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Chamberlain College of Nursing: NR-534- HEALTHCARE SYSTEMS MANAGEMENT
Managing Quality to Promote Cost Effectiveness and Value-added Practices (graded)
Nursing leaders understand that to determine the level of success of an activity there must be opportunities to measure, analyze, and evaluate activity-based data. Consider a current National Patient Safety Goal or Institute for Healthcare Improvement care bundle.
Investigate how a systems-approach is utilized in providing patient-centered and value-added care. (PO 4, 6, 7)
Describe a patient-centered model that uses clinical pathways, nursing care plans, and multidisciplinary action plans to assist in planning quality-driven and cost-effective care. (PO 8, 9)
Identify various team strategies for problem-solving that enhance patient-centeredness and value-added care. (PO 8, 9)
What professional and organizational standards are met by these initiatives? How is the performance of staff related to these initiatives measured? Who analyzes them? Explain how the nursing staff is enabled and encouraged to maintain these standards that improve quality care.
Quality Control and Cost-Effective Care
No doubt, most workers in healthcare have heard of Six Sigma, LEAN, or the newer combination process called LEAN Six Sigma. Six Sigma is a specific process developed in manufacturing with a focus on improving quality and sustainability of products to improve customer satisfaction. As applied to healthcare, the use of Six Sigma strives to improve patient-care quality, ensure consistency, and improve patient satisfaction. LEAN is a set of methods or strategies to decrease the time frame to provide products and services (Van Leeuwen & Does, 2011). In healthcare, these methods or strategies decrease the time of consensus decision making and implementation and swiftly leads to positive results. The advantages of healthcare organizations using these combined methods is to improve the overall quality of patient care quickly, sustain the quality, and increase patient satisfaction, thereby improving the organizations business performance.
In the combination, LEAN Six Sigma, there are eight categories of organizational waste that are addressed. These categories are (a) defects, (b) overproduction, (c) waiting, (d) unutilized talent, (e) transportation, (f) inventory, (g) motion, and (h) extra-processing (Van Leeuwen & Does, 2011). Like Six Sigma, LEAN Six Sigma uses the DMAIC phases of change, where D is for define, M is for measure, A is for analyze, I is for improve, and C is for control. Ultimately, through careful and purposeful use of LEAN Six Sigma, improved quality is assured.
Lean Six Sigma: Phases
To begin applying the Lean Six Sigma to an organization, there needs to be a comparison of its current performance in any number of areas with expected or desired performance. The first phase is to define the problem or issue (Van Leeuwen & Does, 2011). For example, one challenge in the emergency department is the length of stay and time to transfer of those patients who have admission orders. The issue for the department is that there is a backup of patients, new patients do not have exam rooms, and currently admitted patients do not have inpatient beds. Quality of care is diminished, patient satisfaction is decreased, and organizational revenue is compromised.
The second phase is to measure. This is accomplished in our example by looking at data. The data that are gathered include (a) length of time from patient time of arrival to time first being seen by a provider, (b) length of time from writing of patient admission or discharge order to actual time of transfer or leaving, and (c) identified factors that are barriers or challenges (such as readiness of inpatient bed, available staff to care for the patient, etc.). A flowchart or matrix diagram is constructed that identifies all of the parts or variables (Van Leeuwen & Does, 2011).
The third phase is analysis. Data collection continues for a period of time, which may be ex post facto or to sometime in the future. Once it is determined that the amount and quality of the data are adequate, the analysis of the data occurs. The issues addressed in the definition of the problem are those that are considered in the analysis. Evaluation of the data for causality is considered and noted. Statistical applications occur to determine if what seems to be intuitively important is really significant. Once completed, a cause-and-effect diagram or matrix is constructed that clarifies the data in a manner that everyone can appreciate (Van Leeuwen & Does, 2011).
The fourth phase is improve. It is at this point that the various solution options are generated, concerns are addressed, and consensus is reached. Some of the discussion may surround the availability of housekeeping to clean inpatient beds, lack of adequate nursing staff to accept the patient to the inpatient bed, delays in processing the admission orders, and so on. Each of the identified causal concerns would be addressed with a solution that supports the goal of the process, which is to decrease length of stay in the emergency department. The implementation of the improvement plan occurs (Van Leeuwen & Does, 2011).
The last phase is control. The processes that were changed during the improve phase are now monitored. The monitoring is done to ensure that the processes are hardwired into the workflow and to evaluate if additional changes are required. Data collection continues, and as the results come in, there is an expected decrease in the patient length of stay in the emergency department. This change-based data is the deliverable from the LEAN Six Sigma process (Van Leeuwen & Does, 2011).
The follow-through that monitors this change once the LEAN Six Sigma process is completed is generally taken over by the quality department of the organization. This process, sometimes called Kaizen after the original Toyota production process, identifies who and how the change will be monitored. The quality department will (a) define the responsibilities related to the process outcome, (b) develop control mechanisms at the unit level, and (c) ensure that processes are performed in a standard manner (Roussel, 2013).
One way that this is determined is through the control pyramid of Juran (Van Leeuwen & Does, 2011). The pyramid, with its defined areas of interest, will be adjusted to the original problem or issue, and those responsible will be identified. In the emergency department, beginning at the bottom of the pyramid, the processes, policies, and defined actions will be carried out by the staff when specific criteria are met. The frontline leaders will address any minor issues related to the policies and actions. The next section up on the pyramid will be the next level of leader, who will address any chronic or repetitive problems and develop a mechanism of quality control in conjunction with the quality department. The top of the pyramid is senior leadership, who are responsible for the coordination of the process improvement projects (Van Leeuwen & Does, 2011).
Meaningful Use: Patient Safety and Quality
Currently, and into the future, the term meaningful use will become common jargon in discussions of cost, quality, and patient safety. In 2004, the beginnings of meaningful use were proposed by President George W. Bush, who addressed the need for an electronic health record (EHR), and in 2009, Congress supported the call through a provision in the Health Information Technology for Economic and Clinical Health Act (HITECH). The purpose of HITECH is to streamline government spending for healthcare by ensuring that systems are in places that will positively impact care diagnosis, ongoing patient and care monitoring, and care delivery (McCulloch & Tegethoff, 2013).
HITECH has three stages that began in 2010 with Stage 1, planned implementation of Stage 2 in late 2014, and Stage 3 implementation is to be determined. Stage 1 had a focus on organizations being able to collect and share data through a comprehensive electronic health information system. Stage 2 emphasizes clinical processes such as quality improvement at the bedside through information exchange. Stage 3 is expected to prioritize outcomes by (a) supporting quality throughout the organization related to care, devices, and services; (b) including multiple medical devices into the EHR where data is automatically populated for use; and (c) implementing clinical decision making, care coordination, and patient tools to support self-management of care (McCulloch & Tegethoff, 2013).
Nursing leaders should expect a changing future in quality and safety measurement and management as electronic devices become integrated into the EHR. One example of this is intravenous pumps that are scanned into the patient record and record all rates, adjustments, and so on. If the intravenous solution is a vasoactive agent, the EHR records the appropriate vital signs and alerts care givers to values that are outside of expected ranges. Some of the current intravenous pumps have central-computer-based interfaces that alert nurses if the rate of the medication to be administered is outside of the expected ranges. Another example of patient self-care management is a device that the patient attaches to himself or herself at specific times of the day; data are transferred to a central point for analysis and feedback. These types of devices are currently in use in obstetrics for those who may be a risk for preterm labor and in cardiology for heart failure patients to monitor weight, blood pressure, and oxygen saturation rates. It should be noted that, from a cost-savings view, patients who manage their care from their home environment have significantly lower costs than presenting to an emergency department or even to the physicians office. Additionally, as groups of disease processes are added to the Centers for Medicare and Medicaid list of no pay for readmission within 30 days of discharge, these new quality and safety measures support the organizational budget because they provide high quality of care and patient satisfaction.
Accountable Care Organizations
With the 2010 Patient Protection and Affordable Care Act (ACA), the United States adopted legislation to promote cost savings, improved access to care, and improved quality of care. The Accountable Care Organization (ACO) is one of the many provisions of the ACA that has a focus on the Medicare and Medicaid recipient population (Marcoux, Larrat, & Vogenberg, 2012). ACOs are to be inclusive, integrated networks in which patients receive comprehensive care including nutrition and dietary counseling, social services, and community outreach as well as the expected healthcare services. Through care coordination, it is believed that there may be substantial cost savings because patients remain healthier or have health issues addressed prior to their becoming acute.
ACOs have three core principles that are to be foundational in their creation. First, the ACO should be led by those who will be the providers of the care, where these providers take responsibility for the quality of care delivered for their population of patients. Second, the mechanism of payment for service is based on the level of quality, which is a change from the popular fee-for-service payment approach. Third, ACOs must have the ability to measure their performance, evaluate the data, and implement improvement to demonstrate high-level care to ensure payment. The types of organizations that are considered to be a part of the ACOs include (a) multi-hospital systems, (b) multiple-physician specialty practices, and (c) associations of different types of providers. Each of these current organizations would be required to add services and supports to achieve the full expectations in order to be identified as an ACO (Marcoux, Larrat, & Vogenberg, 2012).
The performance measures are to include (a) the patient experience, (b) care coordination, (c) patient safety, (d) preventive services, and (e) special services and care for the elderly (Marcoux, Larrat, & Vogenberg, 2012). One of the advances in the associations of different types of providers comes with the assignment of pharmacists to patients discharged from acute care, for the first 30 days post-discharge. This group of pharmacists is active in patient interaction and discussion related to patients responses to medications and convalescence related to drug therapy. One area that is important to the success of the ACOs is patient involvement. In the ACO vision, the patient has responsibility for identifying healthcare issues and seeking assistance. It is this aspect of the ACO success equation that is questionable because many of the patients in these populations are older and have a different cultural perspective and expectation than this government program has.
Nurse leaders, wherever they practice, will be impacted by the ACOs that are a part of their community. The requirements to deliver and monitor care and measure outcomes for high quality, cost reduction, and increased patient satisfaction will be intertwined with everyday leadership responsibilities. Understanding the purpose and goals of the ACO helps nurse leaders to better appreciate their role in ensuring that patient goals are met.
Nursing leaders should have an understanding of the Lean Six Sigma process and the DMAIC categories, with the actions expected at each phase. The use of these tools assists leaders in meeting the organizational goals and professional goals of nursing. The collaboration and high-level view allows discovery of a solution that is organizational rather than unit or division based. More and more organizations are turning to Lean as a way to bring quick, high-quality change that is sustainable to their organizations.
Quality-control and cost-effectiveness management requires nurse leaders to be aware of the many changes that impact the healthcare system and, as such, nursing services. Leaders must be prepared to work in teams to solve the unit, division, and organizational issues while maintaining professional standards and expectations. Keeping the focus on the patient helps nurse leaders make the best choices, maintain the highest quality, be financial stewards, and ensure patient safety.
Marquis, B. L. & Huston, C. J. (2014). Leadership roles and management functions in nursing: Theory and application (8th ed.).Philadelphia, PA: Lippincott, Williams & Wilkins.
Chapter 23: Quality Control
Dearmon, V., Roussel, L., Buckner, E. B., Mulekar, M., Pomrenke, B., Salas, S., Mosley, A., Brown, S., & Brown, A. (2013). Transforming care at the bedside (TCAB): Enhancing direct care and value-added care. Journal of Nursing Management, 21(4), 66878. link to article
Nursing, nurses and accountable care organizations. (2011). Minnesota Nursing Accent, 83(7), 3, 17. link to article
Porter, M. E. (2010). What is value in health care? The New England Journal of Medicine, 363, 2477-2481. doi: 10.1056/NEJMp1011024 link to article (seminal article on healthcare value)
Upenieks, V. V., Akhavan, J., & Kotlerman, J. (2008). Value-added care: A paradigm shift in patient care delivery. Nursing Economic$, 26(5), 29430. link to article
Clarke, R. L. (2011, April). Quality leadership. Healthcare Financial Management, 152.
Cropley, S. (2013, Autumn). Accountable care organizations: Implications for nursing. Texas Nurses Association, 87(4),811.
Marcoux, R. M., Larrat, P., & Vogenberg, F. R. (2012). Accountable care organizations: An improvement over HMOs? P&Ts, 37(11), 629630, 650.
McCulloch, G. & Tegethoff, G. (2013). Meaningful use and its impact on healthcare technology management. Biomedical Instrumentation & Technology, 47(1), 3034.
Van Leeuwen, K. C. & Does, R. J. M. M. (2011). Quality quandaries: Lean nursing. Quality Engineering, 23, 9499.
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