NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

The Health Systems and Organizational Leadership online program prepares nurses for roles in a variety of organizational settings from acute care, to primary care, and community care. Skills gained will allow nurses to lead in formal executive and front-line positions, quality improvement, project management, or other positions where systems-level management and leadership is needed. Nurses will learn about complex dynamic healthcare delivery systems, creating sustainable organizations, how to leverage the legislative and regulatory environment, and steward financial and human resources through effective care delivery models. Complexity and Quality science are central program foci. As a program we are very committed to inter professional education and practice and seek opportunities for our students to experience this rich environment.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

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Evolving Role of Transitional Leadership in Healthcare

Transforming Quality and Safety Across the Organization
When most nurses enter nursing school, their primary focus is to understand how to care for and respond to the needs of patients, organize a plan of care, and provide ongoing assessment and evaluations of their care. Most do not think of becoming a leader, transforming teams and leading change across a complex system. While there are leadership courses in most nursing school curricula, they do not adequately address the realities of the complexities of the healthcare system, idiosyncrasies of health policy as it unfolds in the clinical setting, or challenges of technology. On top of that, most nurses are concentrating on the clinical arena, understanding psychophysiology, the patient response to illness, and juggling the ever-changing world of pharmacology. They are not ready for the challenges posed by these dynamic organizational systems. This leaves the organizations with the task of educating and grooming future nurse leaders.

While the role of nurse leaders is important, healthcare experts encourage all members of the inter professional team to understand organizational dynamics to enable better integration and implementation of change to improve outcomes. Research and evidence-based practice continue to identify the importance of collaborative and diverse teams. Nurse leaders are well positioned in the organization to lead and partner with other members of the inter professional team.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

Strategies that dynamic and respected nurse leaders use must be creative and innovative. Some key strategies are to be visible on the clinical units, communicate effectively the importance of a patient-eccentric environment, and share their vision for excellence. They should also engage in active and visible partnerships with physician colleagues. This partnership should start at the CNO/CMO level and continue to the individual unit level. This model has been successful at the University of Pennsylvania Health System. Most units use a partnership entitled Unit-Based Clinical Leadership (UBCL) teams that consist of physician, nurse, and quality experts as team leaders for a diverse and dynamic inter professional team (Figure 1). Some of the projects they have undertaken include: reducing the left-without-being-seen (LWBS) rate in the emergency department; multidisciplinary rounding; discharge education; and patient- and family-centered care. These projects align with the University of Pennsylvania Health System Blueprint for Quality and Patient Safety.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

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Nurse leadership and patient safety

Most health care organizations are still striving to attain high reliability—the ability to minimize adverse events while consistently providing high-quality care in the context of a rapidly changing environment. Workers at the sharp end are best positioned to identify hazardous situations and address system flaws. Although the concept of leadership has traditionally been used to refer to the top rungs of an organization, front line workers and their immediate supervisors play a crucial leadership role in acting as change agents and promoting patient-centered care. As the safety field has evolved, there is a growing recognition of the role that organizational leadership plays in prioritizing safety, through actions such as establishing a culture of safety, responding to patient and staff concerns, supporting efforts to improve safety, and monitoring progress. Research using a variety of methodologies has defined the relationship between leadership actions and patient safety and has begun to elucidate key organizational behaviors and structures that can promote (and hinder) safety efforts.

This Patient Safety Primer will discuss the role of organizational leadership in improving patient safety. The crucial roles that front line and mid-level providers play in improving safety are discussed in the related Safety Culture and High Reliability Patient Safety Primers.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

The Historical Role of Hospital Leadership in Quality and Safety Activities

All hospitals are overseen by a board of directors, whose responsibilities include (but are not limited to) formulating the organizational mission and key goals, ensuring financial viability, monitoring and evaluating the performance of high-level hospital executives, making sure the organization meets the needs of the community it serves, and ensuring the quality and safety of care provided by the organization. However, hospital boards have traditionally had relatively little direct engagement in evaluating and improving quality and safety. As a 2010 review article explains, board members historically have been community leaders with little to no health care experience, often lacking the knowledge to interpret complex data on the quality and safety of care. Boards also had limited ability to address quality issues that lived within the domain of practicing physicians, given that most physicians are not directly employed by the hospital.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

Surprising as it may seem, despite being accountable for the quality and safety of care being provided in their organizations, until recently board, executive, and medical staff leadership at most hospitals in the United States placed relatively little emphasis on identifying and addressing safety issues. A 2010 survey of more than 700 hospital board chairs found that only a minority considered improving the quality of care to be one of the board's top two priorities, and very few board chairs had any direct training in quality or safety. This situation is changing, driven by data on the influence of leadership engagement, as well as greater emphasis on quality and safety in general. Today, we are seeing a shift toward more direct oversight of quality and safety at the organizational level.

How Leadership Can Influence Patient Safety

An emerging body of data now demonstrates a clear association between board activities and hospital performance on quality and safety metrics. A 2013 review found that high-performing hospitals—defined as those ranking highly on objective measures of quality and safety—tended to have board members who were more skilled in quality and safety issues and who devoted more time to discussion of quality and safety during board meetings. Insight into how boards can positively influence quality was provided by a recent study of hospitals in the US and England, which found that boards of high-quality hospitals used more effective management practices to monitor and improve quality. These practices include structured use of data to enhance care, both by setting specific quality goals and regularly monitoring performance dashboards. They also included explicitly using quality and safety performance in the evaluation of high-level executives and focusing on improving hospital operations. Examples of organizations that have transformed their practices and organizational culture to emphasize patient safety include the Dana-Faber Cancer Institute, which responded to a serious and widely publicized preventable death by ingraining patient safety into the responsibilities of clinical and organizational leadership and emphasizing transparency with patients and families, and Peace Health, which created a governance board overseeing all safety and quality activities across the system and tied executive compensation to specific quality and safety goals.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

Hospital boards influence quality and safety largely through strategic initiatives, but data also shows that executives and management can improve safety through more direct interactions with front line workers. Leadership walk rounds—visits by management to clinical units in order to engage in frank discussion around safety concerns—can positively impact safety culture. Although walk rounds are widely used and recommended as a safety intervention, recent research indicates that relatively small differences in the way walk rounds are conducted can markedly enhance or limit their effectiveness. For example, issues raised by front line staff during walk rounds must be promptly addressed, lest staff view the rounds as simply a visibility exercise for leadership. Similarly, voluntary error reporting systems often lack credibility among front line staff due to insufficient follow up after an error is reported. By engaging with those who take the time to report errors and devoting time and resources to structured follow through, hospital leadership can both address specific safety issues and tangibly illustrate the importance of patient safety as an organizational priority.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

An important area in which hospital leadership can directly address safety concerns is through managing disruptive and unprofessional behavior by clinicians. As boards have oversight over the medical staff, they have the ability to ensure unprofessional or incompetent clinicians do not put patients at risk. Although there is limited evidence regarding specific strategies leadership can use to prevent disruptive behavior, some organizations have developed a structured approach that emphasizes early intervention by hospital leadership for clinicians who display recurrent unprofessional behavior or are the subject of multiple patient complaints.

Current Context

The Joint Commission issued a 2009 sentinel event alert highlighting the importance of leadership engagement in improving patient safety. The alert called for organizational leaders to take specific actions to enhance safety within their institutions, including improving the culture of safety and establishing a just culture for addressing errors. The Joint Commission also strongly recommended strengthening hospital boards and patient engagement in safety efforts and making safety performance an explicit part of how leadership is evaluated. The Joint Commission evaluates adherence to the recommendations in sentinel event alerts during the accreditation process.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

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The essential role of leadership in developing a safety culture In any health care organization, leadership’s first priority is to be accountable for effective care while protecting the safety of patients, employees, and visitors. Competent and thoughtful leaders* contribute to improvements in safety and organizational culture.1,2 They understand that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes.3-5 James Reason compared these flaws – latent hazards and weaknesses – to holes in Swiss cheese. These latent hazards and weaknesses must be identified and solutions found to prevent errors from reaching the patient and causing harm.6 Examples of latent hazards and weaknesses include poor design, lack of supervision, and manufacturing or maintenance defects. The Joint Commission’s Sentinel Event Database reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events – from wrong site surgery to delays in treatment.7In addition, through the results of its safety initiatives, The Joint Commission Center for Transforming Healthcare has found inadequate safety culture to be a significant contributing factor to adverse outcomes.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study Inadequate leadership can contribute to adverse events in various ways, including but not limited to these examples:  Insufficient support of patient safety event reporting8 Lack of feedback or response to staff and others who report safety vulnerabilities8 Allowing intimidation of staff who report events9 Refusing to consistently prioritize and implement safety recommendations  Not addressing staff burnout10,11In essence, a leader who is committed to prioritizing and making patient safety visible through every day actions is a critical part of creating a true culture of safety.12 Leaders must commit to creating and maintaining a culture of safety; this commitment is just as critical as the time and resources devoted to revenue and financial stability, system integration, and productivity. Maintaining a safety culture requires leaders to consistently and visibly support and promote everyday safety measures.13 Culture is a product of what is done on a consistent daily basis. Hospital team members measure an organization’s commitment to culture by what leaders do, rather than what they say should be done

Essential Skills of a Healthcare Quality Improvement Leader

1. Setting a vision and goals. "Leaders need to understand the importance of setting a common vision and cluster of goals that all key stakeholders can embrace — and be held accountable for," she says.

2. Communicating strategically for commitment. Once quality improvement leaders establish a vision, they need to communicate the vision to physicians and staff to gain buy-in. "Leaders need to frame the need for change in language that appeals to the values of the organization," Ms. Kliger says. For example, leaders at hospitals should discuss the initiative's potential benefit to patient care to appeal to physicians and other clinicians. While there may be an economic benefit, focusing on how it supports the organization's mission may be a more effective persuader, according to Ms. Kliger.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

3. Creating an environment that encourages constructive accountability and constructive conflict. Constructive accountability is shared aims that define success, uniting disparate groups under a common goal. "In order to achieve excellence, which is a combination of reliability and performing against established evidence, you need to have individual providers understand how they are linked and aligned to the larger organization's mission, goals and outcomes," Ms. Kliger says. A physician alignment model is important but in itself is not sufficient for creating constructive accountability. Clearly articulated job descriptions or obligations (for non-employed physicians) and incentives and disincentives are tools leaders can use to tie individuals to the organization's broader goals.

In contrast with constructive accountability, constructive conflict is a process in which two or more people or groups discuss their needs and differences of opinion and eventually develop a solution. "In general, we don't have a culture of feeling comfortable discussing opportunities for improvement, especially when it comes to the way relationships can be managed," Ms. Kliger says. "The more we normalize the idea that we can have respectful conversations about different opinions, we can come to a shared understanding of how to tackle common problems."NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

4. Removing barriers to success. Leaders must seek opportunities to remove barriers to success and provide physicians with tools necessary to achieve goals. For example, leaders of a hand hygiene initiative should ensure there are sufficient and staff-approved alcohol sanitizers, soap and other necessary products.

5. Coaching (versus telling). Leaders' purpose is not to do the change all themselves, but to inspire and empower others to enact a change. To effectively motivate others to improve quality, give front-line workers the authority to implement new processes. "When front-line physicians and nurses are nurtured to think for themselves and build their skills at bringing about change (e.g., [Plan, Do, Study, Act] cycles of learning), leaders multiply their ability to create change," Ms. Kliger says.

6. Celebrating success and failures. Realize that celebrating failure is just as important, and often more so, than celebrating success, Ms. Kliger suggests. "Celebrating and embracing failures lets others within the organization know they can seek the best ways to improve care, even if every effort does not work out," she says. "Being able to creatively try new approaches to care delivery must live within a culture that normalizes 'failures.'"

Normalizing failure is at the core of small tests of change, such as PDSA cycles. Quality improvement leaders need to acknowledge and communicate to their teams that failure is not just acceptable, but that it is inevitable and even valuable for teaching lessons about people and processes. "It's [useful] to understand what works and what didn't, because the organization documents what doesn't work so it doesn't waste time in the future," Ms. Kliger says.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

7. Earn the trust. Quality improvement leaders need to earn the trust of physicians and staff members to create a strong relationship that will withstand the trials and triumphs of improvement efforts.

8. Working from self-awareness. "Successful leaders develop emotional intelligence and are aware of how their words and actions empower or disable others," Ms. Kliger says.

9. Working with and through others. Successful quality improvement requires routine collaboration among leaders and front-line workers. Taking a team approach to improvement brings multiple perspectives that can help spark creative solutions.

Leadership is a critical component for any organization seeking to drive improvements in health care quality and patient safety. More than ever, leaders are facing new and different challenges that require new ideas, behaviors, and actions. The Leadership Track at this year's National Forum engages leaders at all levels in driving results within health and health care. Specific topics include:NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

Key Characteristics of Successful Leaders

What Makes a Good Leader?
Most often, organizations searching for a new leader are looking for someone to drive change rather than maintain the status quo, suggesting that the current strategies aren’t meeting the organization’s goals. A new leader is often tasked with revising the organization’s goals and proposing the best strategies, such as Lean thinking, to achieve them. Ultimately, redefining an organization’s mission and vision requires an organization to change the way it functions.

Driving change in an organization is not easy. The concept of doing something different does not appeal to many people because it is hard work. A strong leader is able to communicate effectively to employees why the hard work is necessary and reassure them that they will be supported on the journey.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study
Searching for a new executive involves more than focusing on resumes and credentials. The focus should also be placed on looking at the qualities potential executives possess and how their business philosophies and leadership style will work within an organization. It’s most important to gauge if the candidate will be able to help lead change. Characteristics that will help leaders successfully guide an organization through a Lean transformation include the ability to:

• Develop and communicate the vision.
• Hold people accountable.
• Create a culture of continuous improvement.
• Foster learning and mentoring across the organization, starting with themselves.

Develop and Communicate the Vision
Given the challenges of healthcare, it is important to find innovative leaders who have a clear vision for the future. These people are not stuck in the paradigms of today, but rather see the path for tomorrow.

In order to effectively sell the vision, leaders must have strong communication skills. They must be able to identify key messages that will resonate with each important audience and convey that important message with authority and confidence to the board of directors, shareholders, and community leaders. They must also convey the message to their partners, stakeholders, and customers, and they must communicate the message to all the people within the organization.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

“As with any initiative, a leader needs to create the vision of where the organization needs to go,” says Dr. Patricia Gabow, former CEO of Denver Health. “The vision must be noble and a stretch. If it is not, the leader will look behind and see no one following.”   

Hold People Accountable
Holding people accountable begins with holding oneself accountable. Mistakes can and will happen, and when they do, there is an opportunity for true learning to occur. In order to capitalize on these pivotal moments that foster and lead to growth, employees must be taught to see mistakes as opportunities instead of failures.

The first step begins with making sure the proper people are put in place. Leaders cannot move the organization forward with staff members talking constantly about the good old days. That rhetoric is counterproductive, as past success does not guarantee anything for the future.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

Second, leaders must have clear and measurable goals at all levels. Whether using strategy deployment, a systematic strategic planning methodology for defining breakthrough objectives, or another methodology to drive strategy and deliver on goals and objectives, a good leader must help people understand what success looks like.

Third, with the vision as a foundation, and clear measurable goals communicated to all levels, leaders must establish the values and supporting behaviors that will be required to create a culture of continuous improvement and learning. These behaviors, often described as core competencies, should be embedded into the organization’s training and human resources materials. From the employer branding statement to orientation, talent development and performance management, these core competencies must be reinforced and evaluated. Employees must know that it is no longer “just about results,” but equally necessary to exhibit the required behaviors, such as teamwork and knowledge sharing, in order to be successful.

Holding employees accountable is not done with an iron fist; it’s done through communicating expectations clearly, setting local goals collectively, and making sure people live up to the commitments they have made to their job and the organization. For example, during a Lean transformation, roles and responsibilities at all levels will change as a result of process improvements. Employees will have an opportunity to provide input and design these changes through their participation on event teams. It is critical that all impacted employees understand the changes through frequent communications and open forums during which they can voice concerns and seek clarification. NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

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Changing behaviors and learning new skills requires time, practice, and feedback. Leaders and managers must be willing to provide feedback and coaching to reinforce the new behaviors as well as address unacceptable behaviors aligned to the old culture. Employees should be actively involved in setting goals specific to their area of influence, thereby creating buy-in and ownership of the results.  

Create a Culture of Continuous Improvement
Leaders must have a passion for continuous improvement. Given the ever changing healthcare landscape, organizations must improve each day or they will not be in business. The level of transparency will continue to increase in healthcare, giving patients and families more knowledge about which provider to select.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

One way to motivate executives and staff is by sharing data and further demonstrating that change is working. Leaders, too, must be data-driven. They must strive for perfection. They must foster a culture that candidly admits imperfections. Historically, healthcare has done a good job measuring how well they are doing on certain metrics. However, high-performing organizations also measure what they are not doing well. They analyze every type of error and are relentless in finding the root cause to problems and improving quality every hour, every day. With the ultimate goal to achieve perfection, improving processes and outcomes becomes the cultural norm.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

Through Lean, new leaders have the tools to encourage formal continuous improvement strategies that involve staff and members of the medical team and allow everyone to operate at the top of their license. For example, Theda Care Health System in Appleton, Wisconsin, worked with Simpler to develop a Collaborative Care Unit where caregivers are empowered to coordinate the delivery of treatment plans to patients. By developing a new treatment plan where a nurse, pharmacist, and physician meet with the patient as a team within 90 minutes following admission, and redesigning the unit to reduce the amount of paperwork and steps to find supplies, Theda Care was able to dramatically reduce the amount of time caregivers spend on administrative tasks and increase the time they spend on patient care. Through this process, Theda Care has experienced a 25% reduction in total cost of care, and patient and nursing satisfaction is ranked at 100%. In addition, they have not had a medication error in more than three years.

It’s not enough to say you do continuous improvement. You must have a formal, systematic approach to improvement. It should be part of an overall business system that drives financial, operational, and cultural performance. NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

Foster Learning and Mentoring Across the Organization, Starting with Themselves
Leaders must have a drive for continuing to develop their own skill sets as well as fostering a culture that provides opportunities for employees to do the same. Being a visionary doesn’t mean you must have all the answers. Effective leaders understand this and consult with others to contribute to the overall success of the business. I’ve learned from many great teachers. They all helped me to learn and allowed me opportunities to fail. We know we learn from our mistakes, but it’s what we do when they occur that makes us great.

Leaders must first learn to be good students. They must be willing to learn new ideas that will advance the organization and ensure its long-term success. Humility is sometimes looked at as soft, but strong leaders are willing to admit they don’t have every answer and will publicly admit their mistakes.
Mentoring is a leader’s most important skill; it is the ability to develop other leaders. A leader can’t expect people automatically to know everything expected of them. A leader must be willing to spend time with the staff and coach them.

“Since the inception of our Lean journey, we have encouraged our senior leaders to alter their allocation of time to ensure they spend enough time to observe and participate in performance improvement activities throughout the practice,” said Dr. Gene Lindsey, CEO of Atrius Health and Harvard Vanguard. “By ‘going to the gemba’ and personally getting involved with those who do the work, we strengthen our ability to make breakthroughs and improvements.”NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

To achieve sustainable change, quality improvement initiatives must become the new way of working rather than something added on to routine clinical care. However, most organizational change is not maintained. In this next article in this Moving Points in Nephrology feature on quality improvement, we provide health care professionals with strategies to sustain and support quality improvement. Threats to sustainability may be identified both at the beginning of a project and when it is ready for implementation. The National Health Service Sustainability Model is reviewed as one example to help identify issues that affect long-term success of quality improvement projects. Tools to help sustain improvement include process control boards, performance boards, standard work, and improvement huddles. Process control and performance boards are methods to communicate improvement results to staff and leadership. Standard work is a written or visual outline of current best practices for a task and provides a framework to ensure that changes that have improved patient care are consistently and reliably applied to every patient encounter. Improvement huddles are short, regular meetings among staff to anticipate problems, review performance, and support a culture of improvement. Many of these tools rely on principles of visual management, which are systems transparent and simple so that every staff member can rapidly distinguish normal from abnormal working conditions. Even when quality improvement methods are properly applied, the success of a project still depends on contextual factors. Context refers to aspects of the local setting in which the project operates. Context affects resources, leadership support, data infrastructure, team motivation, and team performance. For these reasons, the same project may thrive in a supportive context and fail in a different context. To demonstrate the practical applications of these quality improvement principles, these principles are applied to a hypothetical quality improvement initiative that aims to promote home dialysis (home hemodialysis and peritoneal dialysis).NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

Health Care Quality Improvement

Clarifying Health Care Quality Improvement

Care giving organizations enhance service quality via steady, continuous tasks that produce measurable improvements. [2] They measure their success according to patient and population outcomes and satisfaction produced by current procedures. Organizations continuously change their policies and procedures to improve performance using varying practices, with most employing four core concepts, which are:

• Data analysis
• Ongoing quality improvement processes
• Patient centered care giving
• Teamwork

Organizations vary in size, from small local clinics to national care provider networks. Quality improvement initiatives work best when geared toward an individual organization’s resources, procedures and current services. Clearly understanding current policies and procedures makes it easier for organizations to identify improvement opportunities. Consequently, health care enterprises evaluate resources in tandem with procedures to accurately measure performance.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

Improving Quality in a Complex Environment

Care giving organizations use process mapping to outline their practice and processes. The map visually represents organizational service sequences and processes, while revealing possible improvement opportunities.
Organizations optimize their clinical practices using process maps to achieve positive outcomes called critical pathways. Similar to process mapping, the care providers create critical pathway maps for each organizational service.
Together, the process and critical pathway maps along with medical field best practices help care providers improve organizational performance. The tools help care providers meet patients’ needs and expectations, such as:NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

• Cultural sensitivity
• Evidenced based service delivery
• Information accessibility
• Patient engagement
• Safety
• Service coordination

Successful health care quality initiatives serve as an outline for other organizations, which use this information to improve critical pathways. By comparing the maps to best practices throughout the medical field, organizations discover improvement opportunities.

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Improving Quality Through Teamwork

Quality improvement is a team effort. Health care leaders harness the combined knowledge, skills and perspectives possessed by individual team members, a talent critical to implementing successful changes for complex services and processes. By gathering the team’s collaborative input, leaders access foreseeable issues and viewpoints regarding a specific process or discipline. Additionally, a fully invested and supportive team nurtures a common, creative mindset and resourceful thinking.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

This environment naturally solicits active contributions from the entire care giving team, with each contribution originating from a distinct perspective. This team approach leads to a synergistic effort among staff members. Health care leaders also implement a formalized quality improvement infrastructure, which supports team members with guidance and resources. This practice keeps team member efforts aligned with organizational priorities and objectives.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

A Foundation Built on Data

Empirical data clarifies real issues and increases improvement productivity, while eliminating waste caused by misdirected initiatives. This information establishes an organization’s current performance as well as a reference point for improvement. The metric also allows organizational leaders to measure and compare quality improvement initiative performance and make sure team members sustain enhanced service levels. Among large organizations, empirical data helps leaders duplicate quality improvement initiatives across business units and geographical branches.

What Quality Improvement Means to Care Providers

Quality improvement initiatives help organizations increase community welfare as well as patient satisfaction and outcomes. [3] Large providers typically focus on improving organizational performance and primary care safety. Many organizations implement a primary care medical home (PCMH) framework to meet this objective. Quality improvement is central to the PCMH service delivery model. However, each PCMH pursues initiatives relative to their needs, which may include activities such as:NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

• Diabetes management
• Patient identification
• Patient monitoring
• Preventative service delivery

While health care organizations increasingly institute PCMH frameworks, they seek new talent skilled at managing ongoing quality improvement initiatives. For these initiatives, care providers are hiring executive talent to manage tasks such as:

• Data analysis and exploitation
• Identifying improvement opportunities
• Long term performance tracking
• Planning and implementation

Using external and internal information, health care executives educate and train organizational members. The executives also meet with consultants to discuss emerging best practices, utilize data analysis to compare organizational performance to professional peers and identify improvement and employee coaching opportunities. The health care executives deliver the coaching continually through regular training, organizational meetings and digital learning resources, such as Sermo, Doximity and Orthomind.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

Forces Supporting Health Care Quality Improvement

Patient satisfaction is an increasingly important metric. [4] The measurement helps organizations meet the new standards mandated by universal health care reform, which encourages improved performance with financial rewards. Additionally, a more informed public demands improvements in health care service delivery.

Combined influences have moved health care service quality to the administrative forefront. The Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey provides organizations with detailed patient experience feedback. Health care organizations exploiting the resource foster a work atmosphere focused on quality improvement. The survey identifies organizational strengths and weaknesses, which leaders use to develop service quality improvement strategies.

The Centers for Medicare and Medicaid Services (CMS) uses a revised CAHPS survey to measure service quality. The service publishes the survey results online for public review with correlating “star ratings.” The National Committee for Quality Assurance (NCQA) requires health care providers to submit CAHPS survey results to receive accreditation and insurer reimbursements. Many states require care providers to collect and report CAHPS survey results for reimbursement through the Children’s Health Insurance Program (CHIP).NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

The government requires insurers participating in the new Health Insurance Marketplace to poll clients with another CAHPS iteration called the Quality Health Plan (QHP) survey. In the near future, the Health Insurance Marketplace will publish QHP survey results on its website and incorporate the findings with the CMS star rating system. Other new concepts, such as accountable care organizations (ACOs), also rely on the CAHPS to determine their remuneration shares.

The CMS also manages the Physician Quality Reporting System (PQRP), which builds on the results gathered from CAHPS surveys. Eventually, legislation requires all primary care providers employing more than two practicing physicians to collect and report PQRP survey results from patients.

Beginning in 2017, The CMS will publish the results on the Physician Compare Website and adjust care provider payments accordingly. In 2019, to qualify for disbursement under new payment models physicians must submit survey results similar to the CAHPS survey. These models include merit based payment incentive systems (MIPSs) and alternative payment models (APMs). The CMS is still developing the outline for the new models as stipulated by the Medicare Access and CHIP Re authorization Act (MACRA).

Financial analysts predict that the global health care information technology market will grow from $7.4 to almost $25 billion, a more than threefold between 2016 and 2021 due to legislation and big data innovation. [5] During this period, they also predict that the United States will experience more growth than any other nation and simultaneously improve health care service quality at reduced costs. Patients, legislators and insurers support the sweeping reforms engineered to improve health care quality in the United States. This growth and spending suggests that hospitals and physicians will aggressively seek talented professionals as guides through America’s latest health care revolution.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

Skills Required for Real Outcomes Improvement

1. Communication

Communication is the number one skill required of anyone who works in process improvement. You must learn to articulate ideas and concepts verbally, in writing, and by listening. So much of what leads to success in this arena is the ability to listen very well, hear what’s happening, and combine that with what the data reveal. This tends to create better solutions because the people working on the process every day typically understand the problem and many times know the answer. By asking them to participate, you glean their knowledge. Often simply by listening and asking open-ended questions, you help the team work out a solution for themselves. Sometimes, you are just there to provide the wherewithal for approval.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

Communication is typically defined to include articulation, verbalization, coaching, and cheer leading. But the more interesting point is the consistency of letting people know what’s going on all the time, or at least as much as possible. This is what starts to build trust.

2. Trust Building

Process improvement leaders ask teams to change, whether big or small, to do something different from what they’ve always done before. Build and share the vision for where the team is going, articulate and communicate it, and eventually build to where the team trusts that the outcome will be better than where they are today. They need to trust the leader, think of you as part of the team, and know you have their back.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

3. Coaching

The successful process improvement leader is a good coach. You come from a change management perspective, so you understand how to help people grow from whatever they are doing today, to whatever they will be doing in the future. This typically means filling a knowledge or training gap where the organization has to move from the current state to future state. A successful leader needs to encourage people that they can complete steps a, b, and c to get outcomes x, y, and z. You must be able to step back and look at the process or situation from an outsider’s viewpoint, to help individuals on the inside see what that new world needs to be and how they can get there. Like a coach of a sports team, you need to be supportive, but also be able to critique if something needs to improve or be done differently. This is a critical success factor.

4. Understanding Process Management

How does work…work? It’s not such a silly question when looking at the critical nature of workflow and methodology used in problem solving. I’ve seen a million different approaches to any given problem. Some are good in their own way, and some may present a new set of problems. But without a fundamental understanding of the work process, or methodology that one must go through to study a problem, identify a solution, and then implement the solution, it becomes very difficult to get anything truly accomplished. It becomes an academic, rather than an actionable, exercise.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

To be able to change a process, you need to be able to understand workflow that is occurring, and the individual steps that make up the process. The process improvement leader needs to understand the current process (current state), and once a solution is determined, to design and implement how the process should happen (future state.) The ability to breakdown the work processes into their individual steps is a critical skill to help identify the root cause of the process failure, and ultimately develop a solution.

The successful process improvement leader takes a scientific approach to resolving a problem or situation, or making something better, as far as an outcome goes. This means understanding that data—the right data, in the right hands, at the right time—is required for every scientific measure or approach. With data, you can make informed decisions, gain understanding, and allow your organization to implement true fixes to the problem. Without data, you are merely guessing at what steps to take. Having the data component allows you to address the real problem, rather than conjuring what the real problem might be.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

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5. Understanding Care Management Personnel

The successful leader understands the front line work processes and demonstrates an ability to work with and through others. From the process improvement perspective, successful leaders understand not only the process, but how it relates to the real environment. You have steps A to Z to help diagnose and dissect an issue and come up with a resolution. But you also need to have an understanding of the people involved, what the issue is becoming, and how that progress is going. You involve the people who are working on the issue on a daily basis: doctors, nurses, radiology/surgical/lab techs, housekeeping, finance…location within the facility isn’t an issue. Involvement is. The people who need to be involved are those who are really doing the work that is being analyzed. Fundamentally, the methodology and tools used to solve a clinical issue are the same as a non-clinical one. But like in any project, some steps will require different amounts of work, and some tools will be better than others in analyzing the situation. We need to follow the workflow to determine the right skill set, knowledge, and expertise required to solve the problem. Clinical or non-clinical, their knowledge and expertise is needed to understand the issues, and resolve the problem. Getting the right people involved is the key to improve the overall process.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

6. Constructive Accountability and Constructive Conflict

As difficult as it may seem while in the thick of it, if you create an environment of constructive accountability and conflict, you will have a more positive outcome than if you don’t. You need to understand how to communicate using a contraceptive approach because by creating an environment of accountability and conflict, in some respects, you create an energy that eventually shatters the mold of “that’s the way we’ve always done it.” Only then can you design a new mold to create the new process. Without this constructive energy, people won’t move into this new world.

7. Resiliency and Persist ency

Change management is very complex. Everything won’t always go perfectly; in fact, it probably never will. Like Sisyphus and his boulder, there will be resistance along the way. This resistance appears in different ways: people don’t want to change, the status quo is fine; someone wants to challenge what’s historically been done by a certain skill set; people are trying something that nobody else have ever done before; the literature says this is a great thing to do; the organization is trying to implement a theoretical model.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

There are lots of reasons why resistance surfaces, but the ability to address them and continue with renewed energy hour after hour, day after day, and week after week is the hallmark of a successful process improvement leader. Also, the organization must allow the team that’s trying to implement a new solution to get to a tipping point where results start to happen and they can see the progress they’ve been trying to achieve. This demands resilience to stand up to a lot of negative feedback and the influential people who say this can’t work for a million different reasons.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

The successful leader says “instead of telling me all the reasons why it’s not going to work, tell me why it will work!” You need to look at it from the opposite extreme, and many times, this starts to break up the logjam. One must keep pushing, otherwise the energy in the room will ebb, and it will be much easier to fall back into the status quo. And if the data showed that something can be made so much better, why would you want to sit back and let status quo take over? The leader has to be persistent and keep pushing forward to make change happen.

8. Seeing the Big Picture

Process improvement experts understand and analyze detailed steps, but you also keep the bigger picture in perspective. You have short-term milestones and big-term goals that you need to hit. It is very easy for individuals and teams to “get lost in the weeds” and begin questioning “why are we doing this?” But as a leader, it is important to see the big picture, and to connect the intricate details to the ultimate goal to help the team keep moving. You have to be organized so you can manage the step-by-step details, while also making sure the compilation of all those tasks are matching and meeting the ultimate goal.NURS 8300 - Organizational and Systems Leadership for Quality Improvement Case Study

What Is Quality Management in Health Care?

Quality management seeks to improve effectiveness of treatments and increase patient satisfaction with the service. With an aging population and rising health care costs, quality management in health care is gaining increased attention. A health care system comprises small and large entities, such as pharmacies, medical clinics and hospitals, and all components need to provide quality service for the system to work properly.