore, the concept of zero defects, though largely unattainable, guides the thinking of many healthcare administrators. Quality Improvement Programs and Tools Chapter 14 WEB FIELD TRIP Why is the Baldrige Award an important distinction for healthcare organizations? Visit http://www.

nist.gov/baldrige to find out more about the values associated with this award.

• Why did the U.S. Congress create the Baldrige Award?

• According to the Baldrige Criteria for Performance Excellence, what are the seven critical aspects of managing and performing as an organization?

• What are the results of aligning an organization with the seven critical aspects?

• What are the eligibility requirements to apply for the award? Plan-Do-Study-Act, Plan-Do-Check-Act, and Find-Organize-Clarify- Understand-Select Some quality improvement programs and tools contain common elements. As the name implies, the plan-do-study-act (PDSA) tool engages in the activities of planning, doing, studying, and act - ing. The essence is to plan a change or find out how something works through a test. Do means to carry out the plan. Study means to examine the results and report findings. Act involves deciding what actions should be taken to improve the situation. Figure 14.1 provides a visual representa - tion of PDSA.

Figure 14.1 Plan-do-study-act f14.01_HCA340 ACT PLAN DO STUDY Source: Wiseman & Kaprielian, 2005. Based on the PDSA model by Associates in Process Improvement. Used with permission.

In a similar program—plan-do-check-act (PDCA)—the plan outlines a program for process improvement. Do begins implementation. Check (the variance from “study” in PDSA) involves the manager determining whether the measures used to assess the process improvement are working. Act is a follow-up step in which management assesses whether a process improvement worked. The PDCA system has its origins in what was known as the Deming cycle or the Shewart cycle (Deming, 1986). Quality Improvement Programs and Tools Chapter 14 The find-organize-clarify-understand-select (FOCUS) system represents an additional tool that can be used for quality improvement. Find means identifying a problem in a medical process.

In the organize step, a team is put together to deal with the process. Clarify occurs as the team maps the process. Understand requires the collection of key metrics (measures) that specify the problem in the process. This step, which represents the check in the PDCA approach, serves as a benchmark for future interventions. Select identifies specific process improvements. This last step represents the plan step in the PDCA model.

As an example of these three tools, consider the potential use of instant messaging as a new method of contacting patients for scheduling or rescheduling appointments. In PDSA, the plan would involve testing whether patients would use the system to contact the physician’s office.

Doing would be establishing a method to monitor instant messages and beginning use of the pro - gram. Study of the program would identify whether the system improved the schedul - ing process through fewer missed appoint - ments. Act would consist of fine-tuning the system for future use.

In a PDCA program, the plan outlines how instant messaging would feed into the physician’s practice. Doing would initi - ate the program. Checking would take the form of determining whether fewer missed appointments and greater patient satisfac - tion resulted. Act would assess whether instant message scheduling actually worked as intended.

A FOCUS approach would identify the potential uses for instant messaging in a physician’s practice. The primary differ - ence is that FOCUS would not actually involve trying or implementing the system. Instead, the experts would point out the approach that they believe is most viable.

Focus-Analyze-Develop-Execute-Evaluate The FADE approach, or focus-analyze-develop-execute-evaluate, is a tool developed by the Organizational Dynamics Institute (ODI). The FADE approach is used in “a remarkably diverse spectrum of service and manufacturing organizations” (ODI, n.d.). According to ODI, “People are successfully applying FADE in virtually all functions and at all organizational levels. The reason for the consistent applicability of FADE is clear: All work can be seen as a process.” In this approach, focus involves defining and verifying the process to be improved. Analyzing occurs as experts collect and analyze data to establish baselines, identify base causes, and suggest potential solutions. Development creates an action plan that is based on the data and that identi - fies methods of implementation, communication, and measuring or monitoring for the future.

Executing is the actual implementation of the action plans, on a pilot basis as indicated, and joins © Medioimages/Photodisc/Digital Vision/Thinkstock ▲ ▲ Continuous quality improvement programs emphasize anal- ysis of all aspects of patient care. Quality Improvement Programs and Tools Chapter 14 with evaluation , or monitoring of performance. The system is directed by a quality action team, which trains managers and team leaders as follows:

• Form and focus teams on priority improvement opportunities • Make sure that team meetings and activities are highly productive • Track the progress of teams as they proceed through FADE • Recognize team achievement and document the impact of continuous improvement activities • Use the FADE approach to replicate quality advances in all parts of the organization In the FADE system, the healthcare organization’s managers and team leaders form the nucleus of an organizationwide support structure. The purpose is to empower teams, leading them to think of innovations, eliminate any unnecessary “costs of quality,” and improve both quality and customer satisfaction.

ODI also engages in continuous improvement programs specifically directed at the medical industry. The organization employs the scientific method to address problems experienced by those engaged in medical practice. As with other continuous improvement programs, ODI relies on collaboration and systems-based approaches to help physicians and others improve their med - ical treatment organizations.

Healthcare applications of ODI and FADE include three programs. The first identifies systems and causes that interfere with best practices in hospitals and physician organizations. The second assists in scheduling, billing, and resolving common problems that affect doctor’s offices and hospitals. The third helps physicians improve care without requiring them to spend more time in the hospital tending to patients.

Six Sigma The term six sigma originates from a statistical term based in the concept that defects should be held to fewer than 3.4 per million. As with other quality management programs, six sigma stresses an overall, long-term commitment to quality throughout the organization by reducing variation (Scalise, 2001). The program extends previous quality management systems by incor - porating new ideas, such as the following:

• Achieving measurable and quantifiable financial returns • Designating specific individuals to champion the program’s elements • Making decisions based on verifiable data and quality statistical methods • Applying the program to the most important and expensive organizational processes Two methods of implementation have been linked to six sigma—DMAIC and DMADV. These tools are displayed in Table 14.3.

Healthcare organizations can incorporate the principles of six sigma into medical and adminis - trative operations. Treatment programs, methods of patient diagnosis, and other elements can be improved, as can communication systems, billing programs, and other organizational activities. Quality Improvement Programs and Tools Chapter 14 Table 14.3 DMAIC and DMADV PrincipleDescription DMAIC Define Define the problem, the scope of work, the voice of the customer, and specific goals, such as due dates and changes Measure Identify statistics and metrics that are critical to quality Analyze Analyze the nature of the process, including cause– effect relationships, often via the use of a flowchart Improve State the specific steps to be taken to advance the process, using a pilot program as a prelimi - nary test as needed Control Make sure improvements are permanent; use statistics to ensure that goals have been met DMADV Define Outline goals that are consistent both with customer needs and with the company’s approach Measure Identify statistics and metrics that are critical to quality Analyze Analyze the potential effectiveness of various improvements Design Design the improvement method most likely to succeed Verify Check the design to ensure that it works The Role of Management in Quality Improvement Activities In healthcare, three areas present opportunities for quality improvement: medical services, administrative services, and support services. Managers from each area can seek to reduce varia - tion. The best CQI programs begin at the top and operate at the organizational level. Three issues that managers must consider in the area of healthcare are overuse, underuse, and misuse.

Overuse occurs when patients frequent doctors and hospitals when it is not necessary and, more important, when doctors prescribe medications and treatments that are redundant or that have risks that outweigh the benefits, as occurs with some surgeries. An example of overuse is pre - scribing an antibiotic for a cold; a cold is a virus, and antibiotics only treat bacteria, not viruses.

Underuse occurs when physicians or hospitals fail to offer or provide services with benefits that exceed the level of risk. An example of underuse occurs when a geographic area has a substantial disparity problem. It also takes place when certain beneficial medicines or treatments are not given to categories of patients, such as prenatal care for impoverished, pregnant women.

Misuse signifies that the medical system failed in some way. Preventable illness results when a patient has been misdiagnosed and when the appropriate treatment is not provided. Misuse also occurs when a physician prescribes a medicine without noting potentially dangerous interactions with other medicines or substances taken by the patient.

Managers can implement CQI programs to tackle these significant problems. Such programs can help improve patient care and enhance the community’s overall well-being. The next section of this chapter examines community health. Community Health Management Chapter 14 14 . 2 Community Health Management Although a direct connection between quality improvement programs in healthcare facilities and community health systems may not be readily evident, the two subjects have one common theme: improvement in the health and well-being of individuals within the community. Medical administrators seek to achieve this goal by improving the delivery of care. Community health management systems offer more general services that assist the public and employees in indi- vidual companies in improving personal health. Such services include preventive care and wellness care, among others.

Chapter 1 identified a series of stakehold - ers in the healthcare system, including insurance companies, buyers, public health agencies, regulators, suppliers, healthcare providers, and patients. Each group can play a vital role in improving community healthcare. Table 14.4 summarizes some of the ways in which these entities may help enhance the system on an individual, group, and organizational basis. This sec - tion reviews two important components present in Table 14.4—wellness programs and diagnosis and identification systems.

Table 14.4 Community healthcare efforts Stakeholder Roles in improving care Insurance companies Expanded coverage Payments for screenings and wellness programs Buyers Careful selection of products Public health agencies Wellness programs Public education Communication programs Regulators Update of laws Enforcement of laws Suppliers Improvements in products Healthcare providers Diagnostic systems Wellness programs Communication Patients Personal health activities © iStockphoto/Thinkstock ▲ ▲ Misuse occurs when nurses administer the wrong medicines or the right medicines but at the wrong time. Community Health Management Chapter 14 Wellness Programs A recent trend in the U.S. healthcare system that has gained wide acceptance is the adoption of wellness programs by employers. Typically, wellness programs consist of a variety of efforts, usually made in conjunction with an outside organization, that include biometric testing, health risk assessments, and directed employee activities.

Biometric testing organizations provide medical personnel who measure blood pressure, cho - lesterol levels, triglycerides, blood glucose, and any other tests that employees or their organiza - tions choose. Normally, the employee receives feedback that includes the results of the tests.

Then, those with any problem areas, such as high blood pressure, are provided with council regarding the best ways to respond to the health concern.

The health risk assessment is a survey instrument that records information about a person’s lifestyle and health activities. Again, the person receives feedback regarding potential health risks, such as driving without a seatbelt, being exposed to too much stress, or not eating enough fruits and vegetables. Health risk assessments rely on information given by the patient, whereas biometric results are more precise. Many employers provide access to both testing methods.

Directed employee activities include numer- ous programs designed to improve individ - ual health habits. Quit-smoking programs, changes in dietary habits, stress-reduction techniques, and exercise systems are exam - ples of directed employee activities. These activities can be targeted to individual employees or groups of individuals who enjoy having social support from others.

Managing Wellness Programs In most instances, managing a health wellness program begins with top-level management. To gain support from employees, managers should engage in a series of steps (Wellness Proposals, 2013). First, management should specify the program’s objectives and goals. For example, lead - ers in some organizations may conduct an employee survey to determine whether the majority would participate. The survey might also reveal the outcomes that participants hope to gain from the program.

Second, the organization must have sufficient resources to support the program. Wellness programs are often directed by outside companies that are paid for administering the system.

Beyond simply providing resources, however, top management should support the program by becoming involved in the planning process, participating in wellness events, and reserving time for participants to engage in the program. Management can also send letters of encouragement, inviting employees to participate. Thus, fully supporting a program includes building flexibility into employee schedules to encourage participation without inconvenience. © iStockphoto/Thinkstock ▲ ▲ Directed employee activities include numerous programs designed to improve individual health habits. Community Health Management Chapter 14 Third, managers should design and implement a program that leads to activities that will improve the organization’s environment. This may include making policy changes to support the new system.

Fourth, organizers should try to create a program that is fun. They could add incentives to further motivate employees. Someone in the company or from the outside organization that directs the program should be assigned to monitor individual employee efforts. Then, the management team could evaluate the program and make improvements and changes as time passes.

Fifth, many organizations establish a wellness committee to oversee the program. The commit- tee should consist of individuals who wish to help and become a part of the program. Some par - ticipants in the programs should also be appointed. Ideally a wellness committee would include union representatives (for organizations with a union), top management, participants, and mem - bers of the human resource department.

Finally, the organization in charge of the program should conduct a needs assessment survey among employees with the goal of increasing participation. The needs assessment helps those in charge design a plan that will be best suited to the employees in the organization.

Benefits to Employers Aetna (n.d.) promotes wellness programs as providing several benefits to employers. Aetna’s man - agement team believes that wellness systems help organizations reduce direct and indirect health costs. Direct costs arise from payments for medical care, whereas indirect costs include lost time on the job and other complications. Healthy employees tend to be more productive. Thus, a well - ness program that works correctly affects health outcomes and subsequent levels of production, which may create a competitive advantage for the company. Finally, an employee who engages in a wellness program and succeeds may find that the motivational level can transfer to other activi - ties on the job. Consequently, Aetna offers wellness programs to organizations that it insures.

Criticisms of Wellness Programs Despite the potential advantages of wellness programs, some criticisms have arisen (see Kliff, 2013). Among them, analysts argue that the costs are likely to exceed the benefits. The costs of establishing the system, along with worker time away from regular duties to engage in wellness efforts, may be prohibitive to some organizations, especially smaller companies. Many organiza - tional leaders have also discovered that administering programs consumes a great deal of time that could be devoted to other activities. Furthermore, one study revealed few differences in levels of hospitalization of employees after programs had been instituted, with certain negative health outcomes continuing to occur despite the presence of a program.

The Role of Management in Administering Wellness Programs As managers assess the potential benefits and problems associated with wellness systems, they should consider both tangible and intangible outcomes. Tangible outcomes include improved health, leading to lower insurance premium costs and fewer days lost to illness. Intangible out - comes take the form of increased employee satisfaction and commitment to an organization that takes the time to help employees improve their health. Another intangible outcome is that employees who participate may develop other positive habits that transfer to everyday activity within the company. Community Health Management Chapter 14 Diagnostic Systems Another method of improving community healthcare is through the use of diagnos- tic and identification systems. Diagnostic systems should be designed to provide healthcare practitioners with information about the presence, severity, and cause of diseases. Effective systems make it possible for healthcare providers to deliver more effective treatments. The World Health Organization (WHO, 2004) noted three issues associated with the quality of diag - nostic systems. The first, human capital, occurs when insufficient numbers of quali - fied individuals are available to carry out diagnostic tests. The second occurs when a lack of standardized procedures in diag - nostic programs disrupts effective use of medical equipment. The third—resource constraints— limits access to diagnostic equipment in certain regions.

Community health systems seek to address two of the three issues noted by WHO. A combina - tion of government officials and managers in healthcare systems and organizations can seek to attract sufficient numbers of qualified individuals to work in areas that are underserved by the healthcare system—usually rural areas with smaller populations. Patients in those areas may have to travel considerable distances to obtain health services.

Likewise, resource constraints may be addressed by the same community and healthcare lead - ers. Grant programs and other forms of assistance make it possible to obtain access to various forms of healthcare equipment. To further improve access, many mobile medical programs (e.g., mobile labs, magnetic resonance imaging [MRI] machines, and mammography vans) have been instituted in underserved areas to improve both diagnostic and identification systems.

Identification Systems Identification systems take several forms in healthcare organizations, including the identification of patients, visitors, and employees. Due to the constraints of the Health Insurance Portability and Accountability Act (HIPAA; see Chapter 10), plus concerns about security, the importance of proper identification has risen dramatically in the healthcare system. The traditional form of patient identification in a hospital—a wristband that contains all pertinent information— remains in wide use. Among the more modern forms of patient identification, however, is biomet- ric identification , such as iris identification, fingerprint identification, face recognition systems, voiceprint, or retinal scanning. Biometric identification targets each patient’s unique biological characteristics to assist in providing more efficient medical care.

An additional form of identification occurs in the coding of medical instruments. A unique device identification system is “a unique numeric or alphanumeric code that includes a device identi - fier, which is specific to a device model, and a production identifier, which includes the current © Comstock/Thinkstock ▲ ▲ Quality diagnostic and identification systems are crucial to effective healthcare. Community Health Management Chapter 14 production information for that specific device, such as the lot or batch number, the serial num- ber, and/or expiration date” (U.S. Food and Drug Administration, 2013). The system is especially helpful in identifying devices that have injured patients or that did not perform effectively in some other way.

Another type of identification that is used to ensure that medical claims are processed correctly is medical claim coding. As noted in Chapter 6, medical claim coding involves a standard set of identifiers for patient diagnoses, measures taken, equipment used, and medicines prescribed.

HIPAA requires that all healthcare organizations use the Healthcare Common Procedure Coding System (HCPCS) to identify services and procedures. HCPCS includes two levels of codes. The first applies to medical system providers, which must follow the HCPCS code guidelines for each insurer. The second applies to Medicare and Medicaid claims, which usually include more strin - gent guidelines than other insurers.

In summary, effective medical practice requires quality diagnosis and identification systems.

Healthcare managers work to ensure access to the needed diagnostic equipment and the person - nel to operate that equipment. They also take steps to ensure that all forms of identification are properly managed. CASE Wellness Is Getting Better For the past seven years, Lakota McCune had held the position of assistant human resource director for the Grand Island, Nebraska, school district. The school superintendent, in consultation with the city’s school board, believed it was time to upgrade the wellness program for all employees. They charged Lakota with the design and renovation of the program.

The Grand Island system contained only one element—a biometric testing system. Each teacher could receive a $40 per month reduction on his or her health insurance premium by signing up for and attending a screening that included a blood test to report the individual’s cholesterol, triglyc - eride, and glucose levels. The individual was also weighed and measured in order to receive a body mass index score. Finally, the individual’s blood pressure level was assessed. The organization that provides the tests provided qualified medical personnel who offered counseling for any individuals with issues such as being overweight or having high blood pressure.

The problem with the system, according to the superintendent and others, was that it did not offer any incentives to improve one’s health. Lakota’s responsibility was to examine the health risk assess - ment program, which was offered by the same company that conducted the biometric tests. The online assessment system would ask employees to self-report a series of additional health factors, including whether the person smokes or uses seatbelts. In addition, employees would report on dietary issues, such as daily consumption of grains, fruits, and vegetables. The system would then calculate each employee’s biological “age,” as well as perform a life expectancy analysis, given his or her health habits. It would also direct the person to changes in behaviors that could help lower his or her biological “age” and increase potential life expectancy.

Lakota conducted a survey of all employees. Nearly 70% were teachers, about 10% were adminis - trators and clerical personnel, 15% were food service employees, and 5% were janitorial staff. The survey noted that only about half of the teachers and administrators were enrolled in the current wellness system, because many had health insurance through their spouse’s employment and did not purchase health insurance from the school system’s provider. However, nearly all of the food (continued) Additional Programs Chapter 14 14.3 Additional Programs As noted at the beginning of this chapter, the healthcare system interacts with several other industries and entities. Beyond the production and consumption of food products, other factors related to health include the diet industry (e.g., Jenny Craig), the exercise and fitness industry, support group systems (e.g., Alcoholics Anonymous), charitable organizations (e.g., the American Heart Association), religious organizations (e.g., soup kitchens), social clubs (e.g., TOPS Club for weight loss), insurance companies, employer organizations, and government agencies. This section examines two additional programs related to community healthcare—long- term care and ambulatory or outpatient services.

Long-Term Care Long-term care services take a variety of forms that include medical and nonmedical assistance to people with chronic illnesses or disabilities. These services may be provided to persons at any age. The type of support needed begins with personal daily activi - ties, such as dressing, bathing, and using the bathroom, and extends to various forms of healthcare. Long-term care is provided in a patient’s home, community centers, assisted living facilities, and nursing homes. service and janitorial employees did participate in the program. Lakota wondered whether adding a health risk assessment system would change these numbers.

In a conversation with the superintendent, several factors emerged. First, each school within the system employed its own nurse, which meant that all employees of the schools had access to lim - ited healthcare assistance on a regular basis, such as ongoing blood pressure tests. Second, each school had a gymnasium and locker room facilities. The high school also had a swimming pool and a weight room. Third, only about 25% of the teaching and food service staff worked for the school system during the summer.

On the plus side, the school district was willing to devote financial resources to support the well - ness program upgrade. School board members believed that improving the health of teachers and others would create benefits, such as better classroom performance, lower absenteeism, and reduced healthcare costs over time. They viewed improving the wellness system as an investment rather than as an expenditure. Lakota’s job was to design a system that would achieve tangible results.

1. How might a quality improvement program become useful in this situation? 2. If Lakota were to employ a quality improvement system, which would be the best choice? Why? 3. What types of statistics would be most valuable for assessing whether system upgrades were working? 4. What kinds of directed employee activities might best serve the Grand Island school district’s employees? How could they be implemented on a year-round basis? © Stockbyte/Thinkstock ▲ ▲ Long-term care comprises a variety of services, including medical and nonmedical assistance for people with chronic illnesses or disabilities. Additional Programs Chapter 14 Medicaid pays for some health services and nursing home care for older people with low incomes and limited assets. In most states, Medicaid also pays for some long-term care services at home and in the community. Eligibility and the types of services provided vary by state. Normally, income and personal resources determine Medicaid eligibility.

Medicare does not pay for custodial, or nonskilled, care, or care that assists people with daily living activities. The coverage does include some health issues, such as diabetes monitoring and limited nursing facility and home care (skilled care), when medically necessary. However, the patient normally pays some of the cost.

In 2013, about 9 million men and women over the age of 65 required some form of long-term care, and that number is expected to rise. According to Medicare.gov (2013b), “A study by the U.S. Department of Health and Human Services says that people who reach age 65 will likely have a 40 percent chance of entering a nursing home. About 10 percent of the people who enter a nurs - ing home will stay there five years or more.” Forms of long-term care include community-based services, home healthcare, in-law apartments, housing for aging and disabled individuals, board and care homes, assisted living facilities, continuing care retirement communities, and nursing homes. Medicare.gov (2013b) provides excellent descriptions of each form of long-term care, as summarized below.

Community-Based Services Many communities provide seniors and disabled citizens with services and programs related to personal activities. Meals on Wheels, transportation services, personal care, chore services, adult day care, and senior centers are all examples of community-based services. Ordinarily, the ser - vices are provided free or at low cost. The Area Agency on Aging often coordinates these services, all of which are designed to promote the independence and dignity of older adults.

Home Healthcare Some seniors receive assistance with personal daily activities from volunteers. However, certain forms of home healthcare can only be delivered by licensed health workers, such as a registered or practical nurse or a licensed therapist. These individuals assist persons affected by certain ill - nesses or injuries. Medicare only pays for home healthcare that meets specific conditions. Some patients who also retain a home healthcare agency pay for the service from personal funds. Home healthcare costs vary depending on a person’s location, type of care required, and frequency of visits. Most home healthcare organizations charge by the hour.

In-law Apartments An in-law apartment (or second unit, accessory apartment, or accessory dwelling unit) is a sepa - rate housing arrangement within a single-family home. The unit is a stand-alone living space with its own kitchen and bath. The apartment provides a living space for a caretaker or serves as a rental to generate additional income to help cover healthcare costs.

Housing for Aging and Disabled Individuals The U.S. government and most state governments offer programs to help pay for housing for older people with low or moderate incomes. Persons seeking assistance must apply for such hous - ing and are often put on a waiting list. Some housing programs provide meals and assist with personal daily activities. Residents in these settings usually live in individual apartments within the complex. A federal or state agency reviews income and expenses to find out whether a person qualifies. Rent payments are usually a percentage of the individual’s income . Additional Programs Chapter 14 Board and Care Homes A board or care home is a group living arrangement in which employees provide assistance with daily living activities. Residents tend to be individuals who cannot live on their own but who do not need skilled nursing home services. A percentage of these individuals purchase private long- term care insurance to cover the costs of the facility. They may also take advantage of other types of assistance programs to help with payments. Many board and care homes do not receive pay- ment from Medicare or Medicaid.

Assisted Living Assisted living is another form of group-living arrangement. A facility provides help with daily living activities and modest health concerns, such as taking medicine and getting to medical appointments. Residents often live in individual rooms or apartments or may share a space with a roommate. They often live in a building or group of buildings and will dine together for some or all of their meals. These organizations often provide social and recreational activities. Some assisted living facilities have additional on-site health services, such as skilled nursing care.

Residents usually pay a monthly rental fee and are charged more for any services that they receive on an individual basis. Rental and medical fees can vary, depending on the size of the living areas, the services provided, and the type of medical care the individual requires.

Continuing Care Retirement Communities Continuing care communities deliver increasing levels of medical and daily living assistance, based on the person’s needs. A community may contain individual homes or apartments for resi - dents who still live on their own. Residents may eventually progress to an assisted living facility or to a skilled nursing home situation. Such facilities often charge a payment, called an entry fee, to move in. Then residents pay monthly charges based on their level of care. The Commission on Accreditation of Rehabilitation Facilities accredits these types of facilities and organizations.

Nursing Homes Nursing homes provide care to people who cannot take care of themselves. Nursing homes pro - vide a wide range of personal care for residents, who often suffer from physical, mental, or emo - tional problems. Medicare will not pay for most types of nursing home care, except for certain forms of skilled care after an injury or hospital stay. In such cases, if the patient meets certain conditions, Medicare will pay for skilled nursing facility care for a limited time. The cost for nurs - ing homes depends on location and the type of care a person requires. The Joint Commission on the Accreditation of Healthcare Organizations provides information about the accreditation status of individual nursing homes.

Managerial Issues in Long-Term Care Although the basics and fundamentals of management remain the same in any type of organiza - tion, the circumstances vary widely. Managers must adapt to the type of facility in which they are employed. Most community-based services are provided by not-for-profit organizations that connect with local governments and other agencies. In contrast, home healthcare, housing for aging and disabled individuals, board and care homes, assisted living facilities, continuing care retirement communities, and nursing homes are typically profit-seeking organizations. These for-profit organizations interact with local governments, accreditation agencies, insurance com - panies, and other elements of the healthcare system to provide a variety of services that are tai - lored to individual patient and facility needs. Managers who succeed in such organizations are able to understand how each of these publics operates and to adapt their activities to each. Additional Programs Chapter 14 Ambulatory and Outpatient Services Ambulatory care is a personal healthcare consultation, treatment, or intervention that involves the use of medical technology or procedures. Ambulatory services are delivered on an outpa- tient basis, which means the patient’s time in a physician’s office, clinic, or hospital takes place on one day. The term ambulatory also suggests that the patient arrives at a medical facility for treatment under his or her own power.

Ambulatory care takes place in many settings, including primary care physician offices, sur - gical specialty offices, medical specialty offices, hospital outpatient departments, and hospi - tal emergency departments. In addition, numerous medical investigations and treatments for acute illnesses and preventive healthcare are performed on an outpatient basis—for example, visits to a dermatologist for a skin problem, minor surgical and medical procedures, most types of dental services, and many diagnostic procedures, including blood tests, X-rays , computed tomography scans, MRI imaging, endoscopy , and some biopsies of superficial organs. Some rehabilitation programs and even telephone consultations may even be considered ambulatory or outpatient care.

Outpatient care also extends to the treatment of chronic conditions that are treated in regular appointments, such as when an asthma patient goes to a physician’s office for a checkup. Many simple procedures can be performed on an outpatient basis as well. For example, most pregnant women attend a series of appointments as part of prenatal care programs. A physician monitors the progress of the pregnancy while administering procedures, such as ultrasound scans and amniocentesis, along with psychological advice, as needed.

Hospitals deliver ambulatory care in emergency rooms for patients who can be treated without being admitted, such as a person with the flu or a broken arm. Urgent care clinics, optometrist ’s offices, and doctor’s offices also provide this type of care.

Managerial Issues in Ambulatory and Outpatient Care Efficiency and effectiveness represent the two managerial concepts that best apply to ambulatory and outpatient care. One concern is that with the rising number of cases that physicians and organizations are expected to treat on an outpatient basis, patient waiting time has increased (National Quality Forum, 2010). Another problem is decreased physician efficiency in terms of the number of patients treated. To overcome these issues, managers can implement quality con - trol systems and quality improvement programs to create more proficient treatment and billing systems.

Effectiveness, or the quality of care delivered, also has generated some concern. Historically, peo - ple without health insurance were unable to receive basic healthcare and were essentially forced to wait until a trip to the emergency room was necessary in order to receive treatment. Likewise, any person with a medical condition that emerged in the middle of the night or on the weekend might have had an emergency room visit as the only option. As the healthcare system progresses, however, efforts can be made to ensure that each patient can access a healthcare professional in a timely fashion; this will improve the quality of the overall healthcare system in terms of patient outcomes. Additional Programs Chapter 14 CASE Senior Life Center Jorge Rodriguez has served as the chief administrator of the Senior Life Center for the past two years. The center, which is located in the Orange County, California, area, serves persons aged 50 and older. The facility offers local residents a computer lab, dining room, ballroom, music and game room, and arts and crafts facility. The center is located near a major city park, where tennis and racquetball courts, a shuffleboard area, walking trails, a ball field, and a swimming pool are read- ily available. The center sponsors four major events each year—during the Christmas season, near Valentine’s Day, once in the summer, and once in early autumn. Several community companies pro - vide funding and support for the events, which are well attended by citizens in the area.

According to the Senior Life Center’s mission statement, the facility should be more than a meet - ing place and entertainment center for those who frequent its services. As a result of the center’s strong connections with the Orange County Area Agency on Aging, staff members are able to provide regular visitors with connections to numerous services, including the local Meals on Wheels program, transportation to counseling and medical health centers, referrals to organizations that offer home healthcare, and a rotating set of clergy from seven religions in the area who provide spiritual assistance each Friday in a private room within the facility.

The Senior Life Center relies on donations and government funding to maintain its operations.

Recently, however, a member of the local city council began to question the city’s contributions to the Senior Life Center and other senior programs, suggesting that these organizations were drain - ing too many city resources. To keep the funding, Jorge was asked to provide information about the quality of assistance that the center provides to seniors, along with an action plan to enhance exist - ing activities.

Jorge held a meeting with the center’s entire workforce. His first questions were mostly philosophi - cal: “Why are we here?” and “Who would miss this place if we were gone, and why?” He then asked, “What else could we do to assist area seniors?” Many responses were framed in terms that were difficult to quantify. So Jorge wondered, “How does one measure quality of life?” The same question applies to terms such as senior independence and the dignity of older adults . Jorge believed that these elements represent the truest, highest value of the Senior Life Center. The center’s employees held the strong conviction that if the center were actually gone, it would be sorely missed. Many viewed the organization as a cog in the com - munity’s well-being. They even saw it as an attraction drawing older people to move to the area.

Jorge knew he could provide some statistics. For example, he could note how many people, on average, came to the facility each day. He could also quantify the number of referrals to other organizations that his employees provided on a monthly basis. He could specify the number of indi - viduals who sought counsel in the spiritual center. He could also enumerate the number of lunches served to guests each Monday through Friday. He could even calculate the volume of coffee given out to visitors each month.

Jorge wondered, however, whether such straightforward figures would influence council members.

He decided to visit a local university to consult with members of the social work department. His wife suggested that he also visit with members of the school’s college of business—mostly nota - bly, the management department. With national cutbacks in funding for many social programs, he (continued) Chapter Summary Chapter 14 Chapter Summary Healthcare quality is the extent to which health services provided to individuals and patient populations improve desired health outcomes. Quality improvement is an organized, managerial approach designed to improve and sustain continuous performance quality over time through the use of statistical techniques, problem-solving tools, and empowered decision making. Quality improvement programs and tools include continuous quality improvement (CQI), total quality management (TQM), plan-do-study-act (PDSA), plan-do-check-act (PDCA), find-organize-clar- ify-understand-select (FOCUS), focus-analyze-develop-execute-evaluate (FADE), and six sigma.

Managing quality involves performance improvement in administrative systems and quality improvement in healthcare. Each program and tool addresses the issues of overuse, underuse, and misuse.

Community health management includes wellness programs that feature biometric testing, health risk assessments, and directed employee activities. Managing wellness programs requires top-level involvement, sufficient resources to support the program, engaged policy making, a fun and motivational program, a wellness committee for purposes of oversight, and a needs assess - ment survey to correctly identify employee issues. Effective programs reduce direct and indi - rect health costs, lead to improved productivity, and enhance employee motivation. Some critics argue, however, that the costs of such programs exceed the benefits.

Diagnosis and identification systems provide healthcare practitioners with information about the presence, severity, and causes of disease. Community health systems seek to provide suf - ficient numbers of qualified individuals to serve all areas and to obtain the resources necessary to maintain the needed medical services. Identification systems apply to patients, visitors, fam - ily members, and employees. Coding systems help ensure that medical claims are processed c or re c t l y.

Additional community health programs address long-term care. Organizations and providers of long-term care include community-based systems, home healthcare, in-law apartments, housing for aging and disabled individuals, board and care home, assisted living facilities, continuing care retirement communities, and nursing homes. Ambulatory and outpatient services include per - sonal healthcare consultations and treatments or interventions that employ medical technology or procedures. The services take place in a physician’s office, clinic or hospital, medical specialty office, or surgical specialty clinic. Efficiency and effectiveness represent the primary managerial concerns in ambulatory and outpatient care. knew that his future actions might determine whether the Senior Life Center would continue to exist or to function at its current level of activity.

1. What types of statistics, beyond those listed in this case study, would be helpful to Jorge? 2. Which quality improvement program would be most useful to the Senior Life Center? Why? 3. Which criterion—efficiency or effectiveness—should be applied to outcomes at the Senior Life Center? Why? 4. If the Senior Life Center were to expand its services, which might be most useful in the organiza - tion’s current circumstances? Critical Thinking Chapter 14 Ke y Te r m s ambulatory care a personal healthcare consultation, treatment, or intervention that involves the use of medical technology or procedures biometric testing analysis of health measures provided by outside organizations as part of a wellness program continuous quality improvement (CQI) an ongoing process that employs rapid cycles of improvement to a system and that is based on structure, process, and outcome healthcare quality the extent to which health services provided to individuals and patient populations improve desired health outcomes health risk assessment a survey instrument that records information about a person’s lifestyle and health activities as part of a wellness program outpatient a patient’s time in a physician’s office, clinic, or hospital that takes place on one day quality improvement an organized managerial approach designed to enhance and sustain continuous performance quality over time through the use of statistical techniques, problem- solving tools, and empowered decision making performance improvement a positive change, or improvement, in the performance of a sys - tem, such as a healthcare administrative system wellness program a program that consists of a variety of efforts made in conjunction with an outside organization and that includes biometric testing, health risk assessments, and directed employee activities Additional Resources Commission on Accreditation of Rehabilitation Facilities h t t p : // www.carf.org Joint Commission on the Accreditation of Healthcare Organizations h t t p : // w w w.jointcommission.org Medicaid h t t p : //w w w.medicaid.gov Medicare h t t p : //w w w.medicare.gov National Institute of Standards and Technology h t t p : //www.nist.gov National Quality Forum h t t p : //w w w.qualityforum.org Wellness Proposals h t t p : //w w w.wellnessproposals.com/ Critical Thinking Review Questions 1. Define healthcare quality and quality improvement . 2. Define the concept of continuous quality improvement (CQI) in healthcare. Critical Thinking Chapter 14 3. In continuous quality improvement, what three dimensions of quality of care should be addressed? 4. Define the terms in PDSA and PDCA. 5. Define the terms in FADE. 6. What are the basic tenets of six sigma programs? 7. Name three primary elements found in employee wellness programs. 8. What steps can managers take to ensure effective employee wellness programs? 9. What potential benefits emerge from employee wellness programs? 10. What criticisms have been raised regarding employee wellness programs? 11. What types of identification systems are found in healthcare organizations? 12. What forms of long-term care are available in the healthcare system? 13. Define ambulatory care and outpatient. 14 . What two managerial criteria apply to ambulatory care? Analytical Exercises 1. Align the concepts of structure, process, and outcome with the three main aspects of a healthcare organization—clinical, administrative, and support. Explain the overlaps between the concepts. 2. Explain how each of the following total quality management (TQM) concepts applies to a physician’s office, a medical specialty unit, and a hospital:

• Common cause variation • Special cause variation • The cost of quality • Continuous improvement • Zero defects 3. Relate the concepts present in PDSA and PDCA with the managerial processes of plan, orga - nize, lead, and control. 4. Which quality improvement program would be best suited to address each of the following issues in healthcare? Defend your choice.

• Overuse • Underuse • Misuse 5. Compare the benefits of employee wellness programs to the criticisms. What factors should a healthcare manager consider when deciding whether to implement such a system for employees in a hospital or some other medical facility? Critical Thinking Chapter 14 6. How might each of the following organizations become incorporated into the directed employee activity portion of a wellness program?

• Diet Centers of America • Support group for persons who have lost loved ones to suicide • Alcoholics Anonymous • A for-profit fitness center 7. Explain the importance of diagnosis and identification systems in each of the following settings:

• Emergency room • Home healthcare company • Assisted living facility • Nursing home 8. Which quality improvement program would be best suited to ambulatory care in each of the following circumstances? Defend your choice.

• Physician’s office • Medical specialty office • Hospital outpatient department • Emergency room