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CPHQ Preparation Course

Quality Management Trilogy

Quality Planning
Quality Control Quality Improvement

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The Quality Management Trilogy

Quality Planning includes: Identifying and tracking customers, their needs and expectations.

Designing new or redesigning systems, services, or functions based on customer needs and expectations.
Identifying function and process issues critical to effective outcomes; and developing new processes capable of achieving the desired outcome. Setting quality improvement objectives based on strategic goals.

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The Quality Management Trilogy

Quality Control/Measurement includes: Developing process and outcome performance measures.

Measuring actual performance and variance from expected.

Summarizing data and performing initial assessment/ analysis. Measuring and describing process variability.

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The Quality Management Trilogy

Quality Control/Measurement includes: cont.. Measuring and tracking outcomes of populations. Performing intensive assessment as data dictates. Providing accurate, timely feedback. Using the data to manage, evaluate effectiveness, maintain Quality Improvement gains, and facilitate Quality Planning.

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The Quality Management Trilogy

Quality Improvement includes: Collaboratively studying and improving selected existing processes and outcomes in governance, management, clinical, and support activities; Analyzing causes of process failure, dysfunction, and/or inefficiency; Systematically developing optimal solutions to chronic problems; Analyzing data/information for better or best practice.

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The Quality Management Cycle, based on Juran's Quality Trilogy (quality planning, quality control, quality improvement) a. excludes the lab's activities to monitor equipment.

b. requires a departmentalized approach to quality management.

c. encompasses only the non clinical aspects of QM. d. incorporates information from strategic planning.

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That function in the Juran Quality Management Cycle that includes the initial analysis of data/information is

a. quality planning. b. quality initiatives. c. quality control/measurement. d. quality improvement.

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Quality Management Principles

Leadership commitment is the Key. Focus on systems not on individuals.

All decisions are based on information derived from reliable data. Quality is what is perceived by the customer as quality.
Quality management is preventive and proactive not reactive or a quick fix.
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Quality Management Principles

Quality empowers people; it does not police them.
The modern approach to quality is thoroughly grounded in scientific and statistical thinking. Total employee involvement is critical. Sound customer-supplier relationships are absolutely necessary for sound quality management.
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Quality Management Principles

Productive work is accomplished through effective structure and efficient processes. Defects in quality come from problems in processes. Understanding the variability of processes is a key to improving quality. Quality measurement should focus on the most vital processes. Poor quality is costly.
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The major difference between traditional "quality assurance" activities and the expanded quality improvement/performance improvement activities is the QI/PI focus on

a. people and competency. b. analysis of data. c. performance measures. d. systems and processes.

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In the transition from quality assurance to quality management/quality improvement, which of the following emphases has resulted in the most significant benefit?

a. Focusing primarily on process rather than individual performance

b. Focusing on organizationwide rather than clinical processes

c. Organizing activities around patient flow rather than department or discipline d. Initiating more prospective rather than retrospective improvement efforts

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Structure, Process, and Outcome

leads to Process
leads to

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Structure, Process, and Outcome

Structure: is the arrangement of parts of a care system or elements that facilitate care; the care environment; evidence of the organization's ability to provide care to patients, e.g.:
Resources Equipment Numbers of staff Qualifications/credentials of staff Work space

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Structure, Process, and Outcome

Process: refers to the procedures, methods, means, or sequence of steps for providing or delivering care and producing outcomes. In other words, processes are activities that act on an "input" from a "supplier" to produce an "output" for a "customer" e.g. - Clinical Processes - Care Delivery Processes - Administrative and Management Processes

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Structure, Process, and Outcome

Outcome: refers to the results of care, adverse or beneficial e.g.

- Short-term results of specific treatments and procedures

- Complications - Adverse events - Mortality

Functional: - Long-term health status - Activities of daily living (ADL) status Perceived:
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- Patient/family satisfaction


Monitoring the specific organization and content requirements of a medical record system is a review of which focus? a. Outcome of care b. Process of care c. Structure of care d. Administration of care

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Monitoring phlebitis associated with IV insertions by nurses in the Surgical Intensive Care Unit addresses which focus?
a. Outcome of care b. Process of care c. Structure of care d. Administrative procedure

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Which of the following best describes the successful outcome of the quality improvement process?
a. Customer satisfaction b. Enhanced communication c. Employee empowerment

d. Improved statistical data

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What is the most important relationship between structure, process, and outcome as types of indicators of quality?
a. Interdependent: Structure directly affects both process and outcome. b. Causal: Structure leads to process and process leads to outcome. c. Relational: Useful for comparisons, but not causal d. There is no relationship; they are categories used to group indicators.

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Review of the timeliness of high risk screening for diabetes addresses which focus?
a. Outcome of care b. Process of care c. Structure of care d. Administrative procedure

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The Concept of Process Variation

Variation is "change or deviation in form, condition, appearance, extent, etc., from a former or usual state, or from an assumed standard." "Variation" generally refers to the whole process or a step in the process. Variance is "a changing or tendency to change; degree of change or difference; divergence; discrepancy." This term generally refers to specific data or information.

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Clinical Variation
Variation in clinical practice has been defended in the past as the "art" of medicine. In fact, variation can be either positive or negative. In healthcare quality, we tend to think of variation as negative or adverse, based on the quality assurance case-specific review tradition. Sometimes the art of medicine creates a "best practice," which we now try to capture and replicate as part of quality improvement process.

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Process Variation 1. Common Causes

Random or common cause: Intrinsic to the process itself; naturally occurring inliers. " Example: patient response to medication will always vary, within the cohort of patients and even for one patient over time. Common causes" refer to situations, usually within patient care systems and processes (within the normal, bell-shaped curve) that are more ongoing, chronic, and persistent. These common causes contribute to the "normal range of variation" within a process.

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Process Variation
1. Common Causes Cont.
The goal of quality improvement is not to eliminate, but to reduce variation in a process enough to produce and sustain "stability. Common causes may also contribute to what are considered to be the less than desirable parts of a process.

Usually finding and resolving common causes of problems or variation is more time-consuming and may be more difficult for departments, services, The resolution of common causes of problems is often considered to be key, however, to continuous, incremental improvement of the quality of care and services rendered to patients
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Process Variation
2. Special Cause
Special cause: Extrinsic to the usual process; related to identifiable patient or clinical characteristics, idiosyncratic practice patterns, or other factors that can be tracked ("assigned") to root causes. "Special causes" refer to sentinel events, one-time occurrences, or other unique, out-of-the-ordinary circumstances that give rise to a variation from what is normally expected. Special causes are usually more easily identified and resolved, either by departments or QI teams. Special causes account for the majority of what we call "outliers"those problems that occur in the "tails" of a normal, bell-shaped curve representing a particular process. Page 27 27

Statistical Process Control

Walter Shewhart's causes of variation led him to develop a methodology to chart the process and quickly determine when a process is "out of control. This ongoing measurement and analysis is known as "statistical process control (SPC)." As long as assignable or special causes of variation exist, we cannot make accurate predictions about process performance and probable outcome. Once assignable causes are eliminated, we can call the process "stable" and can measure the "capability of the process" by rates of deficiencies or rates of achievement of desired outcomes. At this point we have the data we need to perform the in-depth analysis that leads to improvement. [See also "Statistical Process Control" and Control Chart in "Graphic Representations of Comparison Data," 28

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The Pareto Principle: Prioritizing Variation

Joseph Juran noted that approximately 80% of observed variation in processes was generally caused by only 20% of the process inputs. He called this phenomenon the "Pareto Principle," The "80%" and "20%" are relative figures, representing relationship, not absolute calculations.

In prioritizing for quality improvement, it makes sense to identify and focus on those 20% of process issues that make up 80% of the variation. Juran calls this prioritized 20% the "vital few.
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Examples of application of the Pareto Principle

20% of the possible reasons for dissatisfaction with an ambulatory clinic are responsible for 80% of the recorded dissatisfaction on the survey, enabling the QI team to prioritize improvement efforts..

80% of a physician's practice or a hospital's admissions is accounted for by 20% of the classes of diagnoses providing a focus for practice guidelines and disease management..
20% of a healthcare organization's patients account for 80% of the case managers' time, again providing data for prioritizing the development of clinical paths and disease management protocols.
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"Common causes" of problems in processes refer to

a. one-time situations.

b. temporary situations.
c. acute situations. d. chronic situations.

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Applying the Pareto Principle in quality improvement is

a. prioritizing process issues.

b. tracking and measuring process effectiveness.

c. providing meaningful data to support strategic objectives.

d. prioritizing patient outcome issues.

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Special cause variation is to the process

a. random, extrinsic, outlier. b. assignable, intrinsic, noise. c. random, inlier, identifiable. d. assignable, extrinsic, outlier.

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When common cause process variation is identified, the goal of quality improvement is to
a. promote compliance with established procedure or protocol.

b. eliminate the variation.

c. improve practitioner competency. d. reduce variation sufficiently to produce stability.

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After first describing the problem, the best way to look at "patterns of behavior" over time is to use
a. story telling and "The Five Whys." b. brainstorming and constructing gap hypotheses. c. line graphs and story telling. d. Pareto charts and brainstorming.

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In statistical process control, it is important to first

a. eliminate assignable causes of variation. b. eliminate random causes of variation. c. prioritize causes of variation. d. eliminate all causes of variation.

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The Concept of Outcomes Management

Outcomes Management" refers to a "technology of patient experience designed to help patients, payers, and providers make rational medical care-related choices based on better insight into the effect of these choices on the patient's life" [Ellwood, 1988].
The resulting data, called outcome measures, are measures of performance.

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Outcomes management should consist of

A common language of health outcomes, understood by patients;. A national reference database containing information and analysis on clinical, financial, and health outcomes, estimating:-

Relationships between medical interventions and health outcomes

Relationships between health outcomes and money spent. Opportunity for decision-makers to access analysis relevant in making choices.

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Outcomes management depends on the following four developing techniques

1. Practitioner reliance on standards and guidelines in selecting appropriate interventions Routine and systematic measurement of the functioning and well-being of patients, along with disease-specific clinical outcomes, at appropriate time intervals



Pooling of clinical and outcome data on a massive scale

Analysis and dissemination of results (outcomes) from the segment of the database pertinent to the concerns 39 of each decision maker

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The task of setting up an ambulatory care setting QM/QI program that focuses on "outcomes" as a measure of treatment effectiveness is difficult because:

a. the patient remains in control of treatment. b. patient care outcomes are determined by the payer.

c. there are no required medical records.

d. expected outcomes for ambulatory conditions are too obvious.

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The centerpiece of "outcomes management" in healthcare is

a. the measurement of the patient's functionality and quality of life.
b. morbidity and mortality.

c. data reliability.
d. financial impact.

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System Thinking
A body of principles, methods, and tools focused on the interrelatedness of forces in systems operating for a common purpose. The belief that the behavior of all systems follows certain common principles, the nature of which can be discovered, articulated, understood, and used to make change. According to David Mc Camus, former chairman and CEO of Xerox Canada, systems thinking "requires 'peripheral vision': the ability to pay attention to the world as if through a wide-angle, not a telephoto lens, so you can see how your actions interrelate with other areas of activity"
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System: perceived whole whose elements 'hang together' because they continually affect each other over time and operate toward a common purpose" Systemic structure: Not just the organizational chart, but the pattern of interrelationships among all key components of the system: Process flows Attitudes and perceptions Quality of products and services Ways in which decisions are made Hierarchy, and Systemic structures may be visible or invisible, built consciously or unconsciously based on choices and decisions made over time. Interrelationships are discovered by asking the question: "What Page 43 43 happens if it (process, perception, attitude, task, etc.) changes?"

Steps in Systems Thinking

1. Describe the problem (one that is chronic, limited in scope, with a known history) as accurately as possible, without jumping to conclusions. 2. Tell the story; build the model, providing as many divergent ideas as possible. 3. Ask the question: "How did we-through our thinking, processes, practices, procedures-contribute to or create the circumstances, good and bad, that we now face? 4. Look for causality:-causal relationships between events or patterns of behavior
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Steps in Systems Thinking 2

5. Apply an "Archetype" or pattern of performance to fill in gaps in thinking and construct consistent hypotheses about the governing forces in systems.

6. Determine strategies for solution and their ramifications. 7. Redesign the system. You know you have a good intervention when you can see the long-term pattern of behavior shift qualitatively
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Customer Satisfaction
Customer/supplier Relationships
Customer needs & expectations Measurable characteristics of the process agreed to Guiding principles of good customer service

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Identify Customers


Patients Physicians Community Regulatory Payers


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Tools Used To Identify Customers & Their Needs

Identify Customers:
Wheel & Spoke Sundial Customer lists by type e.g. internal & external Customer lists by categories e.g.:
Patients & families Practitioners / clinicians Suppliers / Vendors Provider organizations .etc

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Tools Used To Identify Customers & Their Needs (Cont.)

Identify Customer needs:


Assigned interviews
Focus groups

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Guiding Principles of Good Customer Service

Pay attention to your customer's needs; a successful, long-term relationship with your customer is built day by day

Own your customer's problem as if it were your problem

Be courteous to your customer

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Guiding Principles of Good Customer Service

Be positive about all aspects of your relationship with your customer

Show through every action that your customer is important to you

Distinguish your product or service through the quality of its delivery to the customer

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Guiding Principles of Good Customer Service

Turn a loss into a win by providing prompt and courteous attention to your customer when your product or service fails; remedy the situation through effective service

Look at all situations through the eyes of your customer, see your product or service as if for the first time

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Guiding Principles of Good Customer Service

Every job, with all its tasks, decisions, and responsibilities, is important, since every action affects the customer

Only the customer's perception of your product or service counts for quality

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Healthcare Customer Expectations in The 21st Century

Healthcare customers provide the perceptive quality Both internal and external customers tend to focus on how services meet their perceived needs and whether their expected outcomes are met. Patients add the degree of caring associated with the service and the outcome of the care related to their sense of well-being and quality of life to the interpretive mix.

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Expectations From Leadership

Leadership integrity before dollars;. Leadership sensitivity to needs for: - More personalization and genuine attention; More time for physician caring and compassion. Leadership involvement in the local community. Leadership attention to the organization's financial health to assure high quality clinicians and technology
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Expectations From Healthcare Delivery

More attention to the empowered, informed customer/patient more apt to challenge "doctor's orders

Reduced hassle, more convenience;

More practitioner time (lack of time perceived as disrespect);- Child-centered orientation; Acceptance and coverage of "alternative" approaches.

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Expectations From Healthcare System

Choice of physician and treatment
Optimizing prevention Access for all High quality and cost control Up-to-date technology for diagnosis and treatment

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The Healthcare Customer Focus

Being truly committed to delivering value to patients and other customers;. Listening to and communicating with patients and other customers;. Seeking customer feedback and insight for strategic initiatives and quality improvement activities; Identifying and addressing true needs and value-based expectations;. Committing to long-term, rather than quarterly (shareholder) business results; .

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The Healthcare Customer Focus 2

Optimizing treatment patterns and outcomes for cohorts of similar patients: Clinical Functional

Enhancing the performance of internal processes to benefit: Patients Vendors All who work there.

Respecting patient confidentiality/ privacy and security needs;.

Responding timely to practitioners', providers', and purchasers' appropriate requests for information;. Building trust, respect, and loyalty in relationships.
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In developing a program to evaluate the effectiveness of physician care, a primary care clinic would select which one of the following indicators?

a. The patients will express overall satisfaction with clinic facilities.

b. The contract lab will provide results within 24 hours of sample delivery. c. The staff complies with all infection control policies and procedures. d. Newly diagnosed hypertensive patients are controlled within 6 months.

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HealthCare Delivery Settings

Emergency care is:
Designated hospital trauma centers, Emergency department of hospitals, Urgent care centers or in the filed by paramedical personnel

Acute inpatient (hospital) care

Intensive/critical care Urgent, elective or rehabilitative care considered unsafe as outpatient depending on:
Type of diagnostic or therapeutic procedure or Patient condition including need for daily physician visit & 24 hour nursing care

Urgent care for immediate care for urgent or emergent conditions not requiring treatment at a fully equipped (level I) emergency or trauma center.

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HealthCare Delivery Settings (Cont.)

Ambulatory care including Primary care, Specialty care, & Ambulatory surgery centers providing outpatient services only in-store health clinics opened in pharmacy & retail chains generally staffed by nurse practitioners offering patients fast access to routine medical services. Home care providing certain treatments, services & nursing care in the patients home Hospice care providing psychological, medical & nursing care to the terminally ill & their families, either in outpatient or non acute inpatient settings.
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HealthCare Delivery Settings (Cont.)

Transitional, sub acute & skilled care provide medically necessary nursing services requiring licensed professionals or professional oversight that must be provided daily & for therapeutic purposes at a stage of care between acute hospital & custodial. Assisted Living is group residential setting providing or coordinating personal & health-related services & 24 hours supervision & assistance. Long term care is Custodial or supportive nursing services that do not require skilled, licensed professional intervention.
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HealthCare Delivery Settings (Cont.)

Behavioral Health & substance abuse programs: are
Partial hospitalization or :nonresidential including day or evening treatment.

Crisis stabilization in the home


Wellness & community health are centers provide special training, education & monitoring for certain healthcare needs such as stop-smoking, weight control, stress reduction programs or for certain patient group with leukemia
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Sample Slide Bullet Points

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CPHQ Preparation Course