Tutorial: using Microsoft Excel for health care CQI

The transition from QA to CQI in health care calls for decentralized data collection and analysis in conjunction with the use of personal computers to support CQI team activities. In this article, we discuss recent advances in PC software and hardware technology that make possible revolutionary changes in health care quality data management. We also present detailed examples of how to use Microsoft Excel 4.0 as a single software platform to support commonly used CQI tools and analyses.     

The CQI paradigm: a pathway to nurse empowerment in a community hospital

Anderson Area Medical Center instituted continuous quality improvement (CQI) hospitalwide two years ago. Three teams were challenged with identifying and improving processes related to accounts receivable. X-ray report turn-around-time, and emergency department patient satisfaction. Nursing participation was sought for all three teams. An eight-step CQI process was used to identify, analyze, and improve these three processes. Substantial nursing participation in these pilot CQI teams led to further participation in many other CQI teams optimizing clinical processes. Nursing personnel gained opportunities to make significant contributions to the enhancement of clinical and administrative processes in a large hospital. Nurses learned to work with other members of the health care team outside of their traditional domains, and this, combined with formalized training in the team process, is empowering.     

Promoting clinical involvement in hospital quality improvement efforts: the effects of top management, board, and physician leadership.

STUDY QUESTION: An examination of the effects of top management, board, and physician leadership for quality on the extent of clinical involvement in hospital CQI/TQM efforts. DATA SOURCES: A sample of 2,193 acute care community hospitals, created by merging data from a 1989 national survey on hospital governance and a 1993 national survey on hospital quality improvement efforts. STUDY DESIGN: Hypotheses were tested using Heckman's two-stage modeling approach. Four dimensions of clinical involvement in CQI/TQM were examined: physician participation in formal QI training, physician participation in QI teams, clinical departments with formally organized QA/QI project teams, and clinical conditions and procedures for which quality of care data are used by formally organized QA/QI project teams. Leadership measures included CEO involvement in CQI/TQM, board quality monitoring, board activity in quality improvement, active-staff physician involvement in governance, and physician-at-large involvement in governance. Relevant control variables were included in the analysis. PRINCIPAL FINDINGS: Measures of top management leadership for quality and board leadership for quality showed significant, positive relationships with measures of clinical involvement in CQI/TQM. Active-staff physician involvement in governance showed positive, significant relationships with clinical involvement measures, while physician-at-large involvement in governance showed significant, negative relationships. CONCLUSIONS: Study results suggest that leadership from the top promotes clinical involvement in CQI/TQM. Further, results indicate that leadership for quality in healthcare settings may issue from several sources, including managers, boards, and physician leaders.     

Incorporation of continuous quality improvement in a hospital dietary department's quality management program

What techniques or steps are necessary to overcome obstacles and achieve the incorporation of continuous quality improvement (CQI) methods in existing quality management programs? Education of staff, identification of customers' expectations, and implementation of a plan to administer activities are critical to a positive outcome of CQI efforts. Our article outlines one approach to the transition from quality assurance to CQI using the FOCUS-PDCA® technique. We use the example of improving the timeliness of late tray deliveries to demonstrate how to implement the conversion to CQI using the FOCUS-PDCA® technique. The dietetics practitioners may apply the sequential steps described in the article to successfully incorporate the CQI concept in most hospital dietary department's quality management activities.     

Cultivating quality. CQI helps a system's members provide efficient, effective care to their clients

In 1990 the SSM Health Care System (SSMHCS), St. Louis, introduced its employees to continuous quality improvement (CQI), a new management paradigm focusing on process, customers, and statistical thinking. For nearly a year before the introduction of CQI, a system implementation team studied CQI and its impact on businesses and healthcare providers. Team members were struck by the close correlation between the system's own mission and CQI principles. When it had completed its study, the team began to develop strategies for implementing CQI. System leaders committed themselves to ensuring that CQI would address both clinical and managerial processes, encouraging managers and medical staff to support CQI, establishing a structure at each entity to support involvement in the process, fostering a high level of awareness in CQI, recognizing employees who make significant contributions to the effort, offering education programs, and communicating successes and encouraging their replication. Before any facility appointed a quality improvement team and began to apply CQI principles, its administrative council (leadership team) was required to work through a series of readiness screens. The implementation process has involved redefining the manager's role as one of empowering employees, cultivating and securing physician involvement, and educating employees and physicians about processes. In the early phases of implementation, the major barriers the system has faced have involved time-the time required of administrators and managers to teach CQI courses and the time it takes teams to work through the SSMHCS CQI model and adapt the system to CQI implementation.     

Assessing the factors influencing continuous quality improvement implementation: experience in Korean hospitals.

OBJECTIVE: To assess the extent of continuous quality improvement (CQI) implementation in Korean hospitals and to identify its influencing factors. DESIGN: Cross-sectional study by mailed questionnaire survey. STUDY PARTICIPANTS: One hundred and seventeen staff members with responsibility for CQI at 67 hospitals with > or = 400 beds. MAIN OUTCOME MEASURES: The degree of CQI implementation was measured using the Malcolm Baldrige National Quality Award Criteria (MBNQAC). Factors related to the degree of CQI implementation were the four components of the CQI pyramid, namely the cultural, technical, strategic, and structural attributes of individual hospitals. RESULTS: The average CQI implementation score across the seven dimensions by MBNQAC was 3.34 on a 5-point scale. The highest score was achieved in the dimension of 'customer satisfaction' (3.88), followed by 'information/analysis' (3.59), and 'quality management' (3.35). Regression analysis showed that hospitals which better fulfilled technical requirements, such as improving information systems (P< 0.05), using more scientific CQI tools, and adopting systematic problem-solving approaches (P<0.01), tended to achieve higher degrees of CQI implementation. Although statistically insignificant, positive trends were observed for group/developmental culture and the degree of employee empowerment, and the use of prospective strategy. CONCLUSION: It appears that the most important contributing factors to active CQI implementation in Korean hospitals were the use of scientific skills in decision-making and the adoption of a quality information system capable of producing precise and valid information.     

Department deployment: integrating quality improvement into day-to-day management

Despite the time and resources that The George Washington University Medical Center (GWUMC) put into training and forming QI teams, QI staff found that CQI was not being used to carry out critical day-to-day departmental functions. In other words, CQI didn't affect the way staff did "real work." In response, the medical center developed an approach that integrates CQI with departmental leadership, structure, culture, and work routine. With the help of a coach, willing departments at GWUMC choose from a series of 155 activities that they complete at their own pace (eg, setting departmental CQI goals, developing a departmental mission). The department deployment process moves staff through three levels of increasing sophistication and maturity with CQI methods: awareness, understanding, and bonding. It is intended to make quality a habit for staff, or a part of the organizational mind set, rather than an isolated "project." This article will describe how the department deployment approach was developed, its philosophical underpinnings, and its methodology and tools. Then, an example will illustrate how one hospital department--social work and utilization case management--successfully used this approach.     

The development of measures of organizational citizenship behaviour and changes in job behaviours related to quality management in health care.

A study was conducted at two tertiary care hospitals in Canada for the purpose of developing instruments to measure organizational citizenship behaviours (OCB) and changes in job behaviours that occur as a result of participation on hospital quality improvement (CQI) teams. Semi structured interviews were conducted among 52 hospital employees in order to elicit critical incidents of OCB and changes in job behaviours related to CQI. The results of the staff interviews were used to develop a measure of OCB in the hospital setting, and a measure of changes in job behaviours related to CQI. 39 employees, who were drawn from the major departments within the two hospitals on the basis of their membership on CQI teams, participated in a test of the psychometric properties of the two research instruments. Exploratory factor analysis, employing an orthogonal rotation, yielded two factors that accounted for 30% of the variation among the OCB items. The Cronbach alpha for items loading highly on the first factor was .88. The factor was labelled 'OCB directed towards individuals within the organization'. This factor was dominated by items reflecting the kinds of extra-role job behaviours employees engage in to assist patients, family members, visitors, and other employees within the organization. The Cronbach alpha for items loading highly on the second factor was 0.71. The second factor was labelled 'organizationally directed OCB', and consisted of behaviours that reflected an impersonal form of OCB in the hospital setting. Factor analysis, employing an orthogonal rotation, yielded four factors that accounted for 48% of the variation among the items measuring changes in job behaviours related to CQI. The four factors were labelled 'problem-solving', Cronbach alpha 0.82; 'customer awareness', Cronbach alpha 0.79; 'use of CQI knowledge', Cronbach alpha 0.77; and 'organizational interests', Cronbach alpha 0.79. The two OCB factors were moderately correlated, there were no significant correlations among any of the factors measuring changes in job behaviours related to CQI, and the problem-solving job behaviours factor was moderately correlated with the two OCB factors. Directions for future research are discussed.     

Continuous Quality Improvement: Status of Canadian Health Care Organizations

The Canadian Council on Health Services Accreditation (CCHSA) surveyed its client groups to determine how involved they had become in continuous quality improvement (CQI) activities. This was a follow up to a 1992 survey. Most of the participating organizations indicated they had adopted a CQI philosophy. A major factor influencing this decision was the use of the CCHSA's client-centred standards.This article outlines the gains organizations have realized by implementing CQI, and the extent to which organizations have implemented CQI principles, methods and tools. The information from this survey has been used to develop the accreditation program for the year 2000 — “The AIM Project: Achieving Improved Measurement.”     

Striving toward continuous quality improvement: a case study of Saint Mary's Hospital

This case analysis is the result of a year-long study designed to identify and assess the ingredients that led to the successful implementation of a continuous quality improvement (CQI) program at Saint Mary's Hospital in Grand Rapids, Michigan. The key ingredients of success included: (1) an organizational structure and leadership commitment for identifying and improving processes, (2) use of data-based statistical and analytical tools to study processes, (3) empowerment of teams of employees to take charge of the operations of their own work tasks in a manner that encourages continuous learning, (4) involvement of internal and external customers through the improvement process, and (5) development of effective measures for monitoring improvement. The benefits of the CQI efforts at Saint Mary's have been remarkable and hospital-wide.     

Using scientific evidence to improve information practice

The recent policy statement of the Medical Library Association (MLA) takes the position that scientific evidence is the basis for improving the quality of library and information sciences now and in the future. Research activity is seen as the foundation of an evolving knowledge base for the profession--a knowledge base that will set health sciences librarians apart from others in an increasingly competitive world of information service providers. The statement represents the culmination of many years of activity by association members, during which the role of research in health information practice has been debated. Over a similar time period, the quality movement, with its increasing demand for the collection and use of data, has been growing. Developments such as total quality management (TQM) and continuous quality improvement (CQI) reinforce the centrality of research with its increasing demand for the collection and use of data, has been growing. Developments such as total quality management (TQM) and continuous quality improvement (CQI) reinforce the centrality of research and its relationship to efficient and effective information practice as envisioned in the MLA policy statement.     

Developing a 'consultation quality index' (CQI) for use in general practice

BACKGROUND: The core values of general practice include holism and patient-centredness. None of the measures of quality of care in general practice presently capture the expression of these values at routine consultations. OBJECTIVES: The aim of the present study was to construct a 'consultation quality index' (CQI) which reflects the core values of general practice, using as proxies 'consultation length' and how well patients 'know the doctor' as process measures and 'patient enablement' as an outcome measure. METHODS: The CQI was constructed from data collected from 23 799 adult English-speaking patients consulting 221 doctors in four demographically contrasting areas of the UK during 2 weeks of March/April 1998. A total of 171 doctors who entered 50 qualifying consultations were allocated scores for the three component variables, and a total CQI was calculated. RESULTS: CQI scores were in the range 4-18. Validity was examined by looking at high and low scorers in greater detail and by searching for correlates with case mix, patient age and gender, and the deprivation scores of the practices concerned. Particular attention was paid to how registrars and doctors new to their practices scored. The scores of different doctors in the same practice were also noted. The results had strong face validity and were independent of case mix and deprivation. Reliability was gauged by examining similar work from a previous study which had collected information on consultation length and enablement over three time periods. High CQI scores were associated with smaller overall practice list sizes. CONCLUSIONS: We have outlined possible uses for the CQI as part of the packages assessing quality of care by doctors and practices. The measure may also have a part to play in recognizing poorly performing doctors. We suggest how CQI scores could contribute to an incentive scheme to reward good consulting practice. Further work is in hand to compare doctors' CQI scores with scores based on performance indicators constructed from routine NHS data on prescribing and preventive medicine.     

Do TQM interventions change management culture? Findings and implications

This study assesses the impact of TQM/CQI interventions on the culture and performance of top management teams. The findings suggest culture is related to performance but that TQM/CQI interventions are not associated with either performance or culture change. Implications for additional research and for practice are discussed.     

Continuous quality improvement: a survey of American and Canadian healthcare executives

The continuous quality improvement (CQI) movement, while experiencing great popularity years ago, has been declining in interest across other industries. This article studied American and Canadian hospital executives who have embraced the concept of CQI and will continue to be committed to CQI efforts in the future. Executives of CQI hospitals strongly believe that CQI is not a fad and is essential to their organizations' survival. The majority of the hospital executives in the sample have a good understanding of CQI. The drive to provide quality service to both internal and external customers is the primary motivation for being involved with CQI. Some unsuccessful CQI efforts can be attributed to a lack of CQI skills, poor planning, and insufficient staffing. Close to 90 percent of the respondents expected their involvement with CQI to increase significantly in the future. This result implies that CQI is still being considered and will maintain its role as an effective management tool in the healthcare sector.     

Introduction of a quality improvement program in a children's hospital in Tehran: design, implementation, evaluation and lessons learned.

BACKGROUND AND OBJECTIVE: Reports addressing continuous quality improvement (CQI) methods in developing countries are scant and there are questions about the applicability of quality improvement methods in such settings. The structure and output of a formal quality improvement program implemented in a teaching hospital affiliated with the Tehran University of Medical Sciences is presented. OBJECTIVE METHOD: During a nine-month period, a multi-stage quality improvement program was implemented. It comprised: (i) training workshops; (ii) a steering committee; (iii) weekly consultation and facilitation of improvement projects; and (iv) a day-long demonstration and recognition meeting. Four cycles of workshops were held in which 132 employees were trained in the basics of CQI. RESULTS: Thirty improvement projects were initiated. Twenty-five of the projects were completed. In an evaluation survey more than 70% of respondents assessed a 'positive impact' on organizational culture, work efficiency and quality of services. More than 90% believed that the changes were sustained, and more than 60% reported that they have implemented additional improvement projects. CONCLUSION: Our quality improvement package supported rapid implementation of multiple projects. The underlying 'change structure' comprised the improvement teams, top management and the university's quality improvement office; it integrated project management, support and facilitation functions by the respective participant. Organization-wide change was more limited than anticipated. To institutionalize the program and ensure sustainability, a local structure for change should be organized, management coaching should be sustained, local facilitators should be developed, incentives should be established and physician involvement should be emphasized.     

The presence of total quality management and continuous quality improvement processes in California public health clinics.

Total quality management (TQM) and continuous quality improvement (CQI) processes have not been fully integrated into public health practice. Current levels of participation and interest in TQM/CQI were assessed in California's 62 county departments of health services. Survey results indicated that only 18.5 percent of the 54 respondents were using TQM/CQI. Of those not using TQM/CQI, 75 percent were interested in these activities. Improvement of public health clinic ability to compete and to survive in a rapidly changing health care environment requires fostering this interest through public health decision-maker support, increased TQM/CQI training opportunities, and demonstration of TQM/CQI cost-effectiveness in public health.     

持续质量改进在医院感染管理中的应用

目的应用持续质量改进(CQI)的管理理念,探索CQI在医院感染管理中的应用,提高医院感染管理质量。方法将不同层次、不同知识结构的管理者和员工组成若干个医院感染管理CQI项目组;各项目组根据各自的标准、规范进行动态的评估,不断寻求医疗活动中的不良因素,及时发现隐患,确定项目名称、目标、具体实施方案并落实执行,以达到医院感染管理的持续质量改进。结果通过医院感染管理CQI小组的持续监测,不断发现和解决问题,使医院感染质量控制达到一个较好的水平。结论实施医院感染CQI管理,各级管理者在医疗活动中能主动寻找安全隐患并予以解决,强化了各级管理者的质量管理意识和医务人员的参与意识;实施过程管理、环节管理的全方位、全过程管理,使质量标准落实到各级医院感染管理工作中,有效控制了薄弱环节,医院感染质量明显提高。     

Can continuous quality improvement be assessed using randomized trials? [see comment]

STUDY QUESTION: Continuous quality improvement (CQI) has been implemented at least to some degree in many health care settings, yet randomized controlled trials (RCTs) of CQI are rare. We ask whether, when, and how RCTs of CQI might be designed. STUDY DESIGN: We consider two applications of CQI: as a general philosophy of management and (by analogy with the use of conceptual models from the behavioral sciences) as a conceptual model for developing specific interventions. The example of warfarin therapy for stroke prevention among patients with atrial fibrillation is used throughout. PRINCIPAL FINDINGS: While it is impractical to use RCTs to study CQI as a general management philosophy, RCT methodology is appropriate for studying CQI as a conceptual model for generating interventions. RCTs of CQI might be considered when the process change under consideration is very large, its implications (e.g., in terms of cost, outcomes of care, etc.) are very great, and the best approach is uncertain. When designing RCTs of CQI, critical decisions include (1) the unit of randomization; (2) whether the focus is on CQI as a method for generating interventions or, instead, is on specific interventions in and of themselves; and (3) the flexibility available to local personnel to modify the intervention's operational details. CONCLUSIONS: RCTs of CQI as a conceptual model for generating interventions are feasible.     

“The pediatric social worker really shepherds them through the process”: Care team members' roles in transitioning adolescents and young adults with HIV to adult care

Increasing numbers of adolescents and young adults (AYA) with HIV need to transition from pediatric to adult infectious disease care. Little research has examined the roles of the care team members in the transition process. Nineteen pediatric and adult providers with experience caring for HIV-infected AYA were interviewed to explore their perspectives on the roles of care team members on multidisciplinary pediatric and adult infectious disease teams. Interviews were transcribed and coded for emergent themes by independent reviewers. All care team members played important roles in the transition process. Qualitative analyses indicated that pediatric social workers played an especially pivotal role in facilitating the transition of AYA with HIV from pediatric to adult care. Pediatric social workers communicated with other providers and prepared the adolescent and family for the upcoming transition. Both pediatric and adult social workers engaged in assessment of psychosocial functioning and facilitated referrals to community resources. Social workers in the adult infectious disease clinic helped the adolescent and family adjust to the new setting. Pediatric medical providers supported the patient and family during transition and communicated pertinent medical information to the family and medical provider in the adult clinic. Participants stated that the role of the adult medical provider was to welcome the newly transition adolescent into the clinic and to obtain a new comprehensive medical history including sexual behavior. Findings offer insight into the roles held by various members of teams associated with the transition of AYA living with HIV from pediatric to adult care. The effectiveness of medical care teams can influence the quality of care provided to patients and can be improved by understanding team roles.     

Health services management manpower and educational needs with American health reform.

This paper argues that our previous health services management (HSM) manpower projections may be overly optimistic as the health networks, managed care, capitated payment, and eventually global budgetary targets become the dominant themes to implement cost restraints, universal access, and social equity. HSM programs should, therefore, focus more on their educational pursuits to produce leaders for clinical management teams, who are able to allocate scarce clinical resources. A sensible strategy for HSM programs is to develop closer ties with the schools of medicine, public health, nursing, or allied health. These cooperative efforts would be particularly beneficial in teaching 'clinical-fiscal performance methodologies' to familiarize students with such concepts as clinical benchmarking, managing quality, resource management, and continuous quality improvement (CQI).