According to the Institute of Medicine (IOM), most medical errors are caused by broken systems and procedures, not people (Hughes, 2008). Institute of Medicine (IOM) defines quality as “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 2018). Centers for Medicare and Medicaid Services(CMS) begins the shift from quantity-based care to a quality of care, this was set into place to force healthcare to assess quality for reimbursement purposes (CMS, 2020). According to Hughes, Quality Improvement (QI) is used in healthcare to assess and define problems that focus on quality and safety improvement for all health services individuals (Hughes, 2008). In healthcare today, there are many forms of assessing the quality and safety outcomes, most of them focus on either direct or indirect measures. There are five steps in quality improvement identifying the problem or issue, analyzing the data, developing the plan to correct, implementing the plan and reassessing to assure that the change has been successful. The two methods of quality measurement used by healthcare today would be Plan-Do-Study-Act and the Six Sigma approach (Hughes, 2008).
The Plan-Do-Study-Act (PDSA) model is one way to have “positive changes in health care processes” generally leading to favorable outcomes (Hughes, 2008). This method has been used “by the Institute of Healthcare Improvement for rapid cycle improvement” (Hughes, 2008). One of the exclusive factors of this method is the scientific nature of assessing and impacting change, this is effective and completed by small and regular PDSA’s instead of large, drawn out process, this is completed before any changes are done to the current system. PDSA’s quality improvement attempts are utilized to create relationships between outcomes and any changes in the process. According to Hughes, “Langley and colleagues proposed three questions before using the PDSA’s cycle: 1. What is the Goal? 2. How will the goal be known whether it has been reached or not? and, 3. What will be done to reach the goal?” (Hughes, 2008). This cycle would begin by identifying the problem, what can and should be changed, planning for specific changes, who fits into the solution, what can be measured to recognize the effect of change and where the approach is targeted. Implementation of change will begin, data can now be collected, and results can be reviewed and defined through several crucial measurements. This will specify if the target has been accomplished or has failed. After the results are completed this will indicate implementing the change or to begin the process over again (Hughes, 2008).
The Six Sigma model focuses on eliminating waste and defects, creating the improvement in quality and proficiency, by improving and restructuring all processes ( AHRQ, 2019). This method is utilized in health care to increase the consistency of the processes delivering health care services, increasing satisfaction and creating financial stability. There are two main approaches used with six sigma, one of the methods “ inspects the process outcomes and counts the defects, calculates a defect rate per million, and uses a statistical table to convert defect rate per million to a sigma metric” (Hughes, 2008). This is a method used for pretest and post-test studies. The second method utilized will estimate the process variation which foresees process accomplishments by determining a sigma metric from the well-defined tolerance levels and any differences recorded for the process. This method is used for the analytical process that the accuracy and precision can be determined by procedures that are under trial (Hughes, 2008). One of the components of Six Sigma is a five-step process also known as DMAIC, this process is define, measure, analyze, improve and control approach. The process on this begins with identifying the project, historical data is studied, and the scope of expected outcomes is defined. Next the quality performance standards are picked, objectives on performance are defined and variances are decided. Implementation of the project begins with, data that will be analyzed to identify how well the process has improved. This will then be supported by developing measures to determine the capability of the process (Hughes, 2008). Both the Six Sigma and PDSA remain interconnected through some of there key elements such as the planning phase in PDSA is related to defining the core process, customers, and requirements of the customers of Six Sigma. The do stages of PDSA is related to the performance measures of Six Sigma, this continues through many stages (Hughes, 2008).
In order to implement any of these quality improvement strategies, healthcare organizations will have to have strong leaders in place, who will support, be involved, be able to consistently push quality improvement commitments and assure changes will be completed as needed (Hughes, 2008). The requirements of leadership to assure the resources are met for the changing processes are as follows.
• Making sure there are adequate financial resources to fund training, purchasing and testing new technologies or equipment.
• Assure all people involved in the changing processes have adequate time and support from administration.
• Allow adequate time for projects to work.
• Create and enforce organizational expectations revolved around safety.
While leadership drives the quality improvement initiatives, it is also important for them to embrace the need for change, allow for change with the culture by enabling change, actively lead to change the culture for quality improvement and safety (Hughes, 2008).
According to Hughes, quality improvement entails five key elements for it to be successful: “ fostering and sustaining a culture of change and safety, developing and clarifying an understanding of the problem, involving key stakeholders, testing change strategies and continuous monitoring of performance and reporting of findings to sustain the change” (Hughes, 2008).
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