Buchbinder, S. B. (2016). Introduction to Health Care Management (3rd Edition). Jones

Buchbinder, S. B. (2016). Introduction to Health Care Management (3rd Edition). Jones & Bartlett Learning. https://online.vitalsource.com/books/9781284119725
Both CQI and Six Sigma use a variety of tools to help improve quality. These can be divided into three categories: process mapping, data collection, and process analysis.
Mapping Processes
Flowcharting (also referred to as Process Mapping) is the main way that processes are mapped (Figure 7-2). A flowchart is a picture of the sequence of steps in a process. Various geometric shapes denote different action steps within the process. A basic flowchart outlines the major steps in a process. A detailed flowchart is often more useful in quality improvement. Developing a flowchart requires not only substantial investigation (e.g., asking front-line staff and professionals how work is carried out), but also direct observation of each aspect of the process to be flowcharted. Determining the level of detail to be used should be driven by its use within the quality improvement process. A top-down flowchart is often used for providing an overview of large or complex processes. It shows the major steps in the process and lists, below each major step, the sub-steps. The development flowchart adds another dimension. Often it is useful for tracking the flow of information between people. That is, the development flowchart shows the steps of the process carried out by each person, unit, or group involved in a process. Since hand-offs are often where errors may occur, this flowchart provides a target for data collection efforts.
FIGURE 7-2 Workflow Diagram
Source: Wait time project, University of Missouri.
A marriage of geographic and processing mapping is the workflow diagram (Figure 7-3). Simply put, this reflects the movements of people, materials, documents, or information in a process. Plotting these movements on the floor plan of a building or around a paper document can present a very vivid picture of the inefficiency of a process. With the advancement of information technology, increasingly sophisticated geographic mapping and tracking programs have become available, making this complex task easier to do.
Value Stream Mapping is used to identify the seven types of waste or non–value added activities discussed in Lean. Material and information flow across the entire process of transforming raw materials into a finished product to delivery to the customer is mapped. These maps include both current value stream maps as well as future state value stream maps. Waste is documented in the gap between the current value stream map and the future stream map. These maps also provide the platform for quality improvement activities.
FIGURE 7-3 Medication Error Reporting Flowchart
Data Collection
The check sheet is a simple data collection form in which occurrence of some event or behavior is tallied. At the end of the data collection period, they are added up. The best check sheets are those that are simple and have well-defined categories of what constitutes a particular event or behavior. For example, a doctor’s office staff wanted to find out the reasons why patients showed up late. This is a “high pain” problem because no or late shows result in disruptions to the clinic’s work schedule and extra work for staff. The staff asked late arrivers about the reasons for being late and after carefully defining each reason, they developed the check sheet. The check sheet was pilot tested, and several new reasons were added while other reasons were refined. The check sheet was then employed during a month-long data collection period. They found that transportation problems and babysitting problems jointly accounted for 63% of the late shows.
Another example is the use of chart abstractions or chart audits. In this process, a check sheet is used to collect information from a patient’s medical record. Often this is a manual process that involves an individual looking at the medical record and finding the requested information and recording it on a check sheet. The use of electronic medical records may take some or all of the labor out of this process, as pertinent medical information can be collected and appropriate metrics reported.
Geographic mapping is a pictorial check sheet in which an event or problem is plotted on a map. This is often used in epidemiological studies to plot where victims of certain diseases live, work, play, etc. For example, the 2014 Ebola outbreak in Western Africa was traced to a single 2-year-old in Guinea. This finding was enabled by tracing the geographic dispersion of the Ebola infections back over time to the original patient. Importantly, such maps also are helpful in then estimating the future growth of an epidemic. Within the clinical setting, geographic mapping can help track infectious disease outbreaks within a hospital, as well as trace the origin of the outbreak to a particular ward, laboratory, or operating theater.
Analyzing Processes
The cause-and-effect diagram helps to identify and organize the possible cause for a problem in a structured format. It is commonly referred to as a fishbone diagram for its resemblance to a fish (see Figure 7-4). It is also called an Ishikawa diagram, in honor of Kaoru Ishikawa, who developed it. The diagram begins with the problem under investigation described in a box at the right side of the diagram. The fish’s spine is represented by a long arrow within the box. The major possible causes of the problem are arrayed as large ribs along the spine. These are broad categories of causes to which smaller ribs are attached that identify specific causes of the problem.
A Pareto chart is a simple frequency chart. It takes advantage of the Pareto principle, or the 80/20 rule, that Juran applied to quality improvement, i.e., the observation that 80% of the problems with any process are due to 20% of the defects (Best & Neuhauser, 2006). Put another way, most of the problems in any process are due to a small number of defects in the procedure. The frequency of each problem, reason, etc. is listed on the x-axis, and the number or percentage of occurrences is listed on the y-axis. This analysis is most useful in identifying the major problems in a process and their frequency of occurrence. Another version of the frequency chart is the histogram, which shows the range and frequency of values for a measure. When complete, it shows the complete distribution of some variable. This is often useful in basic data analysis.
FIGURE 7-4 Fishbone Diagram
As mentioned earlier, quality improvement has its greatest impact if it becomes a part of the strategic mission of a health care organization. When that occurs, it is then possible to look beyond the boundaries of the organization and to consider ways in which the health care system at the local, regional, and national levels could be improved.
Opportunities for in-depth research in health care quality exist in a variety of venues, including your own health care organization. Many of the resources used in writing this chapter also include extensive research holdings and data sets that are available to students and academic researchers to utilize. Herewith is a partial listing of resources.
 Accreditation Association for Ambulatory Health Care;
 Agency for Health Care Research and Quality;
 Agency for Health Care Research and Quality’s Healthcare Cost and Utilization Project Databases;
 Agency for Health Care Research and Quality’s National Guideline Clearinghouse;
 Agency for Health Care Research and Quality’s United State Health Information Database;
 American College of Surgeons’ Inspiring Quality Program;
 American Health Quality Association;
 American Healthcare Association;
 American Nurses Association’s National Database of Quality Indicators;
 American Society for Quality;
 Baldrige National Quality Award;
 Center for Improvement in Healthcare Quality;
 Cochrane Collaboration’s Evidence Based Medicine and Guidelines Database;
 Florida’s Medical Quality Assurance Services;
 Healthcare Team Vitality Instrument;
 Health Resources and Services Administration’s Quality Toolbox;
 Institute for Healthcare Improvement;
 Institute for Healthcare Improvement’s Improvement Map;
 Institute for Healthcare Improvement’s Outpatient Adverse Event Trigger Tool;
 Institute for Healthcare Improvement’s Quality Improvement Measure Tracker;
 The Joint Commission;
 Maryland Health Services Cost Review Commission;
 MATCH Medication Reconciliation Toolkit;
 Medicare’s Hospital Compare Database;
 Minnesota’s All Payer Claims Database;
 National Committee for Quality Assurance (NCQA) HEDIS measures;
 National Library of Medicine’s Health Services Research Information Central;
 National Quality Forum;
 New York’s All Payer Claims Database;
 Organization for Economic Cooperation and Development’s (OECD) Health Care Quality Indicators Program;
 Patient Safety Handling;
 Press Ganey’s Hospital and Nursing Quality Database;
 Texas’s Health Care Information Collection; and
 Understanding the Healthcare Database.
As you can see, quality is a rich area for research in health care. In the future, you can be certain this list will grow.
Quality, access, and cost are the three core policy issues facing every health care system. For the U.S., improving quality is a challenge in a health care system undergoing a vast expansion of access via health insurance reform along with continuous pressures to contain costs. A new brief from the Kaiser Family Foundation indicated that health care quality has improved in the U.S., but still lags on key measures when compared to peer countries (Claxton, Cox, Gonzales, Kamal, & Levitt, 2015). The models and tools presented earlier will be needed, along with new ones, to improve quality of care, even in a challenging environment.