Exceptional health care requires leadership at all levels

In 1990, SSM Health Care, St. Louis, implemented a management approach called "continuous quality improvement" (CQI) to help tap the potential of its employees. Five years later, SSM combined the approach with the "Breakthrough Series," a quality-improvement model developed by the Institute for Healthcare Improvement (IHI), and rapid results followed. With quality improvements under way, SSM facilities began to apply for state quality awards modeled on the Baldrige National Quality Award program. The feedback from Baldrige helped SSM focus its ongoing quality efforts. Also, it provided the necessary framework for quality improvements and for establishing a culture in which leadership is encouraged at all levels. In 2002, SSM became the first health care system to receive the Malcolm Baldrige National Quality Award.     

After years of waiting,health care finally has a Baldrige winner!

SSM Health Care was not an "overnight success;" quality journey has taken many years. Health care faced unique challenges in competing with industry. Baldrige standards helped SSM crystallize mission, goals.     

The future is continuous quality improvement

The SSM Health Care System is a Catholic, not-for-profit, multihospital health care system with headquarters in St. Louis, Missouri. Sister Mary Jean Ryan, FSM, the President and Chief Executive Officer, has led the implementation of continuous quality improvement (CQI) throughout the system since 1990. This article presents excerpts from a speech Sister Ryan delivered at the system's annual leadership conference in 1990. Sister Ryan delivered this speech at the conclusion of a retreat where the principles of CQI were introduced to the SSM Health Care System leadership. The editors believe this inspiring speech provides insight into the kind of leadership needed to successfully implement quality management.     

"Diversity is at the core of who we are"

In an effort to become a more fully diverse organization, St. Louis-based SSM Health Care (SSMHC) implemented a plan called "Strategic Goals for Diversity for 1998 to 2004." The plan called for Increasing diversity among SSMHC employees. Improving support to, and alliances with, organizations that pursue fairness and equality for all people. Establishing a work environment that rewards and recognizes excellence and attracts and retains the best people, regardless of factors like race, religion, disability, and gender. Increasing business partnerships with minority and women suppliers. Having established strategic goals, SSM launched a Diversity Forum: a corporate-sponsored gathering designed to develop the careers of people of color, of different ethnic backgrounds, or with disabilities. Diversity Forum participants suggested that mentoring minority employees would help SSM reach its goals. In 2000, the system launched its Diversity Mentoring Program, designed to last four years. The program had two main purposes: To increase the number of people of color, of different ethnicity, or with disabilities in the system's professional and managerial ranks. To prepare these minority professionals and managers for upward mobility by pairing them with executive leaders. Along with the focus on SSM's employees, the system looked outside as well, to its relationships with local communities. The organization worked toward expanding its commitment to purchase from local, small, and minority-owned businesses. In 2005, to help SSM entities meet new goals for 2005-2010 (with a new emphasis on minority patients and customers), the system introduced a new measurement tool, the Diversity Scorecard, which is a comprehensive measuring tool that allows SSM leaders to benchmark their efforts.     

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.     

Highlighting 2003 award-winning initiatives

Just over a year ago, SSM Health Care, headquartered in St. Louis, achieved a place in healthcare history by being named the first healthcare winner of the annual Malcolm Baldrige National Quality Award. This year, history was made again when two healthcare organizations--Saint Luke's Hospital of Kansas City, MO, and Baptist Hospital, Inc., of Pensacola, FL--became dual winners of the Baldrige Award. This issue of The Quality Letter for Healthcare Leaders talks with individuals at those organizations--and also to representatives of two winners of the Ernest A. Codman Award (Baptist Medical Center of Jacksonville, FL, and the Cleveland Clinic Health System)--to see how their vision, dedication, hard work, and quest for quality and innovation helped them become award winners.     

The revolution in hospital management

Five healthcare systems that have either won the Malcolm Baldrige National Quality Award in Health Care or been documented in extensive case studies share a common model of management: they all emphasize a broadly accepted mission; measured performance; continuous quality improvement; and responsiveness to the needs of patients, physicians, employees, and community stakeholders. This approach produces results that are substantially and uniformly better than average, across a wide variety of acute care settings. As customers, courts, and accrediting and payment agencies recognize this management approach, we argue that it will become the standard for all hospitals to achieve. This article examines documented cases of excellent hospitals, using the reports of three winners of the Baldrige National Quality Award in Health Care and published studies of other institutions with exceptional records.     

Empirical support for the Baldrige Award framework in U.S. hospitals.

Examined are relationships among constructs in the Baldrige Award Health Care Criteria framework to investigate whether quality management systems are related to organizational results and customer satisfaction in hospitals. Measures for the 19 dimensions of the Baldrige Criteria are obtained from 220 U.S. hospitals. This study provides empirical evidence that focusing on the content addressed in the Baldrige Criteria leads hospitals to improvement on some dimensions of performance.     

Improving clinical processes: one dialysis facility's experiences

Northeast Louisiana Dialysis Center implemented continuous quality improvement (CQI) to improve the quality of care delivered to end stage renal disease (ESRD) patients treated by hemodialysis in their facility. The unit chose to address normalization of calcium and phosphorus and parathyroid hormone (PTH), anemia, nutrition, adequacy of dialysis and dialyzer reuse as well as performance benchmarks by the Health Care Financing Administration (HCFA) core indicators. This article presents the results obtained and the methodology used in this improvement effort. The article also presents nine principles the authors believe necessary for a successful CQI program.     

Organizational Learning and Continuous Quality Improvement: Examining the Impact on Nursing Home Performance

Interest is growing in learning more about the ability of total quality management and continuous quality improvement (TQM/CQI) initiatives to contribute to the performance of healthcare organizations. A major factor in the successful implementation of TQM/CQI is the seminal contribution of an organization's culture. Many implementation efforts have not succeeded because of a corporate culture that failed to stress broader organizational learning. This may help to explain why some TQM/CQI programs have been unsuccessful in improving healthcare organization performance. Organizational performance variables and organizational learning orientation were assessed in a sample of 181 Canadian long-term care organizations that had implemented a formal TQM/CQI program. Categorical regression analysis shows that, in the absence of a strong corporate culture that stresses organizational learning and employee development, few performance enhancements are reported. The results of the assessment suggest that a TQM/CQI program without the backing of a strong organizational learning culture may be insufficient to achieve augmented organizational performance.     

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.     

医院质量管理体系诊断与改进中评价标准应用研究

为实现医院质量管理体系的诊断与改进，本文对ISO9000：2000标准和Baldrige标准的结构、主要内容以及两者的特点等进行了分析比较。在此基础上，提出一个将ISO9001和Baldrige标准集成的模型，并应用于医院质量管理体系的诊断与改进过程。该模型依据Baldrige标准，分析诊断出医院质量管理体系中存在的主要问题及改进策略，进而通过两个标准之间的相关关系，将质量管理体系改进策略分解配置到相关的ISO9001条款；最后，参照ISO9001标准中相应条款的要求，制订出具体的改进计划和改进措施。     

Enhancing VHA's mission to improve veteran health: synopsis of VHA's Malcolm Baldrige award application

The Veterans Health Administration (VHA) provides health care value to an aging veteran population in the midst of rising health care costs and the necessity to demonstrate improvements in the quality of care. The Malcolm Baldrige framework offers a comprehensive assessment of the organization's management system, performance improvements, and the promise to enhance health outcomes, including quality and patient satisfaction. This article will describe the development, current status, and future plans within VHA for the Malcolm Baldrige Award for Healthcare.     

Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial

PURPOSE

We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation.

METHODS

We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys.

RESULTS

Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices.

CONCLUSIONS

Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.     

Baldrige-based quality awards: Veterans Health Administration's 3-year experience

This article describes the Veterans Health Administration's (VHA's) 3-year experience with an internal, Baldrige-based quality award. The authors examined scores for Veterans Integrated Service Networks (VISNs), which received site visits, variation in year-to-year survey outcomes for repeat applicants, and variation in survey team reports for a VISN with multiple surveys. Individual VISNs that applied in multiple years had mixed results. Variation in feedback reports was not significant. Although some VISNs increased their scores over time, there was not measurable, systemwide improvement. Three years may be too short a time to significantly affect Baldrige scores in an organization as large as VHA.     

Performance improvement based on integrated quality management models: what evidence do we have? A systematic literature review.

PURPOSE: Health care organizations have to improve their performance for multiple stakeholders and organize integrated care. To facilitate this, various integrated quality management models can be used. This article reviews the literature on the Malcolm Baldrige Quality Award (MBQA) criteria, the European Foundation Quality Management (EFQM) Excellence model (Excellence award models) and the Chronic Care Model. The focus is on the empirical evidence for improved performance by the implementation of interventions based on these models. DATA SOURCES: A systematic literature review from 1995 to May 2006 in the Pubmed, Cochrane, and ABI- databases was conducted. STUDY SELECTION: After selection, 37 studies were included, 16 in the Excellence award model search and 21 in the Chronic Care Model search. DATA EXTRACTION AND RESULTS OF ANALYSIS: Data were retrieved about the main intervention elements, study design, evidence level, setting and context factors, data collection and analysis, principal results and performance dimensions. No Excellence Award model studies with controlled designs were found. For the Chronic Care Model, one systematic review, one meta analysis and six controlled studies were included. Seventeen studies (2 in Excellence award model, 15 in Chronic Care Model) reported one or more significant results. CONCLUSION: There is some evidence that implementing interventions based on the 'evidence-based developed' Chronic Care Model may improve process or outcome performances. The evidence for performance improvement by interventions based on the 'expert-based developed' MBQA criteria and the EFQM Excellence model is more limited. Only a few studies include balanced measures on multiple performance dimensions. Considering the need for integrated care and chronic care improvement, the further development of these models for guiding improvements in integrated care settings and their specific context factors is suggested.     

Transforming a health care information management system

The article presents results from a survey of 98 top executives at Baylor Health Care System (BHCS), a large, multifunction health care organization in Dallas, Texas. The survey assessed the executives' perceptions of current BHCS quality practices using the first survey developed for the health care industry based on the Malcolm Baldrige National Quality Award (MBNQA) criteria. Findings regarding the quality of BHCS internal and external data and information include the need for a $50 million information system transformation to achieve seven critical success factors for all business units and improved internal and external data and information for the business process redesign and quality transformation. Results highlight the need for further research investigating the information and analysis MBNQA criteria.     

Reorienting primary health care for addressing chronic conditions in remote Australia and the South Pacific: review of evidence and lessons from an innovative quality improvement process

This paper reviews what is known about the challenges of implementing quality improvement programs and draws on data from a systematic continuous quality improvement (CQI) project in remote communities in Australia and Fiji, known as Audit and Best practice for Chronic Disease, to synthesise lessons and discuss the potential for broader application in low and middle income countries, including Pacific Island countries and territories. Although a number of systematic reviews have indicated that quality improvement programs can be effective in changing professional practice and improving the quality of care and patient outcomes, little is known about the key ingredients for change or how services use and implement different strategies to achieve improvements. We identify key features of an innovative CQI model and factors related to implementation that support improvement in diabetes service delivery and intermediate outcomes. Requirements for supporting CQI are identified and the potential for wider application discussed. It is argued that the participatory action research approach supports innovation and broad-based change and the evidence it has produced extends the current knowledge base and facilitates the translation of knowledge into action, for both policy and practice.     

Continuous quality improvement as an ideal in hospital practice

Continuous quality improvement (CQI) is an important part of successfully managing change in health care. This article describes a CQI plan and process created to develop a comprehensive plan for a rapidly evolving organization. Four key components of the planning process are described: initial initiatives, customer service orientation, teamwork approach, and physician involvement. A case study is also included to illustrate how one CQI plan and process was implemented and evaluated.     

Continuous quality improvement in acute health care: creating a holistic and integrated approach

Reviews the range of quality activity in a National Health Service hospital trust, using a staff questionnaire survey, self-assessment against the Baldrige Quality Award criteria, and the application of the SERVQUAL approach to service quality assessment. Reviews the acute health care quality programme literature. Finds that there are needs for greater integration of quality effort, to engage with patients in a more meaningful manner, and to achieve greater commitment and involvement from clinicians and managers. Identifies lack of time and resources as a major barrier to greater application of quality programmes. Explores ways of developing a more holistic and integrated programme of quality improvement. Describes the creation and implementation of a model for continuous improvement in health care quality.