Professional Documents
Culture Documents
HQ Solutions Resource For The Healthcare Quality Professional Fourth Edition
HQ Solutions Resource For The Healthcare Quality Professional Fourth Edition
HQ Solutions Resource For The Healthcare Quality Professional Fourth Edition
p. iv
Advisory Panel
Better Care
Quality professionals ensure healthy infrastructures to support effective
and responsive healthcare enterprises. Efforts align care, treatment, and
services with evidence-based, experience-informed structures and
processes yielding care that is safe, timely, effective, efficient, equitable,
ethical, and person-centered. This requires developing and deploying
sustainable performance and process improvement strategies. HQ
Solutions talks to the breadth and depth of critical areas for professional
development and leadership: frameworks for quality management, the
linking of science with practice, and the translation of data into practical
information to use and share with stakeholders, whether practitioner,
third-party payer, or consumer. A learning organization is sustained by
fostering creativity and encouraging the spread of person-centric,
evidence-based innovations.
Smarter Spending
Quality professionals recognize that affordable healthcare happens when
costs are managed side by side with quality and patient safety programs.
Accountability and value result from high-reliability processes and
standardized work. Comprehensive care ensures continuity and reduces the
chance for error, unnecessary treatment, or rework. Techniques to identify
and eradicate waste are an important part of the healthcare quality
professional’s toolkit. In this world of teeming technology, rapid
innovation, and continuously expanding science, we rely on hope day in
and day out—hope that political agendas will reflect the needs of patients,
families, and other stakeholders; that resources will be available for the
work to be done; and that fear will not create barriers to uncovering
mistakes, flaws, and failures. Armed with analytical skills and practical
tools, we are a boundless force that can wildly succeed in a universe with
finite resources. HQ Solutions talks about how data analytics are essential
to understanding where things are working and where to focus efforts for
improvement. Selecting the right design tool improves quality and limits
costs making healthcare efficiencies possible. Prioritization conserves
resources.
p. vi
p. vii
Healthier People
Quality professionals use knowledge, experience, evidence, and tools to
improve individual and population health. Effective care and positive
outcomes result from care partnerships such as an empowered and
engaged workforce or activated patients and families. Whereas prevention
is an important contributor to healthier populations, monitoring care,
recording variance, and exploring root causes play a role in harm
reduction. An enduring and just (nonpunitive) culture supports a safe
workplace. HQ Solutions talks about how patients can be kept safe and
what leaders can do to create a strong, enduring safety culture. In addition
to emerging technologies and techniques, a strong quality foundation is
made possible by the collaborative relationships among stakeholders.
After all, our work is relationship based. People are our business. Mutual
respect and accord lead to a shared mission, alignment with core values,
and a sense of camaraderie as we face complex healthcare quality
challenges.
What’s new with the fourth edition of HQ Solutions? It is innovative
and timely. It is reliable and useful. It anticipates what healthcare quality
professionals will face in the future. It offers setting-agnostic quality and
safety tools and techniques adaptable to your organization and daily
practices. It reflects recent changes in national healthcare quality and
safety imperatives and initiatives, as well as the transformation of
healthcare. It is the primary source for education about quality principles
and practices. And, it serves as a comprehensive and contemporary review
guide to prepare for the Certified Professional in Healthcare Quality
(CPHQ) exam.
HQ Solutions content is informed by the Healthcare Quality
Certification Commission’s (HQCC) practice analysis and feedback from
learners attending the CPHQ review course. The practice analysis assesses
the current functions and competencies for healthcare quality
professionals. Organized under the HQCC detailed content outline, this
edition addresses these core competencies (Organizational Leadership,
Patient Safety, Performance and Process Improvement, Health Data
Analytics). HQ Solutions features critical information about the art and
science of quality management, and environmental considerations such as
legislation and healthcare reform. It delivers on the promise to be “the go-
to resource” for healthcare quality and patient safety professionals. It
appeals to other audiences as well: NAHQ members, academicians,
researchers, consultants, administrators in healthcare organizations and
systems (health plans, ACOs and HMOs), clinicians (solo, group, facility-
based practices), home health, hospice, skilled nursing facilities,
rehabilitation facilities, ambulatory care, board members, students, and
government agencies.
When we embarked on writing the fourth edition, there was no
question about the right people to “make it happen.” Esteemed authors and
quality leaders, namely, Cathy E. Duquette, Robert J. Rosati, and Susie V.
White, once again offer readers fresh, new perspectives on leadership,
performance improvement, and data analytics. We also recognize those
who contributed to previous editions—Drs. Diane Storer Brown,
Jacqueline Fowler Byers, and Jean A. Grube. In addition, a thorough
content examination was conducted and constructive feedback received
from our expert Advisory Panel. Their efforts are greatly appreciated. We
recognize the continuous support of the NAHQ Board of Directors. The
Board allocated the necessary resources for HQ Solutions, which will
contribute to the advancement of the healthcare quality profession in the
21st century. Finally, Elizabeth Kaskie from NAHQ was extraordinary in
shepherding all aspects of the publication project (A-Z) to ensure a
successful product launch.
The work and calling of healthcare quality professionals is noble,
indeed. Nobility comes from our truth-seeking heritage. We want to share
quality stories that are cogent, accurate depictions of healthcare
circumstances, easily understood, and warmly received. For truth and
justice in healthcare, we call on every organization and leader to
May you find blessings in every day and enduring strength to lead.
Luc R. Pelletier
San Diego, CA
Christy L. Beaudin
Los Angeles, CA
p. vii
Contents
Abstract
Learning Objectives
Healthcare Organizations as Complex Systems
Leadership Frameworks and Models
High-Impact Leadership
Leadership Styles
Leadership Practices
Leadership and Organizational Culture
Elements of Culture
Assessing Organizational Culture
Leadership and Culture Change
Strategic Planning and Performance Excellence
Strategic Planning Process
Identifying and Engaging Key Stakeholders
Resource Requirements
Program Development and Evaluation
Organizational Infrastructure for Quality and Safety
Governance and Leadership
Organized Medical Providers
Other Organizational Structures and Departments
Other Elements Influencing Quality
Change Management
Change Models
Leading Change
Planning and Managing Change
Factors Supporting or Accelerating Change
Resistance to Change
Best Practices, Creativity, and Innovation
Disruptive Innovation
Spread of Change and Innovation
External Consultants
Regulation and Leadership
Federal Regulations
Federal Regulatory Agencies
Federal Role in Quality and Safety
Federal Resources
State Regulations
Regulations and Managed Care
Private Quasi-Regulators
Accreditation and Certification
Accreditation Terms and Concepts
Value of Accreditation
Accreditation, Certification, and Recognition Agencies
Accreditation or Recognition Program Selection
Organizational Approaches to Continuous Survey Readiness
Just-in-Time Readiness
Continuous Readiness
Leadership Commitment
Management Accountability
Survey Readiness Oversight
Requirements Oversight
Evaluating Organizational Compliance
Tools and Strategies for Assessment
Leading the Survey Process
Survey Outcomes
Postsurvey Activities
p. viii
p. ix
Abstract
Learning Objectives
The Patient Safety Imperative
Transforming Patient Safety in the 21st Century
National Strategy for Quality Improvement
Patient Safety Organizations
Public Reporting
Partnership for Patients
The Six Aims
The Triple Aim
Patient-Centered Outcomes
Contextualizing Patient Safety
Systems Thinking and Patient Safety
Patient Safety Culture
Patient-Centered Care
Health Equity
Leadership and Patient Safety
Awareness Structures and Systems
Accountability Structures and Systems
Structures and Systems-Driving Ability
Action Structures and Systems
Patient Safety Principles and Practices
Harm Reduction
Human Factors
High Reliability
Risk Management
Risk and Quality
Risk Assessment
Risk Identification
Risk Control
Disclosure of Errors
Patient Safety Tools
Failure Mode and Effects Analysis
Root Cause Analysis
Red Rules
Safety Checklists
Evaluating and Improving Patient Safety
Health Information
Measurement and Improvement
Evaluating the Culture of Safety
Monitoring Safe Medication Practices
Technology Solutions
Patient Safety and the Learning Organization
Agency for Healthcare Quality and Research
ECRI Institute
Institute for Healthcare Improvement
Institute for Safe Medication Practices
The Joint Commission
National Association for Healthcare Quality
National Patient Safety Foundation
World Health Organization
Other Resources
Section Summary
Abstract
Learning Objectives
The Evolution of Healthcare Quality
Quality Pioneers
p. ix
p. x
p. x
p. xi
Abstract
Learning Objectives
Historical Perspectives on Quality
New Era of Data Analytics
Data and Information
Design and Management
Quality Measurement
Risk Adjustment
Evidence-Based Practice
Epidemiological Principles
Population Health
Information Systems
Administrative Support Information Systems
Management Information Systems
Clinical Information Systems
Decision Support Systems
Registries
Patient Data
Authorized Release of Information
Medical Peer Review
Study Design
Data Types
Statistical Power
Sampling Design
Types of Sampling
Sample Size
Variation
Trends
Comparison Groups
Measurement Tools
Reliability
Validity
Statistical Techniques
Measures of Central Tendency
Measures of Variability
Statistical Tests
Methods and Tools
Activity Network Diagram
Stratification Chart
Histogram or Bar Chart
Pie Chart
Pareto Diagram/Pareto Chart
Cause-and-Effect, Ishikawa, or Fishbone Diagram
Scatter Diagram or Plot
Run or Trend Chart
Statistical Process Control
Types of Variation
Data-Driven Decision-Making
Displaying Data
Balanced Scorecards
Dashboards
Benchmarking
Reporting
Section Summary
Acronyms
Glossary
Index
p. xi
p. xii
p. xii
For additional ancillary materials related to this
chapter, please visit the point.
Abstract
Learning Objectives
Healthcare Organizations as Complex Systems
Leadership Frameworks and Models
High-Impact Leadership
Leadership Styles
Leadership Practices
Leadership and Organizational Culture
Elements of Culture
Assessing Organizational Culture
Leadership and Culture Change
Strategic Planning and Performance Excellence
Strategic Planning Process
Identifying and Engaging Key Stakeholders
Resource Requirements
Program Development and Evaluation
Organizational Infrastructure for Quality and Safety
Governance and Leadership
Organized Medical Providers
Other Organizational Structures and Departments
Other Elements Influencing Quality
Change Management
Change Models
Leading Change
Planning and Managing Change
Factors Supporting or Accelerating Change
Resistance to Change
Best Practices, Creativity, and Innovation
Disruptive Innovation
Spread of Change and Innovation
External Consultants
Regulation and Leadership
Federal Regulations
Federal Regulatory Agencies
Federal Role in Quality and Safety
p. 1
p. 2
Federal Resources
State Regulations
Regulations and Managed Care
Private Quasi-Regulators
Accreditation and Certification
Accreditation Terms and Concepts
Value of Accreditation
Accreditation, Certification, and Recognition Agencies
Accreditation or Recognition Program Selection
Organizational Approaches to Continuous Survey Readiness
Just-in-Time Readiness
Continuous Readiness
Leadership Commitment
Management Accountability
Survey Readiness Oversight
Requirements Oversight
Evaluating Organizational Compliance
Tools and Strategies for Assessment
Leading the Survey Process
Survey Outcomes
Postsurvey Activities
Education and Training in a Learning Organization
Staff Knowledge and Competency
Quality, Safety, and Performance Improvement Education and Training
Staff Education for Continuous Survey Readiness
Training Effectiveness
Section Summary
References
Suggested Readings
Online Resources
Abstract
Organizational leadership and management of quality and safety are
critical to effective continuous quality and performance improvement
programs. This section provides relevant context for healthcare quality
professionals regarding organizational leadership structure and
integration; regulatory, accreditation, and external recognition; and
education, training, and communication. Information regarding healthcare
organizations as complex systems, leadership fundamentals,
organizational infrastructure required to support quality and safety,
strategic planning, organizational culture, and key concepts related to
change and change management is provided as context to enhance the
healthcare quality professional’s ability to facilitate the assessment and
development of the organization’s culture to support organization-wide
strategic planning and linking of quality, safety, and performance
improvement activities to strategic goals. Regulatory, accreditation, and
external recognition programs that impact healthcare quality and safety
are also presented. Finally, an overview of education, training, and
communication within the context of learning organizations is provided.
This supports the promotion of staff knowledge and competency so the
strategic goals of healthcare organizations related to quality, safety, and
continuous readiness can be achieved and sustained.
Learning Objectives
1. Facilitate the assessment and development of the organization’s
culture to support organization-wide strategic planning and linking of
quality and performance improvement activities with strategic goals.
2. Integrate the results of the quality and performance improvement
process into the organization’s strategic planning, and explain the
value proposition for quality and safety.
3. Facilitate program and project development and evaluation, including
the use of performance measures, key performance and quality
indicators, and performance improvement models.
4. Discuss the functions and types of regulatory agencies (federal, state,
and local) and recognize the impact of regulations on healthcare
quality and safety; understand the different types of accreditation and
processes associated with different accreditation procedures.
5. Identify the benefits and outcomes of continuous readiness and
promote staff knowledge and competency to achieve the healthcare
organization’s goal of continuous readiness.
p. 2
p. 3
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.