Introduction
This paper discusses appropriate strategies for administering the quality improvement and risk-management processes within a healthcare delivery system. According to Esain and Williams (2012)., risk management and quality processes complement each other in such a way that they provide a platform for considering all activities in the health care delivery system, the way they are performed, and suggest ways for their improvement before any problems occur. Various organizations in the U.S. have been successful in implementing appropriate quality improvement and risk management strategies through encouraging their staff to take part, give their views and share their experiences. For such success to be realized in the healthcare delivery system, the leadership team as well as the governing body should demonstrate their commitment to the appropriate strategies and clarify their prospects for all stakeholders (Esain & Williams, 2012).
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Besides, healthcare delivery system management requires ensuring that adequate resources are provided in order to satisfy organization and system requirements. This will enable efficient mitigation, control as well as management of all risks thereby enhancing attention on the healthcare organization’s main business, which entails caring and treating all patients in a clinical environment that is safe and of desirable quality. Therefore, implementation of appropriate strategies for quality improvement and risk management boosts reliability, accountability and safety within healthcare environment. According to Millar (2013), such strategies will emphasize the framework for identifying, analyzing, applying corrective treatment, monitoring as well as reviewing problems, risks, or opportunities.
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The necessity for implementing quality improvement and risk management strategies permeates healthcare delivery system. This is because, individuals are not the ones responsible for most of the errors that occur in the medical environment; but faulty processes and systems (Millar, 2013). The existence of such errors points to the significance of adopting improvement and management strategies for identifying ineffective care, preventable errors and inefficiencies in order to influence positive changes within healthcare delivery system. It is worth noting that each of the improvement and risk management strategies will entail performance assessment and utilization of results to influence informed changes. However, it is also significant to note that efforts and strategies for quality improvement and risk management should have the following qualities: ability to contribute to unintended findings in various sections of the system; should enable the primary beneficiary (consumers/patients) experience improvements in the desired manner; and demand extra efforts to return processes in the health care delivery system in satisfactory ranges (Esain & Williams, 2012). Complexities in the healthcare delivery system result from interdependence among clinicians, occupational differentiation, and the impulsive nature of health. For this reason various organizations in the U.S. such as the Joint Commission, the National Quality Forum (NQF), and the Agency for Healthcare Research and Quality (AHRQ) endorse the utilization of reliable and valid strategies that can improve patient safety and the overall processes in the healthcare delivery system (Abdallah, 2014).
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Quality Improvement Strategies
In considering the strategies for quality improvement and risk management process, sufficient levels of consideration should be given to three essential aspects: process measures, outcome measures and structure measures (Abdallah, 2014). Process measures entail assessment of the manner in which providers and clinicians deliver health care services to patients; for instance, implementation of proper guidelines in administering care to diabetic patients. Structure measures entail assessment of availability, accessibility, and quality of resources like bed capacity of a health care facility, the number of health care staff; professional nurses and doctors, and health insurance. Outcome measures entails indication of the resulting status of health care and the manner in which it can be influenced by both behavioral and environmental issues. Such outcome measures include improved status of health, patient satisfaction, and the rate of mortality.
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There is regular interchangeable use of Total Quality Management (TQM) with Continuous Quality Improvement (CQI) in the health care delivery system (Abdallah, 2014). The use of CQI has been significant for facilitating development of clinical practice with underlying principle that every process comes with an improvement opportunity at all the time. For a long time, there have been quality assurance programs that have been used in the health care industry to attend to issues that accreditation or regulatory organizations identify. Such issues include studying credentialing processes, reviewing functions performed by oversight committees, and checking documentation. However, there are several other strategies that can be embraced in order to realize improvements in clinical practice. This paper will discuss the following tools and strategies relevant for quality improvement in health care delivery system: Plan-Do-Study-Act, root-cause analysis, Lean, Six Sigma, and health failure modes and effects analysis (HFMEA). These are appropriate strategies, which healthcare experts require embracing to improve quality and mitigate risks in the health care delivery system.
Plan-Do-Study-Act (PDSA)
This is s useful model in the health industry when undertaking quality improvement studies and projects with the purpose of influencing positive changes in order to realize favorable outcomes. This strategy has been widely embraced by the Institute of Health Improvement and has enabled it realize rapid cycle improvement (Millar, 2013). This strategy has various unique features; but the most impressive one is its cyclical nature in the manner in which it impacts and evaluates changes especially when frequent and small PDSAs are performed ahead of the changes in the system. Plan-Do-Study-Act is a quality improvement strategy whose main purpose is to form a causal or functional relationship as observed in the changes between outcomes and processes (capabilities and behavior). However, in regard to PDSA strategy of quality improvement, Millar (2013) in his view, proposed an individual requires asking three essential questions before embracing PDSA cycles. The questions included: (1) what is the project’s main objective? (2) How will achievement of the goal be known or verified? And (3) what steps should one consider to attain the objective? In the respect to the health care delivery system, the PDSA cycle commences at the point of defining the scope and nature of the challenge, the kinds of changes that require being implemented, a structured plan for each change, the people that should be involved, the issues to consider and measure in order to realize the impact of change, and finally, areas where the strategy will be applied.
Root Cause Analysis
This is a problem solving and formalized investigation strategy whose main focus is to facilitate identification and comprehension of hidden causes of an occurrence as well as any other potential occurrences that might have been intercepted (Esain & Williams, 2012). In applying this strategy, the Joint Commission requires health care organizations to perform root cause analysis as a reaction to sentinel events. The Joint Commission, also, requires an organization establishing and implementing a plan of action that contains quality improvements intended to mitigate risks in the future. Monitoring of the effectiveness of such improvements should also be included in the plan. Root cause analysis strategy is essential for identification of trends and evaluation of risks in the event of the suspected human error. The premise of RCA is that the system as opposed to human factors is the root cause underlying many problems. As a reactive evaluation, root cause analysis commences immediately after an event has occurred, it regressively sketches the order of events that influenced the occurrence of the identified incident. Root cause analysis ascertains root causes and charts causal factors in order to perform a complete examination of the incident. Being a labour intensive process, root cause analysis specialists should triangulate key findings in order to increase their validity.
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The application of a qualitative process in RCA is essential for uncovering the hidden causes that lead to errors. It uncovers the hidden causes through evaluation of enabling or influential factors like lack of education, latent conditions such as failure to check the ID band of the patient, and situation factors such as two or more patients having a similar last name in the same hospital; a situation that can influence an adversarial drug incident (Esain & Williams, 2012). It is significant to note that root analysis experts involved in the investigation process have to ask questions like what occurred, why it occurred, what factors proximately influenced its occurrence, the source of those factors, and what processes and systems were influential to proximate factors. The moment answers to these questions have been provided; they will assist in the identification of safety barriers that are ineffective and all causes of problems in order to prevent a repeat of similar incidents in the future. Therefore, root cause analysis is composite of a number of steps; however, it is significant to note that the last step is vital. It entails development of recommendations necessary for process and system improvement and, eventually, quality improvement of the entire healthcare delivery system. Besides, in order to improve its effectiveness, various RCAs should be embraced to examine manifold cases during a single review in case of certain classifications of events. Considering that there are numerous causes that lead to errors, which result in a wide scope of adverse events, much more focus should be directed towards differentiating process from system factors than individual blame.
Lean Methodology
This strategy is widely used in the manufacturing process of machines such Toyota cars and has seen a lot of success such companies. The driving force behind this strategy is the identification of essential needs to the customer and focuses on improving the quality of health care delivery system by excluding activities or processes that do not add any value to the overall product. Lean methodology procedure entails maximization of value added activities and/process in the most desirable sequence to ensure that there is continuity of operations. It should, also be clear that lean methodology is dependent upon root cause analysis for investigation of errors, general quality improvement, and prevention of similar errors. The application of lean methodology in health care has seen managers, technicians, nurses, and physicians reduce costs in blood banks, pharmacies and laboratories, and enhance the efficiency of patient care (Esain & Williams, 2012).
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Embracing this strategy can enable a healthcare organization improve the quality of health care and patient safety through systematic definition of the problem. This entails utilization of root cause analysis, outlining objectives, removal of workarounds and ambiguity, and clarification of responsibilities. Regarding the processes, stakeholders in health care require developing plans of action that can improve, streamline and reform processes of work. Application of this strategy in health care delivery system entails removal of wasteful daily activities and processes that relate to rework, workarounds and overcomplicated processes. This will entail focus on the output (assigning correct procedures to the right patients), responsibility (assigning the correct aspect of work to the right people), connection (identifying correct signals to indicate commencement of work), and the correct implementation of every step.
Six Sigma
Originally created and embraced as a business strategy, Six Sigma entails improvement, crafting, and monitoring in order to remove wastes while, at the same time, increasing financial stability and optimization satisfaction (Esain & Williams, 2012). In this case, process capability or performance is essential for measuring improvement through comparison of process capability ahead of upgrading with the capability of a given process following potential solutions necessary for quality improvement. Six Sigma entails the use of two basic methods. The first method utilizes estimates derived from process variation to help in predicting process performance. The calculation of a sigma metric is performed based on the variation and definite tolerance limits observed for a particular process. The second method involves inspection of the outcome of a process, enumerates the defects, computes the rate of defect per million, and coverts the rate of defect per million to a sigma metric by utilizing a statistical table (Gunasekaran, 2012). It is significant to note that one constituent of Six Sigma utilizes a five phased procedure popularly referred to as define, analyze, improve, and control (DMAIC) methodology (Aveling & Martin, 2012). This aspect starts by identification of the project, review of historical data, and definition of the range of expectations. The next phase involves continuous selection of overall quality standards of performance, definition of performance objectives, and definition of variability sources. During implementation of the new project, there is collection of data to assist in evaluating the effects of the changes regarding process improvement.
Failure Modes and Effects Analysis
Errors are inevitable occurrences, and it is usually difficult to predict the times of their occurrence. Failure modes and effects analysis (FMEA) as observed by Aveling and Martin (2012) is an assessment strategy utilized for the purpose of identification and elimination of known and/or likely failures errors, and problems from a service, process, design, and/or system ahead of their actual occurrence. FMEA has been embraced widely by both the National Aeronautics and Space Administration (NASA) and the U.S. military for prediction and assessment of potential failures as well as unrecognized hazards (Aveling & Martin, 2012). This facilitates proactive identification of steps within a system or process, which could decrease or eradicate failures in the future. Therefore, the main purpose of FMEA is deterrence of errors through trying all options that can lead to process failure, estimation of the effects of every failure, and implementation correct steps to prevent any occurrences of such failures. Therefore, it is significant to note that FMEA, in health care, employs a multidisciplinary team to conduct process assessment from the perspective of quality improvement.
Outpatient Boom
Proper administration of outpatient boom can result into improved quality of health care delivery system. Outpatient services have experienced tremendous growth that exceeds the rate of infrastructure expansion. According to Millar (2013), existence of appropriate infrastructure as well as modification in the way physicians practice can influence sixty percent of outpatient services performed in hospitals to be performed in different other settings. In this regard, managed care organizations should embrace fair use of capitation and the government should create incentives to reduce lengths of admissions and stays.
Primary care policing
Utilization procedures of managed care in the current dispensation subject doctors and their approaches of treatment to intense external scrutiny. It is a technique that pushes the system to incur more costs and yet it does not result into significant returns. Therefore, for purposes of quality improvement in health care delivery system, managed care organizations require empowering primary care physicians by utilizing risk sharing agreements in order to police the system (Millar, 2013). In order to decrease and manage the increasing number of admissions in hospital, incentives should be structured for primary care physicians. It is worth noting that empowering primary care physicians is a crucial representation of the basic power shift as far as the relationship between primary care physicians and specialists is concerned.
Quality Push
Health care organizations should embrace quality initiatives and actively re-engineer the strategy of delivering health services in order to achieve the best in terms overall quality improvement CITATION. This implies that every hospital requires having a continuous quality improvement (CQI) and/or total quality management (TQM) program.
Ensuring family and person-centered care
In many countries such as the United States, the design of health care delivery is often not aligned to satisfying the needs of the customer or patient. In fact, specific clinical conditions have been influential on the organization of most clinical services and thereby designed without the patient’s input. However, making realistic changes in system design and thus within health care can lead to achievement of quality improvement. Health care organizations should encourage each family and individual patient to take up active roles regarding their own health. Health care organizations should design health care services in such a way that they adapt readily to the circumstances of families and individuals and their varying languages, cultures, social backgrounds, health literacy levels and disabilities (Deckard & Weber, 2011). Person-centered care is essential because it regards an individual as a multifaceted individual and not as a person carrying a certain illness or symptoms. However, to achieve this status, there should be regular partnership between patients and health care providers accompanied with joint responsibility and power in care management and general decision making.
Promoting coordination of care and effective communication
Enhancing care coordination and effective communication among health care providers is significant for ensuring that relevant support and care is made available to patients how and when they need it. According to Deckard and Weber (2011), models of effective care coordination have great potentials to lower the costs and deliver improved quality in settings of practices that accommodate both small and large hospital centers. Improved care coordination in health care systems is essential for ensuring that patients suffering from chronic illnesses receive the most effective seamless care from providers. Besides, proven technologies like telemedicine, e-prescribing, and electronic health records can be useful for reducing or eliminating duplication and gaps in the delivery of patient care. Effective care coordination among clinicians, nurses, physicians, hospital management, and rehabilitation and long-term care facilities is essential for ensuring that recently discharged patients successfully avoid needless rehospitlization. Besides, healthcare organization should be on the front line of implementing policies proposed by the National Quality Strategy.
However, to ensure that patients experience improved quality every time they seek health care services, there requires being strong leadership commitment as well as support. Leadership in various hospital organizations should empower their staff and encourage their active involvement in order to constantly drive quality improvement (Laihonen & Karppinen, 2012). Lack of support and commitment from senior leadership can greatly distract the best intended processes and projects. Health care organizations also, require embracing a safety and improvement culture, which rewards improvement. The culture is an essential foundation of a quality infrastructure, which accommodates human capital and the resources necessary for successful quality improvement. All stakeholders and quality improvement teams should work together to ensure that there is clear comprehension of a problem and its root causes. In this case, there requires being a consensus regarding the meaning of the problem at hand.
Strategies for administering risk management process
According to Edozien (2013), risk is a possibility that an adverse consequence such as injury or loss can be incurred. Risk is inevitable in the health care delivery system because of its innate existence in every process undertaken, ranging from taking decisions regarding strategies for the future, determining service priorities, or even choosing to have no action taken at all. In regard to health care delivery system, it is significant to note that risk has associations that include people (staff, visitors, clients, and patients), consumables and equipment, estate and buildings, management and systems. Health organizations require considering risk management as one of the most essential elements that can contribute to quality improvement in the overall health care delivery system. Risk management is a preemptive process that entails identifying risks, impact assessment and possibility of risk occurrence and recurrence, risk control and reduction or eradication of the risk. It entails the structures, culture and processes that are essential for effectively managing adverse effects and potential opportunities.
It is essential to ensure that health care risk is effectively managed in order to preserve and protect the finances, reputation and services of a health care organization in the context of staff, financial and corporate governance. Healthcare risk management process that is evidence-based is essential for providing all staff with a secure working environment and enables a healthcare organization to be more responsive and flexible in terms of delivering satisfactory services to its clients patients in a dynamic environment (Edozien, 2013). Considering the multifaceted and complex nature of the current healthcare system, it is clear that delivery of healthcare service continues happening in an extremely pressured environment. Besides, it is within this kind of environment that health care experts make various judgments and decisions. It is therefore within such an environment that there is high possibility of things going wrong following the presence of errors. Individuals are not the main causes of errors because there is always an interaction between technological factors, human, equipment and environment whereby all these elements contribute to the possibility of errors occurring.
Since risk management is a progressive process, the personnel charged with such responsibilities require following main steps as suggested by Helmchen and Burke (2014) as: risk identification, analysis of risk, risk treatment/control, and financing of risk.
Risk Identification
This entails the collection of data regarding the present as well as the past incidences including any other events that may potentially cause adverse effects on the health care delivery system. According to Helmchen and Burke (2014), such risks happen in form of breach of contract, defamation, antitrust violations, casualty exposure, environmental damage, embezzlement, exposure to hazardous substances, general liability, fraud and abuse, workers’ compensation, transportation liability, securities violation, and professional malpractice. It is significant to not that identification of risk is a continuous process in order to effectively expose the possibility of certain liability risks such as antagonistic events responsible for causing harm, the complaints of patients regarding care, unexpected treatment outcomes. Risk management should be able to utilize early warning signals or data that occur in quality assessment studies, security reports, patient complaints, and licensure and accreditation surveys. Besides, specific department of a healthcare organization should ensure continuous flow of information to risk managers.
Risk Analysis
This entails assessment of experiences from both the past and the present exposure in order to eliminate and/or, also, reduce the risk effects on medical staff and employee morale, community image and cash flow (Helmchen & Burke, 2014). Risk managers require considering the risk in terms of its seriousness and likely severity to the organization and individual, the number of casualties, and the frequency as well as possibility for occurrence. Risk managers should rely on closed claims data in order to achieve a comprehensive evaluation as far as the current risks are concerned.
Risk Control/treatment
This refers to the response of a healthcare organization to significant areas of risk including its rejoinder to reduce or limit the liability following incidents which have just happened. It is an essential function in relation to risk management programs. Due to many overlapping and interrelated programs in a health care organization, activities concerning loss control should not be considered as single formal program. In some cases, safety management equates activities relating to loss control due to similarities in their objectives. Therefore, it is significant to note that a risk control program is a concerted effort, which comprises safety management, quality assessment, and risk management (Helmchen & Burke, 2014). Fundamentally, a management program responsible for risk control requires categorizing probable liability glitches into four key areas: liability losses, bodily harm, consequential losses, and property loss. In this case, it is the responsibility of the chief executive officer and the governing board in every health organization to ensure that there is a sound system for controlling risks in order to enhance the efficiency of health care delivery system.
Risk Acceptance
This applies to a situation where a healthcare facility does not initiate insurance cover against certain adverse events following the impossibility to avoid, transfer, or reduce the risk (Helmchen & Burke, 2014). Besides, the probable loss may not be excessive and the likely fiscal consequences fall within the capacity of the health care facility to resolve.
Risk Financing
Proper risk indemnification needs an all-inclusive retrospective and prospective organizational scrutiny of direct expenses associated with quantification as well as funding of risk management activities and losses (Helmchen & Burke, 2014). Financing options include commercial insurance coverage, self-insurance, and insurance premiums. Although risk financing functions do not fall in the domain of risk managers, it is significant for them to make their contributions to the negotiations by effective communication with the organization’s department of finance, and embrace terminology that is familiar to the finance personnel.
In the United States, the American Society of Healthcare Risk Management (ASHRAM) enlisted a number of risk management activities that should be practiced under a risk management program in a healthcare organization (Rest & Hirsch, 2012). Risk managers should be enabled ta access all medical data, management, and necessary credentialing. Every healthcare organization or facility requires having an experienced, trained and designated manager who should obtain more than eight hours for advancing risk management education on a yearly basis. Healthcare organizations require committing essential resources for risk management in respect to a policy statement, which should be embraced by medical staff, administration, and the governing body.
Risk Management Tools
In administering risk management process in the health care delivery system, it is significant to note that rapid identification of harms and accidents to staff members, visitors and patients has always been the main concern under the risk management programs right from the onset. In this regard, healthcare organizations require addressing likely problems and eliminate their causes before their reoccurrence. In respect to prompt identification, Rest and Hirsch (2012) outline three significant systems that are useful for accomplishing the process: incident reporting, occurrence reporting, and occurrence screening.
Incident Reporting
These systems were established in the mid-20th century to assist in identifying events, which were inconsistent with the hospital’s routine operation or administration of routine care to certain patients (Rest & Hirsch, 2012). Such inconsistencies include medication errors or malfunctioning equipment. These systems have assimilated computer technology. For instance, Calgary General Hospital in Canada invented a computer program, which helps in identifying five main categories of incidents: medication errors, computer errors, assaults, treatment errors, and falls. Facility personnel should complement the functions of the reporting systems in order to recognize and accurately report an observed incident to the management team member, quality assurance coordinator, or risk manager. Such reports require focusing on equipment problems, falls, birth injuries, burns, infections, blood errors, medication and treatment procedures against which the organization can be claimed.
Occurrence Reporting
Healthcare organizations or facilities require developing a comprehensive list of adverse patient occurrences, which physicians, staff and the entire medical personnel should report (Rest & Hirsch, 2012). Adverse patient occurrences may include allergic reaction, unexpected return to the facility by a surgical patient, or infant or maternal death.
Occurrence Screening
These are systems utilized for identifying deviances from routine procedures or regular treatment outcomes and are useful in both quality assurance and risk management (Rest & Hirsch, 2012). Although these systems identify adverse patient occurrences (APOs) by using criteria, they do not involve staff member in order to report an event. These systems can identify APOs such as nosocomial infection, moving a patient from a general unit to an intensive care unit.
Conclusion
This paper discussed appropriate strategies for administering the quality improvement and risk-management processes within a healthcare delivery system. It is clear that risk management and quality processes complement each other in such a way that they provide a platform for considering all activities in the health care delivery system, the way they are performed, and suggest ways for their improvement before any problems occur. Appropriate strategies are useful for emphasizing the framework for identifying, analyzing, applying corrective treatment, monitoring as well as reviewing problems, risks, or opportunities. In considering the strategies for quality improvement and risk management, sufficient levels of consideration should be given to three essential aspects: process measures, outcome measures and structure measures. Appropriate strategies for quality improvement in healthcare delivery system include Plan-Do-Study-Act, root-cause analysis, Lean, Six Sigma, and health failure modes and effects analysis. In regard to health care delivery system, it is significant to note that risk has associations that include people (staff, visitors, clients, and patients), consumables and equipment, estate and buildings, management and systems. In the United States, the American Society of Healthcare Risk Management (ASHRAM) enlisted a number of risk management activities that should be practiced under a risk management program in a healthcare organization.
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