Definition/Introduction

Quality in the traditional sense pertains to examining whether a product or service meets its expected characteristics and satisfies the consumer—in other words, how well does a product or a service do what it is meant to do.[1] For healthcare, the Institute of Medicine (IOM) has defined quality as “the degree to which health care services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge.”[2]

Healthcare Quality Domains

The goal of the healthcare system is to provide ideal care from a qualified provider in an appropriate setting for a particular patient. In other words, the patient is to receive the best possible care (i.e., standard of care based on evidence-based medicine) by a provider with the right expertise in a setting that maximizes efficiency and minimizes risk and abuse of resources—all the while treating the patient with respect and allowing involvement in care plan as the patient desires. In recent years, six domains have been identified by IOM that help to achieve a high degree of quality; health care must be safe, effective, patient-centered, timely, efficient, and equitable.[3] Meeting all these domains is at the core of quality management. “Safe” pertains to preventing harm to patients stemming from the care they are receiving. “Effective” uses evidence-based care with the correct utilization of resources. “Patient-centered” refers to care that is receptive and considerate of the patient’s inclination, needs, and values to guide all clinical decisions. “Timely” focuses on preventing delays in care. Efficient” relates to minimizing or avoiding waste of resources such as supplies and time. Lastly, “equitable” indicates providing care to all patients regardless of characteristics such as appearance, socioeconomic status, and values. The success of health care in achieving these quality domains can be measured by collecting data and evaluating “the five D’s:”  death (mortality), disability (morbidity), disease (resolution or persistence of disease following treatment), discomfort (the process of providing medical care) and dissatisfaction (the patient’s experience during the process of providing care).[4]

Quality Management

In healthcare, quality management refers to the administration of systems design, policies, and processes that minimize, if not eliminate, harm while optimizing patient care and outcomes.[5] The objective of quality management is to ensure that a particular product, service, or organization will consistently fulfill its intended purpose. To achieve this, there is a constant collection of data and alterations in process to create an optimal product or service that fulfills its intention and satisfies the consumer. Further data is then collected to ensure that no additional changes are necessary. Quality management systems (QMS) are tools used to implement quality management and organize, standardize, and improve activities involving a product or service aimed at customers.[5][6] By measuring outcomes and effects of different factors via data collection, issues within the system are identified, and evidence-based medicine and resources are used to develop or alter processes to improve the quality of care. Information is then collected regarding new outcomes to determine if the changes were beneficial or if other alterations are required. The ultimate goal is to achieve consistent, high-level care with minimal morbidity, mortality, disease, discomfort, and high patient satisfaction while meeting or exceeding all six of the IOM domains (safe, effective, patient-centered, timely, efficient, and equitable care).

Here is the definition of quality and quality management as applied to a case scenario, noting that all six IOM domains are easily identifiable. A trauma hospital offers a service: to safely and efficiently assess and stabilize a patient after suffering a traumatic injury. Regardless of the patient’s history or background, the patient is seen within a specific time frame based on the acuity of the trauma. To achieve optimal care, all trauma providers are all trained in Advanced Trauma Life Support (ATLS) to keep the evaluation of this patient organized and address the most life-threatening injuries first.[7] Despite the intensity of a trauma scenario, all efforts need to respect a patient’s privacy and goals of care. After the patient’s hospital stay, quality management teams measure data, including adverse events, patient outcomes, and experience (i.e., the five D’s) to optimize future care and make changes and recommendations as needed.

Issues of Concern

Quality Management Models and Approaches

There are different Quality Management models and approaches. A recent review of existing quality management models for inpatient healthcare identified 64 different models, 17 of which gained recognition as significant to current healthcare practice.[8] Below, we discuss a few of the models and potential issues.

Total Quality Management (TQM). TQM is an “integrated process involving all systems and employees in a continuous effort to improve quality, reduce cost, and enhance service to [the] customer.”[9] To identify essential elements of TQM in healthcare, researchers conducted a meta-analysis to determine crucial aspects to the success of TQM in healthcare. Among these were leadership, employee involvement, training, process management, support from upper administration, and planning.[10] Interestingly, another meta-analysis identified factors contributing to the failure of TQM implementation in healthcare.[11] These include lack of employee involvement (specifically by physicians), lack of consistent upper- management support, poor leadership, lack of a quality-oriented culture, insufficient education and training, and inadequate resources.[11]  The similarity between the two studies indicates the essential elements of a healthcare organization. The development of these features leads to success, but inadequacy will result in the breakdown of TQM implementation.

Continuous Quality Improvement (CQI). CQI involves the systematic use of tools and processes to identify and analyze strengths and barriers within an organization and continually test and improve outcomes. CQI methods started in the business and engineering fields post World War II and have been used in healthcare in the last few decades.[12] In healthcare, CQI’s approach to improvement allows for connecting the most recent best evidence with current practices to achieve better patient outcomes.[13] While finding success in different aspects of healthcare, some areas have identified barriers with CQI.[14] For example, implementation of CQI programs in colonoscopy services found a significant knowledge gap concerning barriers and facilitators pertaining to nurses, patients, and managers.[14]

Joint Commission on Accreditation of Healthcare Organizations. Accreditation of healthcare organizations has been another Quality Management pathway. An example is The Joint Commission, which is a voluntary process that enforces, monitors, and improves upon the quality of healthcare in the United States and internationally.[15][16] It currently evaluates greater than 20,000 healthcare organizations and is the largest accreditation group in the nation. The Joint Commission measures whether a facility is meeting accreditation standards for healthcare quality, which includes incorporating programs that perform quality measurement, evaluation, and improvement of patient outcomes. Accreditation also provides external validity to hospital administration and increases transparency to patients and providers.[17] The Joint Commission hospital standards focus on the following areas[15]:

• Patient-related issues such as care, education, and ethics
• Organization-related functions such as performance, leadership, surveillance, infection control, and prevention
• Organizational structure such as governance, management, and medical staff

The question lingers: what is accreditation, and why is it important for hospitals? When a hospital is accredited, its performance is within the range of nationally-accepted criteria based on government guidelines; this means the hospital has its system of assessment and self-improvement, resulting in compliance with the standard of care and, ideally, better outcomes. Additionally, accredited hospital enhances public confidence (i.e., satisfies the consumer).

A recent study determined whether patients admitted to accredited US hospitals have better outcomes and whether accreditation by The Joint Commission has any additional benefits for patients compared with other independent accrediting organizations.[18] Results indicated that US hospitals accredited by independent organizations did not experience significantly lower mortality but did demonstrate slightly reduced readmission rates for the fifteen common medical conditions. Also, there was no indication that patients choosing a hospital accredited by The Joint Commission had any healthcare benefits compared to a hospital accredited by another independent accrediting organization. Of note, there were limitations to the study as it was observational.

Clinical Significance

Principles of Quality Management

Regarding the study of quality management, the International Organization for Standardization (ISO) identified seven basic principles that, when applied properly, can aid in the evaluation and optimization of a service or product based on data collection, process improvement, and coordination amongst involved parties.[5] ISO is an independent international group of voluntary experts that develops consensus-based and market-relevant International Standards. These quality management principles, or QMPs, include customer focus, leadership, engagement of people, process approach, improvement, evidence-based decision making, and relationship management.[5]

Customer service/ customer satisfaction is essential to quality management. Without customers, there is no one to offer a service or product. The goal is to keep customers returning by meeting their expectations and building confidence in the offered product or service. While an institution’s employees are each other’s customers, the ultimate customer is the patient. Both patient experience and patient outcomes define healthcare quality. While we do not want the patients cycling through a hospital more than needed, the hospital would like to be their provider of choice if hospitalization is warranted.  By taking into account the patient’s perception of care—did they feel respected, were they included in the plan of care—and by fulfilling patient expectations, the financial aspect of the healthcare system also will thrive. As an example, patients coming into the emergency department expect to be seen and cared for in a timely fashion. One example of a way to ensure a timely evaluation is to record when each member of the team arrives to evaluate a patient.  As mentioned, while the patient remains the ultimate customer of healthcare institutions, it also should be emphasized that the people at every level of the organization are one another’s customers, and each other’s performance is intertwined. The goal is for each group/department to meet or exceed the needs and expectations of the departments or groups they are serving. This approach allows the entire institution to deliver the utmost care and safety to its patients. For example, the paramedics rely on the emergency department to be ready for a patient, and, in turn, the emergency physician relies on quick test results from the laboratory and radiology departments.

Leadership is necessary at all levels to reinforce the goals and purpose of an organization, product, or service. Leadership at the top is needed to set the mission and vision of the organization and to promote support, efficiency, and open communication by encouraging a unified and attainable approach to reach objectives via pre-set process/policies. Returning to our trauma scenario, the trauma surgeon ensures that the ATLS protocol is followed, and appropriate interventions are taken, whether it be a chest tube insertion or exploratory surgery. Their job is to encourage the team and communicate the needs of the patient to those within the trauma bay and other involved parties such as the operating room or interventional radiology.

Engagement of people at all ranks is essential to reach the objective of an organization, product, or service. Healthcare institutions are built on the strength and commitment of its people. It is ideal to have enthusiastic workers who are competent in their particular role within the process. By respecting those at all levels, there is an improvement in job satisfaction, motivation, and collaboration; thus, better feedback for improvement within all stages of the process.  As an example, in the operating room (OR), all providers have a known, pre-identified role, whether it is the scrub technician monitoring the sterile field, the anesthesiologist evaluating patient vitals, or the OR nurse who is leading the pre-operative timeout. Feedback from all providers is essential to ensure they can perform their job at the highest level possible.

Process approach is the key to achieving a consistent, desired outcome. While it is often multiple interrelated processes that are required to achieve the ideal outcome, these all must function consistently and as a unit to thrive. Once standardized, individual processes require continuous assessment and appropriate optimization if areas needing improvement are identified. For a cardiac arrest patient, the process begins the moment 9-1-1 is called and continues through assessment by EMS, handoff to the emergency department team, performance of advance cardiac life support protocol, and throughout the patient’s hospital stay. While each aspect of care provides different services, each must be standardized and eventually optimized to achieve the ultimate objective of getting the patient home safely with minimal morbidity.

Improvement is the key to success. By continually collecting data and assessing outcomes, opportunities for improvement come to light and are addressable. The end result is better quality through improved performance, outcomes, and customer satisfaction. Root cause analysis and failure mode and effects analysis are two methods used to examine sentinel events and promote improvement within a health care system. In the medical world, there are frequent morbidity and mortality conferences and peer review sessions pertaining to a patient not having an ideal outcome. What could have been done better throughout all stages of care? Was the patient seen and evaluated in a timely fashion? Was there a missed diagnosis? Were the appropriate interventions taken for the clinical picture? Was there a breach in the standard of care? What can possibly remedy this?

Evidence-based decision making (i.e., evidence-based medicine) is the evaluation of facts, evidence, cause-and-effect relationships, and other data that will allow for the delivery of the best product or service. By basing decisions on facts, processes can be standardized, which is more likely to produce consistent and desired results. After changing processes, it is important to continue to monitor outcomes to determine whether corrective action is reaching the desired endpoint. By repeating this cycle and sharing results with other health care intuitions, quality care, and ideal outcomes can be widely replicated.  For example, Level 1 trauma centers have in-house trauma and neurosurgeons around the clock to ensure expedited care because studies and clinical experience have shown that immediate access to these physicians reduced cost, time to intervention, and hospital length of stay.[19]

Relationship management is essential for an organization to thrive. Supportive relationships with suppliers, retailers, monetary providers, and partners must be maintained as well as a common understanding of goals across all parties. Shared goals and understanding also ensures a reliable supply chain to allow the institution to deliver high-quality care to its patients consistently. For example, donations to a hospital allow a new interventional radiology suite to be built with the highest level of technology so that patients can be accessed quicker, and providers have more space and resources for treatment.

Nursing, Allied Health, and Interprofessional Team Interventions

Pioneers such as Ignaz Semmelweis and Florence Nightingale were among the first in medicine to make changes to process based on observation and data collection.[20][21] Semmelweis was a Hungarian physician who observed increased mortality in obstetric patients who were cared for by physicians versus those cared for by nurse-midwives within the same institution. It was not until one of his colleagues suffered an injury and death due to scalpel puncture while performing an autopsy that Semmelweis noted an association. He instituted a policy of handwashing after completing autopsies and prior to delivering babies, and, as a result, the mortality rate decreased substantially to a level similar to that of midwives. As for Florence Nightingale, an English nurse, she is known for her observation of poor healthcare conditions while serving the British army. She also was an advocate for the development of standardized, formal nursing education and was recognized as one of the earlier adopters of evidence-based medicine using data and data visualization.[21]

Going forward, healthcare education should promote quality management as part of its curriculum and interprofessional collaboration efforts. By introducing medical, healthcare, and allied professions students and practitioners to quality improvement, they will be more likely to reap the benefits of improved patient outcomes and satisfaction. Not to mention, knowledge of the benefits of quality management will enhance compliance with and feedback from all areas within the health care system. With insurance companies denying reimbursement for issues such as foley catheter or central line-associated infections developed during a hospital stay, the push for quality improvement increases.  More than just meeting criteria for reimbursement, quality management, when used to its full potential, will encourage optimal outcomes, supreme patient satisfaction, reduce work by improving efficiency, and lower overall patient and hospital costs. It all begins with collecting data to identify problems, evaluating possible causes, determining potential solutions, and subsequently monitoring corrective actions for effectiveness. These measures not only serve to improve patient outcomes, experience, and hospital performance, but also fulfill requirements by joint commission and even insurance companies. Whether it is evaluating a trauma M&M, a root-cause-analysis after a sentinel event, or the rate of catheter-associated UTI, the importance of quality improvement cannot be under-emphasized. They should continue to grow as a part of conventional health care education and practice.