Quality management in healthcare

¶ … categories of variation in health care: process variation, outcome variation and performance variation. Process variation reflects differences in established processes. Outcome variation reflects differences in outcomes that are occur versus those that are expected. Performance variation is variation in how things are done.

Process variation occurs when there is a defined process, and then the person expected to undertake that performance deviates from the specifications. A benign example would be the process for cleaning a room after a patient is discharged, before the next patient arrives. There is a checklist that represents that process, and if something is not done, that would be a process variation.

Outcome variation occurs when even if something is done according to the right process, for one reason or another it does not work out that the outcome is as expected. For example, suppose that the nurse does everything that was part of the role, but the patient suffered a negative outcome that was against the odds. In such a situation the outcome would be different than expected, but not because of the process.

Performance variation is when the performance is not up to the standards as set by the process. So the process is basically designed in the right way, but the person tasked with implementation of the process made a mistake and the outcome was less than optimal as a result of this.

In health care quality management, understanding these different types of variations matters. The quality manager looks at outcome variance to know when something went wrong, but just knowing that something went wrong is not enough. The manager needs to be able to recognize which different type of variation occurred, because these different types reflect quite different approaches to solving the problem. When the problem is the process, you redesign the process. When the problem is performance, you work with the staff to improve performance. When the problem is outcome, that means that the issue lies somewhere else; maybe random chance but maybe some other variable that has yet to be accounted for.

Q3. Quality assurance is finding ways to ensure that quality is at a steady rate. It reflects management that is focused on determining and maintaining standards of quality. So this is the set of tactics and strategies that results in consistently high levels of quality.

For the health care manager, quality improvement reflects understanding what the current level of quality is, and undertaking changes to raise that level of quality. Quality improvement is basically an objective, and for the manager this is something to work towards over time -- a process of setting targets, devising tactics to achieve those targets, and then implementing those measures.

Quality control is the mechanisms by which quality is maintained. Basically, managers have the ability to influence quality within the organization. The quality control process seeks to identify mistakes, or otherwise the sources of error, and then eliminate those error sources. Quality control consists of the measures that identify where gaps in quality exist, and then the steps that are taken to eliminate such issues, thereby ensuring a higher standard of quality than existed previously (Investopedia, 2016).

Total quality management is a quality management approach that began in the 1950s. The TQM approach "seeks to integrate all organizational functions to focus on meeting customer needs and organizational objectives" (Hashmi, 2016). TQM is a foundational approach, and its customer focus is built into the organization's other quality-related activities.

All of these four things are important in health care organizations. First, health care organizations need to define quality, but then they also need to understand the steps that should be undertaken to ensure quality. The TQM approach is useful here, because it orients quality to the customer, and asks that all parts of the organization are oriented towards this one conceptualization of quality. Furthermore, the organization needs to set quality standards, and then implement the means by which those standards can be attained. So overall, achieving a consistently high level of quality is fairly difficult, but this something that health care managers need to be concerned about because of its influence on the average business.

Case Q1. Good indicators of patient-centeredness would include having the right amount of staff on hand to look after the patient. In this case, Mr. Gee would have benefitted from having someone there more frequently. Part of this was psychological -- he was in a fragile state -- but part of it was physical. Having mucus always getting in the way of his breathing was surely going to be an issue for him, but he simply did not have the attention that he would have needed. His spirits sagged as the result of the physical issues he was facing, and being already in a fragile mental state he was ill-equipped to fight for himself.

Q2. A) In terms of patient safety, it seems that the nurse realize that Mr. Gee needed more attention than the other patients. The nurse aide was present for much of the time on the day that Mr. Gee died. The error was really to have Mr. Gee in a position where there was nobody to look after the mucus buildup that he was facing -- this was a holdover from his prescription drug issue, and it was something that was going to threaten his breathing. But the staffing level he needed was not met by the situation he was put in.

b) Detecting the error would have been helpful. This is the type of situation where detecting the error would have required there to be somebody in the room at all times. That would have been the case in intensive care, but of course Mr. Gee was taken out of intensive care. So the patient at that point was put in a position where the staffing levels were lower than would have been necessary to ensure detection of the mucus buildup. His respiratory failure indicated just how delicate he was at that point, and yet the medical facility did not have adequate staffing to detect the issue soon enough, and to deal with it. The result is that he died, but ultimately if there had been someone with him throughout that entire period, this negative outcome would have either been avoided or at the very least would have been prolonged.

c) The harm to the patient would have been mitigated if the management had ensured that there was adequate staffing. At issue here is really the decision to move Mr. Gee out of intensive care. Had this patient remained in the unit with the higher staffing levels, then the patient's issue would have been identified much sooner, and ultimately this would have probably kept him alive. But with the lower level of staffing, things were not the same. The nurse recognized the potential problem with the patient and the nurse aide spent most of the time with the patient. But both had other patients to serve, other work to do, and because of that they were not able to give the patient due attention. Reducing harm to the patient would have meant preventing the mucus buildup and respiratory issue, but it could easily have also just meant that they were on hand such that when the respiratory issue did develop there were people on hand to deal with it immediately.

3) There are a few different principles when it comes to quality in health care. One of these is just developing professional curiosity. Sometimes health care staff just sort of go through the motions. That does not appear to have been the case here, but it happens. If management is able to instil in the staff a high level of motivation to understand the unique circumstances of each patient, then that shows the benefit of increased curiosity (Li, 1989).

Another principle is adoption of innovations. Across the health care field, research & development departments are working hard to bring about improvements to the quality of care. It is necessary that health care managers are aware of the latest changes in health care technology, so that they are open to the different changes that could profoundly improve the quality of health care. Being aware of what changes are made is an important aspect of continuous improvement in health care.

A third pillar of quality improvement is training. Nurses and other employees in the medical sector arrive with a high level of training, but that does not mean that there are no opportunities for supplemental training. Indeed, subsequent training is an important element in the quality processes, especially when that training is based on innovative and new techniques -- keeping up with the latest in quality improvement tactics is one of the ways that an organization can always ensure that it is improving quality.