McLaughlin and Kaluzny’s Continuous Quality Improvement in Health Care FIFTH EDITION Julie K Johnson, PhD, MSPH Professor, Department of Surgery Center for Healthcare Studies Institute for Public Health and Medicine Feinberg School of Medicine, Northwestern University Chicago, Illinois William A Sollecito, DrPH Clinical Professor, Public Health Leadership Program UNC Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill, North Carolina World Headquarters Jones & Bartlett Learning Wall Street Burlington, MA 01803 978-443-5000 info@jblearning.com www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other 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professional service If legal advice or other expert assistance is required, the service of a competent professional person should be sought Production Credits VP, Product Management: David D Cella Director of Product Management: Michael Brown Product Manager: Sophie Fleck Teague Product Specialist: Carter McAlister Production Manager: Carolyn Rogers Pershouse Production Editor: Brooke Haley Senior Marketing Manager: Susanne Walker Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: codeMantra U.S LLC Cover Design: Scott Moden Text Design: Kristin E Parker Director of Rights & Media: Joanna Gallant Rights & Media Specialist: Merideth Tumasz Media Development Editor: Shannon Sheehan Cover Image (Title Page, Chapter Opener): © ALMAGAMI/Shutterstock Printing and Binding: Command Robbinsville Cover Printing: Command Robbinsville Library of Congress Cataloging-in-Publication Data Names: Sollecito, William A., author Title: Mclaughlin and Kaluzny’s continuous quality improvement in health care / William A Sollecito, DRPH, UNC, Chapel Hill, Julie Johnson, PhD, MSPH, Northwestern University Medical School, Chicago, Illinois Other titles: Continuous quality improvement in health care Description: Fifth edition | Burlington, Massachusetts: Jones & Bartlett Learning, [2019] | Includes bibliographical references Identifiers: LCCN 2018029625 | ISBN 9781284126594 (paperback) Subjects: LCSH: Medical care—United States—Quality control | Total quality management—United States Classification: LCC RA399.A3 C66 2019 | DDC 362.10973—dc23 LC record available at https://lccn.loc.gov/2018029625 6048 Printed in the United States of America 22 21 20 19 18 10 To my home team—Paul, Harrison, Tore, and Elijah –JJ To my family for their loving support always and especially to our newest addition, Mason, who represents the future, which is what this book is all about! –WS © ALMAGAMI/Shutterstock Contents Acknowledgments viii Contributors x Preface xii Foreword xiv Chapter The Global Evolution of Continuous Quality Improvement: From Japanese Manufacturing to Global Health Services Definitions Rationale and Distinguishing Characteristics Elements of CQI Evolution of the Quality Movement The Big Bang—The Quality Chasm 17 From Industrialization to Personalization 18 The Scientific Method of CQI 24 Conclusions 28 References 28 Chapter Factors Influencing the Application and Diffusion of CQI in Health Care 32 The Current State of CQI in Health Care 33 CQI and the Science of Innovation 35 Chapter Integrating Implementation Science Approaches into Continuous Quality Improvement 51 Implementation Science Defined 51 Integrating Implementation into QI: The Model for Improvement and Implementation 53 Implementing Well: Using Frameworks for Implementation 63 Conclusions 65 References 67 Appendix 3.1: Definitions of CFIR Constructs 69 Appendix 3.2: Implementation Strategies and Definitions .73 Appendix 3.3: Categories and Strategies 80 Appendix 3.4: List of Behavioral Change Techniques 82 Chapter Understanding Variation, Tools, and Data Sources for CQI in Health Care 107 Health Care Systems and Processes Gaining Knowledge Through Measurement Quality Improvement Tools Sources of Data for CQI Conclusions References 108 112 124 134 139 140 Kotter’s Change Model 47 Chapter Lean and Six Sigma Management: Building a Foundation for Optimal Patient Care Using Patient Flow Physics 143 Conclusions 48 Lean and Six Sigma Management Defined 144 References 48 Lean Management System (LMS) 157 v The Business Case for CQI 37 Factors Associated with Successful CQI Applications 38 Culture of Excellence 43 vi Contents Conclusions 171 Conclusions 232 References 172 References 232 Chapter Understanding and Improving Team Effectiveness in Quality Improvement 175 Chapter Assessing Risk and Preventing Harm in the Clinical Microsystem 235 Teams in Health Care 179 Risk Management—Background and Definitions 236 High-Performance Teams and Quality Improvement 180 Models of Risk Management 240 Understanding and Improving the Performance of Quality Improvement Teams 182 Resources and Support 189 Engineering a Culture of Safety 240 Applying Risk Management Concepts to Improving Quality and Safety Within the Clinical Microsystem 242 Team Processes 193 Role of Risk Management and Patient Disclosure 249 Conclusions 199 Conclusions 250 References 199 References 251 Chapter The Role of the Patient in Continuous Quality Improvement 201 Patient Involvement in Health Care Improvement: A Brief Overview 202 Rationale for Patient Involvement in CQI 204 Methods for Involving Patients in CQI 205 Factors Affecting Patient Involvement 207 Measuring Patient Involvement in CQI 207 The M-APR Model of Patient Involvement 208 Conclusions 213 References 213 Chapter A Social Marketing Approach to Increase Adoption of Continuous Quality Improvement Initiatives 217 Chapter 10 Classification and the Reduction of Medical Errors 253 Why Classify Safety Events? 255 Skill-, Rule-, and Knowledge-Based Classification 255 Conclusions 267 References 267 Chapter 11 Continuous Quality Improvement in U.S Public Health Organizations: Widespread Adoption and Institutionalization 270 Clarifying Key Terms 271 Hallmarks of Social Marketing 219 History of Actions to Promote CQI in Public Health 272 Social Marketing Applications to CQI in Health Care 220 Factors Affecting the Ongoing Adoption and Institutionalization of CQI in Public Health 273 A Scenario for How to Apply Social Marketing to a Health Care CQI Initiative 225 Conclusions 279 References 279 Contents Chapter 12 Health Service Accreditation: A Strategy to Promote and Improve Safety and Quality 282 An Overview of Accreditation 282 Accreditation: A Common Strategy to Improve Health Organizations and Care 284 vii QI Frameworks and Methods 299 Conclusions 307 References 307 Chapter 14 Future Trends and Challenges for Continuous Quality Improvement in Health Care 311 Accreditation: A Process Promoting Continuous Quality Improvement 285 Setting the Stage for CQI 312 Accreditation Agencies, Standards, and Surveyor Reliability 287 Road Map for the Future 315 Public Health Accreditation in the United States 291 References 329 Conceptual Frameworks for Improving Care 312 Conclusions 327 Conclusions 292 References 293 Chapter 13 Quality Improvement in Low- and Middle-Income Countries 297 Variation in Health Outcomes 297 New Challenges and Opportunities for QI 298 Index .333 © ALMAGAMI/Shutterstock Acknowledgments As we developed the fifth edition of Continuous Quality Improvement in Health Care, we were inspired once again by Drs McLaughlin and Kaluzny While we are very appreciative of their contribution of the Preface, their contribution has been so much greater through the years, as mentors and as colleagues We were also inspired by the thought provoking Foreword written by Dr Paul Batalden where he outlined the model of CQI in improving quality, safety, and value and the model of coproduction in improving the “value of the health care service contribution to better health.” We have benefited greatly from the feedback of students who have provided insight and understanding of the importance of making this book a practical teaching tool that addresses the continuing challenges of improving quality and safety of health care in the future We are most appreciative to our friends and colleagues around the globe who authored chapters The coordination and integration of the contributing authors was a tremendous undertaking and we were privileged to work with excellent colleagues, who are truly expert practitioners of continuous quality improvement in health care The production of the book required a team effort at all levels and in multiple locations We would first like to acknowledge the assistance and guidance of the editorial team at Jones & Bartlett Learning In Chapel Hill, special appreciation goes to Dean Barbara Rimer, of the UNC Gillings School of Global Public Health, whose leadership inspires a learning environment that stimulates innovations and viii the motivation to pursue them Deep appreciation is also given to the faculty and staff in the Public Health Leadership Program at the University of North Carolina and the Center for Healthcare Studies and Surgical Outcomes and Quality Improvement Center (SOQIC) at Northwestern University with whom we shared ideas that led to a better product We especially thank Dr Rohit Ramaswamy, who not only authored two chapters but also shared his wisdom about the current and future trends in CQI globally Finally, we appreciate the feedback and guidance that we received from the readers of the Fourth Edition, which among other things led us to reduce the number of chapters in this edition, but also gave us the incentive to go into greater depth on some of the new topics, such as implementation science While several chapters of the Fourth Edition have been eliminated, we would like to acknowledge several of the authors of those chapters here, as the concepts (listed below) were integrated into this edition’s remaining chapters They include: ■ ■ ■ Vaughn Upshaw and David Steffen—the importance of the learning organization concepts in CQI Anna Schenck, Jill McArdle, and Robert Weiser—the use of Medicare data in CQI and the real-world example of the Clemson Nursing Home Case Study Curt McLaughlin and David Kibbe—the importance of health information technology and understanding the strengths and weaknesses of various data sources used in CQI Acknowledgments Once again, as with CQI itself, the production of this book truly required teamwork and we appreciate and acknowledge the vital ix role of all of our fellow team members, not the least of which includes our families Julie K Johnson, Chicago, IL William A Sollecito, Chapel Hill, NC 340 Index Health Information Technology (HIT), 137 health outcomes, variation in, 297–298 health service accreditation requirements and motivations, 285 strategy to promoting safety and quality, 282–292 health-services organization, requirements, 110–111t health systems, 321–323 aims of, 312–313, 312f Healthy North Carolina Improvement App (IMAPP), 275–276 HFACS See Human Factors Analysis and Classification System high-reliability organizations (HROs), 154, 266–267 HIT See Health Information Technology Hoeft, Steve, 157 Home Visiting Collaborative Improvement & Innovation Network (COIIN), 277 honesty, 248 hospital administrator, marketing of, 227 Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS), 137 Hospital Corporation of America (HCA), 17 HROs See high-reliability organizations Huddle, 161, 169 huddle board template, 164f, 171 human error, classification of, 255 See also risk management Human Factors Analysis and Classification System (HFACS), 258, 259f I ICPS See International Classification for Patient Safety identification of self, as role model, 102 identifying risk, 235 identity, 102–103 imaginary punishment, 105 imaginary reward, 106 IMAPP See Healthy North Carolina Improvement App implementation aims, 54 climate, 70 consolidated framework for, 58f determinants, 54, 57–59 drivers, 59 frameworks for, 63–65 improvement and, 53, 54f list of factors affecting, 58t plan, social marketing, 229–232 stages of, 59, 64f, 66b, 66t strategies, 55, 59–63, 61t, 73–79 teams, 59 implementation outcomes, 54, 55–57, 55f, 56t in hospital, 57b mapping to strategies, 62t implementation science defined, 51–53 frameworks for, 63–65 integrating into continuous quality improvement, 53–63 implementer involvement, as philosophical element, improvement cycles, 59 and implementation, 53, 54f Improvement Guide, 125 incentives outcome, 98 and rewards, 71 incidents, 254t type, 260 incompatible beliefs, 102 individual identification with organization, 72 individualization of care, 205 individuals, characteristics of, 71–72 individual stage of change, 71 industrialization, of health care, 18–24 industrial quality, and health care quality, 14–16 inherent variability, Index initial implementation, 64, 66t inner setting, 70–71 innovation, 34–37 installation, 64, 66t Institute for Healthcare Improvement (IHI), 16, 204, 276 Triple Aim, 313 Institute of Medicine (IOM), 2, future of public health, the, 272 institutionalization, public health organizations, 273–278 intellectual capital of workforce, 38 interaction patterns, 196–197 Interactive Systems Framework (ISF), 64–65, 65f intermediate objectives of social marketing, 227 internal implementation leaders, 72 International Classification for Patient Safety (ICPS), 260–264 framework, 261f International Society for Quality in Health Care (ISQua), 284–285 intervention characteristics, 69 intervention source, 69 intra- and inter-rater reliability, 290 intrinsic motivation, 40 inventory, 150 buffers, 154 as waste, 170t involvement of patient See patient involvement IOM See Institute of Medicine ISF See Interactive Systems Framework Ishikawa, Kaoru, 11–13, 130 Ishikawa diagrams, 130 ISQua See International Society for Quality in Health Care J Jackson, Thomas L., 146 Janani Suraksha Yojana (JSY), 297 Japan, evolution in, 11–13, 13b 341 JCAHO See Joint Commission on Accreditation of Health Care Organizations JCI See Joint Commission International Job Characteristics Model, 192 The Joint Commission (TJC), 2, 5, 109, 284, 289 Patient Safety Event Taxonomy, 258–260 Joint Commission International (JCI), 17 Joint Commission on Accreditation of Health Care Organizations (JCAHO) See The Joint Commission Jones, Daniel, 145 Jones, Karen R., 146 Jones Hospital, case study, 194–195, 198 journey mapping, 222, 223f JSY See Janani Suraksha Yojana judgement sampling, 135, 136 Juran, Joseph, 11 “just-in-time” production systems, 144 K kaizens (continuous improvement), 6, 159, 278 kappa statistic, 258 key performance indicators (KPIs), 163 knowledge based mistakes, 256 and beliefs, about intervention, 71 and information, access to, 71 shaping, 88–89 Kotter’s change model, 47, 47b KPIs See key performance indicators L lateral linkages, 38–39 leadership, 44–45 engagement, 71 examples of, 46–47 by people at multiple levels, 322 role of, 317–318 342 Index team, 193–196 transformational, 43, 46 Lean Management Systems (LMS), 143, 157–171, 302–303 daily accountability, 169–171 leader standard work, 158–161, 159t, 160t, 161t Venn diagram model, 158f visual controls, 161–169 Lean methods, 52, 145 Lean Six Sigma (LSS), 143 defined, 144 muda, wasting resources, 144 mura, uneven process workflow, 144–145 muri, overburdening staff and equipment, 144 origin, 145–146 patient flow as application, 146–150 Physics Framework, 150–151 and VUT equation, 151–157 Lean Thinking, 145 learning climate, 71 organization, 321–323 organizational, societal, Learning Collaboratives See Quality Improvement Collaboratives learning organizations (health systems), 321–323 length of stay (LOS), 163, 166 LHDs See local health departments linkages, lateral, 38–39 LMS See Lean Management Systems local health departments (LHDs), 291–292 localized improvement efforts, long term objectives of social marketing, 227 LOS See length of stay low- and middle-income countries Quality Improvement (QI) in See Quality Improvement, in low- and middleincome countries LSS See Lean Six Sigma M Machine That Changed the World, The (book), 145 Macon County NC Health Department Case Study, 278–279 macro-level patient involvement, 206–207 macrosystems, 245–248, 247t, 248b relationship between microsystems and, 246 magic bullet, 28 Malcolm Baldrige National Quality Award, 17 managerial overhead, 38 Manitoba Coroner’s Inquest, 204 Mann, D., 157 M-APR model, patient involvement, 208–212, 210t marketing, 217–232 audience, knowledge of, 220b budgets, 229 change, improvement, distinguishing, 220–221 competition, 220b, 227–228 describing plan, 225–226 evaluation plan, 229, 230–231t exchange, concept of, 220b four Ps, 228–229 funding sources, 229 hallmarks, 219–220 implementation plan, 229–232 monitoring, 229, 230–231t objectives intermediate, 227 long term, 227 short term, 227 organizational impacts, 221–222 Plan, Do, Study, Act cycle, 223 positioning statement, 228 principles, 220b Index program evaluation, 222–224 scenario initiative, 225–232 social issue, 225–226 strategic marketing mix, 228–229 strategy and plan, 224–225 strategy of surgical safety checklist, 225–232 SWOT analysis opportunities, 226 strengths, 226 threats, 226 weaknesses, 226 targeting markets, 226–227 anesthetists, 226 cardiac perfusionist, 226 circulating nurses, 226 hospital administrator, 227 scrub nurses, 227 surgeons, 226 surgical medical equipment technicians, 226 Marketing Social Change: Changing Behavior to Promote Health, Social Development, and the Environment, 218–219 mass personalization, 22 health care applications, 22–24 material incentive behavior, 95 material reward behavior, 96 material support and recognition, 192 Matsoso, Precious, 297 McKinsey Global Institute, 14 mean, 115–117 average, 115–116 Xbar, 165 in control/process behavior chart, 115–116, 123, 165 in Xbar chart, 115–116 in XbarR chart, 165 range (R) chart, 165 in XmR chart, 116, 123 meaningful use, of certified EHR technology, 138 343 median, 116, 125, 164 in run chart, 125, 164 in XmR chart, 116 medical center service, case study, 194–195 medical equipment technicians, marketing of, 226 medical errors action vs inaction, 256 classification and, 253–367 Generic Error Modeling System (GEMS), 256f Human Factors Analysis and Classification System (HFACS), 258, 259f International Classification for Patient Safety (ICPS), 260–264, 261f knowledge-based mistakes, 256 patient safety error/event classification, 255 Patient Safety Event Taxonomy, TJC, 258–260 planning and execution, 256–257 reduction of, 253–367 rule-based mistakes, 255 skill-based errors, 255 Swiss Cheese Model, 257, 257f Systems Engineering Initiative for Patient Safety (SEIPS), 264–266, 265f using error classification for mitigation and safety improvement, 266–267 violations, 256 medical staff governance process, medication management, flowchart of, 127, 128f member and team learning, 198–199 mental rehearsal, of successful performance, 105 mental resources, 100 Mercy Hospital case study, 56–57 meso-level patient involvement, 206 MFII See Model for Improvement and Implementation micro-level patient involvement, 205–206 Microsoft’s Excel™ tool, 134 344 Index microsystems, 178, 245–248, 247t, 248b accidents, 237–238 ingredients of, 237 organizational, 238–239 engineering culture of safety, 240–241 Haddon matrix, 243–244, 244f harm in, 235–251 human error, 239 macrosystems, 245–248, 247t, 248b patient disclosure, 249–250 patient safety, 242–243b, 245, 245f, 246f, 247t performance limitations, 239 risk management, 240, 240f safety culture characteristics, 241 system resilience, 248–249 Mid-Staffordshire Hospital Inquiry, 204 MLC See Multi-State Learning Collaborative Model for Improvement, 53, 301, 301f Model for Improvement and Implementation (MFII), 54, 54f monitoring social marketing, 229, 230–231t motion, as waste, 170t motivation, 40–42 intrinsic, 40 managerial overhead, 38 and reward, 192–193 motivational factors internal motivation, 40 profound knowledge motivation, 40–41 quadruple aim motivation, 42 from triple aim to quadruple aim motivation, 41–42 Motorola, 144, 145 moving range, 116, 118, 122–124 average moving range, 122–123 XmR chart, 115–117, 122–124 muda (wasting resources), 144 multiple causation, as philosophical element, multiple teams, 190 Multi-State Learning Collaborative (MLC), 272 mura (uneven process workflow), 144–145 muri (overburdening staff and equipment), 144 N NACCHO See National Association of County and City Health Officials National Academy of Medicine, National Association of County and City Health Officials (NACCHO), 272 National Cancer Institute’s Cancer Information Service, 23 National Committee on Quality Assurance (NCQA), 5, 109 National Implementation Research Network (NIRN), 52, 57, 59, 63–64 National Network of Public Health Institutes (NNPHI), 274, 275, 275t National Public Health Improvement Initiative (NPHII), 273 National Public Health Performance Standards Program, 272 National Transportation Safety Board (NTSB), 258 natural consequences, 89–90 Natural Process Limits, 114 natural variation, 153 NCQA See National Committee on Quality Assurance near miss, 254t negative emotions, 100 networks and communications, 70 never events, 254t Nightingale, Florence, 16 NIRN See National Implementation Research Network NNPHI See National Network of Public Health Institutes “nodal governance,” 284 nonconformance, nonmaterial support and recognition, 192 nonparametic, 116 “non-sampling” errors, 136 non-response, 136–137 Index non-specific incentive, 97 non-specific reward, 96 norming stage, of team, 188 norms, 187–188 North Carolina program, 273 NPHII See National Public Health Improvement Initiative NTSB See National Transportation Safety Board nurses, marketing of, 226 O Ochsner Health System, 151 Oncology Leadership Group, 197 operational excellence leader, 147 opinion leaders, 72 organizational culture, 189–191 organizational impacts, 221–222 organizational incentives and rewards, 71 organizational learning, as philosophical element, team and, 199 Organizational Readiness to Implement Change (ORIC) instrument, 59b organization leadership, structural element, ORIC instrument See Organizational Readiness to Implement Change instrument Osler, William, 201 outcome- and value-driven process, 322 outcome goals, 84 outcome model patient involvement, 201–213 examples, 209–212, 210t factors affecting, 207 individualization of care, 205 macro-level, 206–207 M-APR model of patient involvement, 208–212, 210t measuring, 207–208 meso-level, 206 methods, 205–207 micro-level, 205–206 345 patient self-management, 205–206 rationale, 204–205 shared decision making, 205 risk management, 235–251 accidents, 237–238 characteristics of safety cultures, 241 concept application, 242–249 engineering culture of safety, 240–241 Haddon matrix, 243–244, 244f human error, 239 microsystem characteristics, patient safety and, 247t microsystems, 245–248, 247t, 248b models of, 240, 240f organizational accidents, 238–239 patient disclosure, 249–250 patient safety, 242–243b, 245, 245f, 246f social marketing, 217–232 audience, knowledge of, 220b budgets, 229 change, improvement, distinguishing, 220–221 competition, 220b, 227–228 describing plan, 225–226 evaluation plan, 229, 230–231t exchange, concept of, 220b hallmarks, 219–220 implementation plan, 229–232 journey mapping, 222, 223f monitoring, 229, 230–231t objectives, 227 organizational impacts, 221–222 Plan, Do, Study, Act cycle, 223 positioning statement, 228 principles, 220b program evaluation, 222–224 scenario initiative, 225–232 social issue, 225–226 strategy of surgical safety checklist, 225–232 SWOT analysis, 226 targeting markets, 227–228 statistical thinking, 44 346 Index strategy and plan, 224–225 SWOT analysis opportunities, 226 strengths, 226 threats, 226 weaknesses, 226 systems thinking, 44 targeting markets anesthetists, 226 cardiac perfusionist, 226 circulating nurses, 226 hospital administrator, 227 scrub nurses, 227 surgeons, 226 surgical medical equipment technicians, 226 teamwork, 44, 45–47 examples of, 46–47 outcomes comparison of, 94–95 key ingredients for achieving, 53f outer setting, 70 overcorrection, 93 overhead, managerial, 38 over-processing, as waste, 170t overproduction, as waste, 170t P paradoxical instructions, 100 parallel organization, structural element, “paramount reality of everyday existence,” 147 Pareto, Vilfredo, 131 Pareto charts, 165, 166, 167f Pareto diagram, 131–134 participation, on teams, 192 participative leadership, 194, 196 partnerships, public health organizations, 276–277 past success, focus on, 105 patient-centeredness, 24 patient flow as LSS application, 146–150 Physics Framework, 150–151 and VUT equation, 151–157 patient involvement, 201–213 examples, 209–212, 210t factors affecting, 207 individualization of care, 205 macro-level, 206–207 M-APR model of patient involvement, 208–212, 210t measuring, 207–208 meso-level, 206 methods, 205–207 micro-level, 205–206 national patient safety goals in the United States, 211 partners in health, 209 from partners to owners, 212 patients as partners program, 211–212 patient self-management, 205–206 rationale, 204–205 shared decision making, 205 patient needs and resources, 70 patient outcome, 260 Patient Protection and Affordable Care Act (ACA), 4, 33, 137, 276 patient safety improvement in, 255 microsystem characteristics, 247t safety incident, 260 Patient Safety Event Taxonomy, TJC, 258–260 Patients as Partners: Toolkit for Implementing the National Patient Safety Goal, 211–212 patient satisfaction surveys, 136–137 patterns of demand, 153 P-charts, 124 PDCA cycle See Planning, Doing, Checking, Acting cycle PDSA cycle See Plan, Do, Study, Act cycle peer pressure, 70 penetration, 56t, 62t people-centered quality, in health care, Index performance appraisals, 192 enhancement appraisals, 323 improvement, 3–4 management, 157 norms, 188 performing stage, of team, 188 personal attributes, 72 personalization, 205 in healthcare, 18–24 PHAB program See Public Health Accreditation Board program pharmacological support, 100 Pharmacy Services, 197 PHF See Public Health Foundation philosophical elements, physical environment, restructuring, 100 physician–nurse relationship, 186 pitch chart, for RCM chart reviews, 167f Plan, Do, Study, Act (PDSA) cycle, 15f, 25–28, 27f, 55, 124, 134, 223, 301–302 key features of, 25 Plan, Do, Check, Act (PDCA) cycle, 182 planning errors, 256–257 planning process, 72 POKA-YOKE process, 145 Pollard, William, 270 population health analytics, 154 Population Health Improvement Partners, 274, 275, 275t, 276 positive outcomes, 53 positive reinforcement, 96 Power of Ideas to Transform Healthcare: Engaging Staff by Building Daily Lean Management Systems (book), 157 predictability, 113 preventable adverse event, 254t Prevention and Public Health Fund of the Affordable Care Act, 273 primary medical care homes, 33 principles of social marketing, 220b probability (random) sampling, 135–136 problem solving, 82 process 347 definition of, 300 flowcharts, 126–129 improvement teams, structural element, optimization, as philosophical element, planning, 72 redesign, structural element, reengineering, process behavior, 112, 114 case study, 116–123 charts, 114–116, 124, 152 “process loss,” 188 productivity, 109, 193 professional responsibility, profound knowledge, 25 program evaluation, 222–224 project sponsor, 185 prompts/cues, 91 provider/patient communication protocols, 57 Pryor, Robert W., 157 psychological safety, 187 psychopharmacology, 179 public health, ecological model of, 314f public health accreditation, in U.S., 291–292 Public Health Accreditation Board (PHAB) program, 272, 274, 288, 291 Public Health Foundation (PHF), 274, 275, 275t public health organizations adoption and institutionalization accreditation programs, 273–274 evidence-based strategies and programs, 275–276 factors affecting, 273–278 financing, 277–278 governmental and nonprofit organizations, 274–275 innovative partnerships, 276–277 overview, 271 case study, 278–279 CQI in, 270–279 348 Index history of, 272–273 promotion, 272–273 punishment, 103, 105 Q QA See quality assurance QAHCS See Quality in Australia Health Care Study QC See quality control QI See under quality improvement QSEN approach See Quality and Safety Education for Nurses approach qTrack, 151 Quadruple Aim, 313 quality defined, 271 in health care, improvement principles, 300–301 management, problems, 180, 181 Quality and Safety Education for Nurses (QSEN) approach, 315 quality assurance (QA), 2–3, 9, 271 quality control (QC), 2–3 quality improvement (QI), 3, 10, 32–48, 52, 271 accidents, ingredients of, 237 business case, 37–38 communication, 44 customer focus, 44 factors associated with, 38–42 accreditation, 39–40 culture of excellence, 43–47 intellectual capital of workforce, 38 lateral linkages, 38–39 managerial overhead, 38 motivational factors, 40–42 regulatory agencies, 39–40 teamwork, 45–47 transformational leadership, 43, 46 feedback, 44 innovation, 34–37 Kotter’s change model, 47 leadership, 44–45 examples of, 46–47 in low- and middle-income countries, 297–307 challenges and proposed solutions, 304–307 frameworks and methods, 299–307 lean management systems, 302–303 Model for Improvement, 301, 301f other approaches to improving care delivery quality, 303–304 PDSA cycles, 301–302 Quality Improvement Collaboratives, 302 quality improvement principles, 300–301 six sigma, 303 variation in health outcomes, 297–298 microsystems, system resilience, 248–249 motivational factors internal motivation, 40 intrinsic motivation, 40 profound knowledge motivation, 40–41 quadruple aim motivation, 42 from triple aim to quadruple aim motivation, 41–42 new challenges and opportunities for, 298–299 objectives intermediate, 227 long term, 227 short term, 227 Quality Improvement Collaboratives (QICs), 302, 318–321 Quality Improvement Organizations (QIOs), 16 case study, 138 quality improvement (QI) teams in health care, 179–180 high-performance teams and, 180–181 material and nonmaterial support and recognition, 192 organizational culture, 189–191 Index performance improvement, 182–189 resources and support, 189–193 rewards and motivation, 192–193 team characteristics, 184–189 composition and size, 184–186 norms, 187–188 psychological safety, 187 relationships and status, 186–187 stages of development, 188–189 team processes communication networks and interaction patterns, 196–197 decision making, 197–198 member and team learning, 198–199 team leadership, 193–196 team tasks and goals, 182–184 quality improvement tools, 124–134 cause-and-effect diagram, 130–131 checklists, 129–130 frequency chart and Pareto diagram, 131–134 process flowcharts, 126–129 run charts, 125–126 Quality in Australia Health Care Study (QAHCS), 257 R randomized controlled clinical trials (RCTs), 325 random sampling, 135–136 rationale, for patient involvement in CQI, 204–205 RCM See revenue cycle management RCTs See randomized controlled clinical trials readiness for implementation, 71 Reason, James, 253, 255, 257 re-attribution, 89 record keeping, 184 redesign of processes, structural element, reduce prompts/cues, 92 reengineering process, 349 reflection and evaluation process, 72 regulation, 100 regulatory agencies, 39–40 rehearsal, 93 relative advantage, 69 relative priority, 71 reliability, in accreditation, 290–291 repetition and substitution, 93–94 research, future developments, 325–327 resilient groups, 248 resources and support, for team material and nonmaterial support and recognition, 192 organizational culture, 189–191 rewards and motivation, 192–193 resource utilization, 163 response cost, 103 response rates, 125–127 responsibility, by leaders and employees, 322 “responsive regulation,” 288 revenue cycle management (RCM), 166, 168 revised Boynton, Victor model, health care, 20–21, 20f rewarding completion, 104 rewards, 71, 103, 179 alternative behavior, 104 approximation, 103 frequency, 105 incompatible behavior, 104 and motivation, 192–193 outcome, 99 remove access to, 92 and threat, 95–99 Rhode Island Department of Health, 277 risk-adjusted outcome measures, risk assessment, 255 risk management, 235–251 accidents, 237–238 ingredients of, 237 characteristics of safety cultures, 241 concept application, 242–249 engineering culture of safety, 240–241 Haddon matrix, 243–244, 244f human error, 239 350 Index microsystem characteristics, patient safety and, 247t microsystems, 245–248, 247t, 248b system resilience, 248–249 models of, 240, 240f organizational accidents, 238–239 patient disclosure, 249–250 patient safety, 242–243b, 245, 245f, 246f performance limitations, 239 strategy, 235 Robert Wood Johnson Foundation (RWJF), 272 Culture of Health, 277 “robust” (forgiving) design, 13 Roos, Daniel, 145 R programming language, 124 rule-based mistakes, 255 run charts, 125–126, 152, 168–169, 168f RWJF See Robert Wood Johnson Foundation S Safe Childbirth Checklist (SCC), 303 safety accidents, ingredients of, 237 journey mapping, 222, 223f microsystems, system resilience, 248–249 objectives intermediate, 227 long term, 227 short term, 227 organizational impacts, 221–222 patient, 235–251 patient involvement, 201–213 examples, 209–212, 210t factors affecting, 207 individualization of care, 205 macro-level, 206–207 M-APR model of patient involvement, 208–212, 210t measuring, 207–208 meso-level, 206 methods, 205–207 micro-level, 205–206 patient self-management, 205–206 rationale, 204–205 shared decision making, 205 program evaluation, 222–224 quality in health care, risk management, 235–251 accidents, 237–238 characteristics of safety cultures, 241 concept application, 242–249 engineering culture of safety, 240–241 Haddon matrix, 243–244, 244f human error, 239 microsystem characteristics, patient safety and, 247t microsystems, 245–248, 247t, 248b models of, 240, 240f organizational accidents, 238–239 patient disclosure, 249–250 patient safety, 242–243b, 245, 245f, 246f scenario initiative, 225–232 social marketing, 217–232 audience, knowledge of, 220b budgets, 229 change, improvement, distinguishing, 220–221 competition, 220b, 227–228 describing plan, 225–226 evaluation plan, 229, 230–231t exchange, concept of, 220b four Ps, 228–229 hallmarks, 219–220 implementation plan, 229–232 monitoring, 229, 230–231t objectives, 227 Plan, Do, Study, Act cycle, 223 positioning statement, 228 principles, 220b social issue, 225–226 strategic marketing mix, 228–229 strategy and plan, 224–225 SWOT analysis, 226 targeting markets, 226–227 strategy of surgical safety checklist, 225–232 SWOT analysis Index opportunities, 226 strengths, 226 threats, 226 weaknesses, 226 targeting markets anesthetists, 226 cardiac perfusionist, 226 circulating nurses, 226 hospital administrator, 227 scrub nurses, 227 surgeons, 226 surgical medical equipment technicians, 226 safety culture, 43 characteristics of, 241 sampling, 135–137 judgement, 135–136 random (probability), 135 satiation, 92 satisfaction surveys, patient, 135 Baptist hospital, 135 Press Ganey, 135 HCAHPS, 137 scaffolding, 185 SCC See Safe Childbirth Checklist scenario initiative, 225–232 SCF See Southcentral Foundation scheduled consequences, 103–105 scrub nurses, marketing of, 227 SDS See State Donor Services secondary data, 137–139 sectors of health care, evolution across, 16–17 SEIPS See Systems Engineering Initiative for Patient Safety self-belief, 105 self-efficacy, 71 self-incentive, 98 self-management, 205–206 self-monitoring, 86, 87 self-respect, 248 self-reward, 98–99 self-talk, 105 Senge, Peter, 198, 321 sentinel events, 254t shared decision making, 205 351 Shewhart, W.A., 114 Shewhart cycle See PDSA cycle, 15, 15f, 25–27, 223 Shipman inquiry, 204 short-term objectives of social marketing, 227 SIPOC diagrams See Suppliers, Inputs, Process steps, Outputs, Customers diagrams situation-specific reward, 104 Six Sigma See also Lean Six Sigma DMAIC process, 52, 52f QI paradigm, 303 skill-based errors, 255 skill-, rule-, and knowledge-based information processing, 255 social and environmental consequences, 90 social comparison, 91 social environment, restructuring, 101 social incentive, 97 social marketing, 217–232 audience, knowledge of, 220b budgets, 229 change, improvement, distinguishing, 220–221 competition, 220b, 227–228 describing plan, 225–226 evaluation, 229, 230–231t evaluation plan, 229, 230–231t exchange, concept of, 220b four Ps, 228–229 funding sources, 229 hallmarks, 219–220 implementation plan, 229–232 journey mapping, 222, 223f monitoring, 229, 230–231t objectives intermediate, 227 long term, 227 short term, 227 organizational impacts, 221–222 Plan, Do, Study, Act cycle, 223 positioning statement, 228 principles, 220b program evaluation, 222–224 scenario initiative, 225–232 352 Index social issue, 225–226 strategic marketing mix, 228–229 strategy and plan, 224–225 strategy of surgical safety checklist, 225–232 SWOT analysis opportunities, 226 strengths, 226 threats, 226 weaknesses, 226 targeting markets, 226–227 anesthetists, 226 cardiac perfusionist, 226 circulating nurses, 226 hospital administrator, 227 scrub nurses, 227 surgeons, 226 surgical medical equipment technicians, 226 social reward, 96–97 social support, 87–88 emotional, 88 performing behavior, 88 practical, 88 unspecified, 87 societal learning, solution identification, as philosophical element, SOPs See standard operating procedures Southcentral Foundation (SCF), 212 special cause variation, 7, 152 SQUIRE guidelines See Standards for QUality Improvement Reporting Excellence guidelines staff suggestions, 169, 169f standardization, of activities, 153–154 standard operating procedures (SOPs), 127 Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines for documenting QI projects, 305, 325 State Donor Services (SDS), 175 case study, 176–177 state regulatory agency case study, 190, 192 State University Hospital (SUH), 175 statistical analysis, structural element, statistical process control, 112 Steering Committee, 272 storming stage, of team, 188 strategic focus, as philosophical element, Strategic Governance Council, 198 strategic marketing mix, social marketing, 228–229 strategies, in social marketing, 224–232 strategy and plan, 224–225 strategy of surgical safety checklist scenario initiative, 225–232 structural characteristics, 70 subject matter expert, 185 SUH See State University Hospital supervisors/managers, 159 Suppliers, Inputs, Process steps, Outputs, Customers (SIPOC) diagrams, 124 support system, 64, 67t surgeons, marketing of, 226 surgical medical equipment technicians, marketing of, 226 surveyor reliability, 290–291 sustainability, 56t, 62t Swiss Cheese Model, 257, 257f SWOT analysis, 226 synthesis and translation system, 64, 67t system focus, 6–7 Systems Engineering Initiative for Patient Safety (SEIPS), 264–266 model 2.0, 265f systems thinking, 44 systems view, as philosophical element, T Taguchi, Genichi, 11–13 takt time, 163 Taleb, Nassim Nicholas, 240 targeting markets, in social marketing, 226–227 anesthetists, 226 cardiac perfusionist, 226 circulating nurses, 226 hospital administrator, 227 Index scrub nurses, 227 surgeons, 226 surgical medical equipment technicians, 226 TCS strategy See Total Customer Satisfaction strategy teaming, 185 teams See also quality improvement teams concepts, 178 in health care, 179–180 oriented organizations, 192 teamwork, 45–47, 175, 318 technical expertise, 185 tension for change, 70 time, 156–157 buffers, 154 quality in health care, TJC See The Joint Commission To Err Is Human report, 17, 33–34, 204, 253 Toffler, Alvin, 32 tools, continuous quality improvement, Total Customer Satisfaction (TCS) strategy, 145 total quality management (TQM), 3, 10–11 Toussaint, John, 143 Toyota Production System (TPS), 155, 158 TPS See Toyota Production System TQM See total quality management training matrix, 168, 168f transformation, 150 transformational leadership, 43, 46 transformational models, for organizational performance, 321t transportation, as waste, 170t trend chart, 170f triage, 156 trialability, 69 Triple Aim of Health Care, 147 trust, 248 Tukey, John, 149 Turning Point initiative, 272 353 U understanding causes of variation, 112–116, 152–153 common causes of variation, 113–115, 152–153 control/process behavior charts, 114–124, 152–153, 165 special causes of variation, 113–115, 152–153 United States (U.S.) Department of Health and Human Services (DHHS), 273, 278 public health organizations, CQI in, 270–279 unnecessary variability, usable interventions, 59 utilization, 154–155 V value, 301 value-added health care, 323–325 value chain mapping, 303 value stream, 147, 155f valued self-identity, 103 variation and actions for improvement, 114 common causes of, 113 critical role of understanding, 112 patient flow, 152–154 reasons for studying, 113 special causes of, 113 verbal persuasion, about capability, 105 vicarious consequences, 106 violations, 256 Virginia Mason, 155 visual controls, LMS, 158, 161–169 VUT equation patient flow and, 151–157, 152b time, 156–157 utilization, 154–155 variation, 152–154 354 Index classification challenges, 262–263t International Classification for Patient Safety (ICPS), 260–264, 261f W Wall Street Journal, The, 52 waste, the definition of, 144–146 See Lean Six Sigma (LSS) waste walk tool, 170t weaknes ses, in social marketing plans, 226 Western North Carolina (WNC) Healthy Impact, 276 Wheeler, Donald, 116–117, 122–123 WHO See World Health Organization W K Kellogg Foundation, 272 Womack, James, 145 workforce, intellectual capital of, 38 World Alliance for Patient Safety, 260 World Health Organization (WHO) X X-bar charts, 115, 124 XbarR charts, 165, 165f XmR charts, 115, 116 average moving range, 122–123 clinical preparation time case study, 116–123 scaling factors for LCL and UCL computation, 116, 118, 123 mean in XmR chart, 115–116 median in XmR chart, 116 ... ALMAGAMI/Shutterstock Acknowledgments As we developed the fifth edition of Continuous Quality Improvement in Health Care, we were inspired once again by Drs McLaughlin and Kaluzny While we are very appreciative... Improvement in Health Care was published in 1994 Continuous quality improvement in health care was in its infancy Paul Batalden had kindly educated us, and others, on his philosophy and groundbreaking.. .McLaughlin and Kaluzny’s Continuous Quality Improvement in Health Care FIFTH EDITION Julie K Johnson, PhD, MSPH Professor, Department of Surgery Center for Healthcare Studies Institute