Read an Excerpt
CHAPTER 1
FOCUS ON QUALITY
LEARNING OBJECTIVES
After reading this chapter, you will be able to
* recognize factors that influence consumers' perception of quality products and services;
* explain the relationship between cost and quality;
* identify quality characteristics important to healthcare consumers, purchasers, and providers; and
* give examples of the varied dimensions of healthcare quality.
KEY WORDS
* Cost-effectiveness
* Defensive medicine
* Healthcare quality
* High-value healthcare
* Institute for Healthcare Improvement (IHI)
* IHI Triple Aim framework
* National Academy of Medicine
* National Quality Strategy
* Providers
* Purchasers
* Quality
* Quality assurance
* Reliability
* Value
Since opening its first store in 1971, Starbucks Coffee Company has developed into an international corporation with more than 23,000 locations worldwide. The company's dedication to providing a quality customer experience is a major contributor to its success. Starbucks's customers expect to receive high-quality, freshly brewed coffee in a comfortable, secure, and inviting atmosphere. In almost every customer encounter, Starbucks meets or exceeds those expectations. This consistency does not occur by chance. Starbucks puts a lot of behind-the-scenes work into its customer service. From selecting coffee beans that meet Starbucks's exacting standards of quality and flavor to ensuring baristas are properly trained to prepare espresso, every part of the process is carefully managed.
Providing high-quality healthcare services also requires much work behind the front lines. Every element in the complex process of healthcare delivery must be carefully managed. This book explains how healthcare organizations manage the quality of their care delivery to meet or exceed customers' expectations. These expectations include delivering an excellent patient care experience, providing only necessary healthcare services, and doing so at the lowest cost possible.
What Is Quality?
In its broadest sense, quality is an attribute of a product or service. The perspective of the person evaluating the product or service influences her judgment of the attribute. No universally accepted definition of quality exists; however, its definitions share common elements:
* Quality involves meeting or exceeding customer expectations.
* Quality is dynamic (i.e., what is considered quality today may not be good enough to be considered quality tomorrow).
* Quality can be improved.
Reliability
An important aspect of quality is reliability. From an engineering perspective, reliability refers to the ability of a device, system, or process to perform its prescribed function without failure for a given time when operated correctly in a specified environment (Crossley 2007). Reliability ends when a failure occurs. For instance, your laptop computer is considered reliable when it functions properly during normal use. If it stops functioning — fails — you have an unreliable computer.
Consumers want to experience quality that is reliable. Patrons of Starbucks pay a premium to get the same taste, quality, and experience at every Starbucks location (Clark 2008). James Harrington, past president of the American Society for Quality, cautioned manufacturers to focus on reliability more than they have in recent years to retain market share. First-time buyers of an automobile are often influenced by features, cost, and perceived quality. Repeat buyers cite reliability as the primary reason for sticking with a particular brand (Harrington 2009).
Reliability can be measured. A reliable process performs as expected a high proportion of the time. An unreliable process performs as expected a low proportion of the time. Unfortunately, many healthcare processes fall into the unreliable category. Healthcare processes that fail to consistently perform as expected a high proportion of the time contribute to medical errors that cause up to 400,000 annual deaths in the United States and even more serious harm events (DuPree and Chassin 2016). Healthcare consumers are no different from consumers of other products and services; they expect quality services that are reliable.
Cost–Quality Connection
We expect to receive value when purchasing products or services. We do not want to find broken or missing parts when we unwrap new merchandise. We are disheartened when we receive poor service at a restaurant. We become downright irritated when our banks fail to record a deposit and our debit card withdrawals are denied.
How you respond to disappointing situations depends on how you are affected by them. With a product purchase, if the merchandise is expensive, you will likely contact the store immediately to arrange an exchange or a refund. If the product is inexpensive, you may chalk it up to experience and vow never to do business with the company again. At a restaurant, your expectations increase as the price of the food goes up. Yet, if you are adversely affected — for example, you get food poisoning — you will be an unhappy customer no matter the cost of the meal. The same is true for banks that make mistakes. No one wants the hassle of reversing a bank error, even if the checking account is free. Unhappy clients tend to move on to do business with another bank.
Cost and quality affect the customer experience in all industries. But in healthcare, these factors are harder for the average consumer to evaluate than in other types of business. Tainted restaurant food is easier to recognize than an unskilled surgeon is. As for cost, everyone agrees that healthcare is expensive, yet if someone else is paying for it — an insurance company, the government, or a relative — the cost factor becomes less important to the consumer. If your surgery does not go well, however, you'll be an unhappy customer regardless of what it cost.
In all industries, multiple dynamics influence the cost and quality of products and services. First, prices may be influenced by how much the consumer is willing to pay. For example, one person may pay a premium to get the latest and most innovative electronic gadget, whereas another person may wait until the price comes down before buying it. This phenomenon is also evident in service industries. Rosemont College, a private coeducational institution in Bryn Mawr, Pennsylvania, reduced tuition to attract students. For the 2016–2017 academic year, the college dropped tuition from $32,620 to $18,500, and room and board costs from $13,400 to $11,500. These cost reductions resulted in a 64 percent increase in applications without any change in academic offerings (Hope 2017).
Second, low quality — say, poor customer service or inferior products — eventually causes a company to lose sales. The US electronics and automotive industries faced this outcome in the early 1980s when American consumers started buying more Japanese products (Walton 1986). Business and government leaders realized that an emphasis on quality was necessary to compete in a more demanding, and expanding, world market.
Consumer-Supplier Relationship
The consumer–supplier relationship in healthcare is influenced by different dynamics. For example, consumers may complain about rising healthcare costs, but most are not in a position to delay healthcare services until the price comes down. If you break your arm, you immediately go to a doctor or an emergency department to be treated. You are not likely to shop around for the best price or postpone treatment if you are in severe pain.
In most healthcare encounters, the insurance companies or government-sponsored payment systems (such as Medicare and Medicaid) are the consumer's agent. When healthcare costs are too high, they drive the resistance against rising rates. These groups act on behalf of consumers in an attempt to keep healthcare costs down. They exert their buying power by negotiating with healthcare providers for lower rates. In addition, they monitor billing claims for overuse of services and will not pay the providers — the suppliers — for services considered medically unnecessary. If a doctor admits you to the hospital to put a cast on your broken arm, your insurance company will question the doctor's decision to treat you in an inpatient setting. Your broken arm needs treatment, but the cast can be put on in the doctor's office or emergency department. Neither you nor the insurance company should be charged for the higher costs of hospital care if a less expensive and reasonable treatment alternative is available.
The connection between cost and quality is value. Most consumers purchase a product or service because they will, or perceive they will, derive some personal benefit from it. Healthcare consumers — whether patients or health plans — want providers to meet their needs at a reasonable cost (in terms of money, time, ease of use, and so forth). When customers believe they are receiving value for their dollars, they are more likely to perceive their healthcare interactions as quality experiences.
Healthcare Quality
What is healthcare quality? Each group most affected by this question — consumers, purchasers, and providers — may answer it differently. Most consumers expect quality in the delivery of healthcare services: Patients want to receive the right treatments and experience good outcomes; everyone wants to have satisfactory interactions with caregivers; and consumers want the physical facilities where care is provided to be clean and pleasant, and they want their doctors to use the best technology available. Consumer expectations are only part of the definition, however. Purchasers and providers may view quality in terms of other attributes.
Identifying the Stakeholders in Quality Care
Purchasers are individuals and organizations that pay for healthcare services either directly or indirectly. If you pay out of pocket for healthcare services, you are both a consumer and a purchaser. Purchaser organizations include government-funded health insurance programs, private health insurance plans, and businesses that subsidize the cost of employees' health insurance. Purchasers are interested in the cost of healthcare and many of the same quality characteristics that are important to consumers. People who are financially responsible for some or all of their healthcare costs want to receive value for the dollars they spend. Purchaser organizations are no different. Purchasers view quality in terms of cost-effectiveness, meaning they want value in return for their healthcare expenditures.
Providers are individuals and organizations that offer healthcare services. Provider individuals include doctors, nurses, technicians, and clinical support and clerical staff. Provider organizations include hospitals, skilled nursing and rehabilitation facilities, outpatient clinics, home health agencies, and all other institutions that provide care.
In addition to the attributes important to consumers and purchasers, providers are concerned about legal liability — the risk that unsatisfied consumers will bring suit against the organization or individual. This concern can influence how providers define quality. Suppose you have a migraine headache, and your doctor orders a CT (computed tomography) scan of your head to be 100 percent certain there are no physical abnormalities. Your physician may have no medical reason to order the test, but he is taking every possible measure to avert the prospect that you will sue him for malpractice. In this scenario, your doctor is practicing defensive medicine — ordering or performing diagnostic or therapeutic interventions to safeguard the provider against malpractice liability (Minami et al. 2017). Because these interventions incur additional costs, providers' desire to avoid lawsuits can be at odds with purchasers' desire for cost-effectiveness.
Defining Healthcare Quality
Before efforts to improve healthcare quality can be undertaken, a common definition of quality is needed to work from, one that encompasses the priorities of all stakeholder groups — consumers, purchasers, and providers. The Institute of Medicine (IOM), a nonprofit organization that provides science-based advice on matters of medicine and health (and now called the National Academy of Medicine), brought the stakeholder groups together to create a workable definition of healthcare quality. In 1990, the IOM committee charged with designing a strategy for healthcare quality assurance published this definition:
Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM 1990, 4).
In 2001, the IOM Committee on Quality of Health Care in America further clarified the concept of healthcare quality in its report Crossing the Quality Chasm: A New Health System for the 21st Century. The committee identified six dimensions of US healthcare quality (listed in critical concept 1.1), which influence the improvement priorities of all stakeholder groups.
The IOM healthcare quality dimensions, together with the 1990 IOM quality-of-care definition, encompass what are commonly considered attributes of healthcare quality. Donald Berwick, MD (2005), then president of the Institute for Healthcare Improvement (IHI), put this description into consumer terms when he wrote about his upcoming knee replacement and what he expected from his providers:
* Don't kill me (no needless deaths).
* Do help me and don't hurt me (no needless pain).
* Don't make me feel helpless.
* Don't keep me waiting.
* Don't waste resources — mine or anyone else's.
The attribute of reliability is also important in healthcare quality. It is not enough to meet consumer expectations 90 percent of the time. Ideally, healthcare services consistently meet expectations 100 percent of the time. Unfortunately, healthcare today does not maintain consistently high levels of quality over time and across all services and settings (Burstin, Leatherman, and Goldmann 2016). Quality continues to vary greatly from provider to provider, and inconsistent levels of performance are still seen within organizations. In addition to the goal of achieving ever-better performance, healthcare organizations must strive for reliable quality.
When consumers define healthcare quality, they include high-value healthcare that achieves good outcomes at reasonable prices. Currently, the cost–quality ratio is far from ideal. Quality shortfalls exist in areas such as treatment effectiveness, care coordination, patient safety, and person-centered care (AHRQ 2016). Poorly designed processes can create quality problems and unnecessarily increase costs throughout the healthcare system. For example, when previous test results or health records are not available to the doctor during a patient's appointment, inaccurate diagnoses or duplicate testing can occur. In a recent survey, nearly 20 percent of patients in the United States reported that records or test results had not been available at an appointment in the past two years, or that duplicate tests had been ordered (Osborn et al. 2016). Better value in healthcare cannot be attained until the quality shortfalls are greatly reduced.
Selecting Improvement Aims
The National Quality Strategy, led by the Agency for Healthcare Research and Quality (AHRQ) on behalf of the US Department of Health and Human Services, was first published in 2011 as the National Strategy for Quality Improvement in Health Care (AHRQ 2017). The purpose of the National Quality Strategy is to guide and assess local, state, and national improvement efforts. It was developed with input from more than 300 individuals, groups, organizations, and other stakeholders representing all parts of the healthcare sector and the public.
When setting national aims, the National Quality Strategy adapted the IHI Triple Aim framework (Berwick, Nolan, and Whittington 2008). This framework detailed an interrelated approach for achieving optimal health system performance by simultaneously making improvements in three dimensions (care, health, and cost) that IHI called the "Triple Aim." The three broad aims of the National Quality Strategy are similar (AHRQ 2017):
* Better Care: Improve the overall quality, by making healthcare more patient-centered, reliable, accessible, and safe.
* Healthy People/Healthy Communities: Improve the health of the US population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.
* Affordable Care: Reduce the cost of quality healthcare for individuals, families, employers, and government.
(Continues…)
Excerpted from "Introduction To Healthcare Quality Management"
by .
Copyright © 2018 Foundation of the American College of Healthcare Executives.
Excerpted by permission of Health Administration Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
