NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Permalink: nurs-6230-case-s…n-research-paper / ? Few people have had more influence on the science and practical application of process management than Dr. W. Edwards Deming. His impact on the automotive industry is legendary, and many other industries have tried with varying degrees of success to implement his principles as well. For years I have followed and admired those that have tried to bring his quality improvement processes to healthcare. I strongly believe that healthcare has much to gain by successfully implementing key Deming principles. Let me share five principles that I believe can make the biggest difference in healthcare process improvement.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper 1. Quality improvement is the science of process management. When Deming and others developed their approach to modern quality improvement in the 1940s, they were basically developing a way for modern organizations to deal with the complex challenges that were confronting them. The approach they developed to improvement was remarkably simple, yet extraordinarily powerful. It’s centered on the fact that quality improvement is really about process management. These quality improvement concepts and techniques have been used to transform almost every major industry in the world with dramatic results. The last holdouts, the last passions of resistance, are primarily healthcare, higher education, and government. Now, it’s happening to healthcare. I believe higher education is imminent; it’s anyone’s guess whether government will ever succumb to these forces.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Now, we all know healthcare is very complex, but it’s not fundamentally different from other industries. Healthcare simply consists of thousands of interlinked processes that result in a very complex system. If we focus on the processes of care one at a time, we can fundamentally change the game and deal with the challenges facing healthcare. Now, this may seem like a tall order, but the Pareto principle tells us that there are probably 20 percent of those processes that will get us 80 percent of the impact. So, the challenge of every organization is to identify that 20 percent, roll up their sleeves, and begin the important work of addressing those challenges.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper 2. For quality control in healthcare, if you cannot measure it—you cannot improve it. Deming clearly understood the importance of data. Meaningful quality improvement must be data-driven. This is particularly true for quality control in healthcare. You’re basically dead in the water if you try to work with healthcare providers and you don’t have good data. I think everybody recognizes that. Deming said, “In God we trust…and all others must bring data.” I love this quote because it reflects that reality. I’ve had physicians during my career tell me pretty much the same thing, only they’re not quite so polite. They basically say, “Dr. Haughom, John, get lost! Bring the data. And then we’ll decide if we believe it.” So, data is critical if we’re going to have a meaningful impact in healthcare. 3. Managed care means managing the processes of care, not managing physicians and nurses.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper An important application or clarification of a Deming principle was put forward by my good friend, Dr. Brent James. Managing care means managing the processes of care. It does not mean managing physicians and nurses. What James said is very true. One of the big mistakes made in the 90s with the managed care movement was naively thinking that managing care meant telling physicians and nurses what to do. The reality is that you need to engage clinicians in the process because they understand the care delivery process and they are best equipped to figure out how to improve the process of care over time. And for this reason, I strongly believe that these changes will, in fact, ultimately be very empowering for all clinicians who try to get involved.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper 4. The right data in the right format, at the right time, in the right hands. If clinicians are going to manage care, they need data. They need the right data delivered in the right format, at the right time, and in the right place. And the data must be delivered into the right hands—the clinicians involved in operating and improving any given process of care. 5. Engaging the “smart cogs” of healthcare. If quality improvement is going to work in healthcare—if we are going to realize value—it means we must engage clinicians. To use Deming’s term, clinicians are healthcare so-called “smart cogs.” They are the front line workers who understand and own the processes of care. And as I said in an earlier slide, we’re very fortunate in healthcare because we have a workforce dominated by clinicians who are extraordinarily committed, very intelligent, and highly educated.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper But we live in a pristine time. I once received from an email from a fellow physician leader at a leading national delivery system. I’m going to withhold the name of the delivery system, but I can tell you that if you ask knowledgeable people to list of top 10 delivery systems in the country, almost everyone would put this organization on their list. Despite that, this physician wrote to me lamenting how difficult it was for him to get his peer physicians to see a new future. And in his email, he succinctly described the problem by saying that his physicians were “historically encumbered and demoralized.” And I love the succinctness of his description because what he is basically saying is they’re clinging to the past and are demoralized because they don’t see a new future. And in that short phrase, this very excellent physician leader pretty much encapsulated the problem and points us towards the solution. Basics of Quality Improvement Quality improvement (QI) is a systematic, formal approach to the analysis of practice performance and efforts to improve performance.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper A variety of approaches—or QI models—exist to help you collect and analyze data and test change. While it’s important to choose a reputable QI model to guide your efforts, it’s more important that you fully commit to using the QI process and good QI practices. Benefits of QI Understanding and properly implementing QI is essential to a well-functioning practice, and is necessary for any practice interested in improving efficiency, patient safety, or clinical outcomes. In addition, good QI practices and improved patient outcomes position your practice for success by: Helping you prepare for the transition to value-based payment models. Allowing you to participate in the public reporting of physician-quality data. Giving you the opportunity to participate in the federal Quality Payment Program (QPP) following one of two tracks: the Merit-based Incentive Payment System (MIPS) or the Alternative Payment Model (APM). Equipping you with the skills necessary to apply for and complete national recognition programs, such as National Committee for Quality Assurance’s (NCQA) Diabetes, Heart/Stroke, and patient-centered medical home (PCMH)-recognition programs.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Helping you earn Family Medicine Certification-Performance Improvement activity credit (formerly Maintenance of Certification) requirements. The AAFP’s Office Champions Project are an example of QI demonstration projects in which participating family physician practices select staff and physician office champions to lead the implementation of an intervention. Read the results: Child and Adult Immunization(794 KB PDF) Treating Tobacco Dependence Practice Manual Tobacco Cessation 2013(15 page PDF) Quality Improvement Basics The QI process is grounded in the following basic concepts: Establish a culture of quality in your practice. Your practice’s organization, processes, and procedures should support and be integrated with your QI efforts. The culture of a practice—attitudes, behaviors, and actions—reflect how passionately the practice team embraces quality. The QI culture looks different for every practice, but may include establishing dedicated QI teams, holding regular QI meetings, or creating policies around your QI goals.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Determine and prioritize potential areas for improvement. You will need to identify and understand the ways in which your practice could improve. Examine your patient population (e.g., to identify barriers to care, frequently diagnosed chronic conditions, or groups of high-risk patients) and your practice operations (e.g., to identify management issues such as low morale, long patient wait times, or poor communication). Use established quality measures, such as those from the National Quality Forum(www.quality, Agency for Healthcare Research and Quality(www.quality, and the Quality Payment Program( to guide your efforts. Collect and analyze data. Data collection and analysis lie at the heart of quality improvement. Your data will help you understand how well your systems work, identify potential areas for improvement, set measurable goals, and monitor the effectiveness of change. It’s important to collect baseline data before you begin a QI project, commit to regular data collection, carefully analyze your results throughout the project, and make decisions based on your analysis.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Communicate your results. Quality improvement efforts should be transparent to your staff, physicians, and patients. Include the entire practice team and patients when planning and implementing QI projects, and communicate your project needs, priorities, actions, and results to everyone (patients included). When a project is successful, celebrate and acknowledge that success. Commit to ongoing evaluation. Quality improvement is an ongoing process. A high-functioning practice will strive to continually improve performance, revisit the effectiveness of interventions, and regularly solicit patient and staff feedback. Spread your successes. Share lessons learned with others to support wide-scale, rapid improvement that benefits all patients and the health care industry as a whole. Quality Improvement Models and Tools Quality improvement models present a systematic, formal framework for establishing QI processes in your practice. Examples of common QI models include the following: Model for Improvement (Plan-Do-Study-Act [PDSA] cycles)( The Institute for Healthcare Improvement’s Model for Improvement combines two popular QI models: Total Quality Management (TQM) and Rapid-Cycle Improvement (RCI). The result is a framework that uses PDSA cycles to test interventions on a small scale. Six Sigma( Six Sigma is a method of improvement that strives to decrease variation and defects.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Lean( is an approach that drives out waste and improves efficiency in work processes so that all work adds value. Five top challenges affecting healthcare leaders in the future Healthcare is a big topic which presents even bigger challenges for healthcare leaders. For centuries there has been much debate about how best to implement affordable healthcare coverage for millions of uninsured Americans has taken center stage in the political arena (Wood, 2011). Today’s leaders are hard pressed to find solutions to multiple complex issues which impacts the ability to successfully implement cost-effective programs, maintain efficient operations and services, staff and trained employees, and support other healthcare initiatives. The future of organizational entertainment in healthcare requires skilled leaders to plan for any potential problems. Over the next five to ten years, healthcare leaders should expect to encounter a plethora of challenges including regulatory and policy changes; medicinal and technological advancements; funding; education; and ethical issues. Leaders must realize a combination of these challenges could quickly consume time and money for medical research, facility upkeep, equipment overhaul, and operational training. Research suggests technological advancements will present additional challenges with programming, control, and support issues. Indoctrination of new systems requires leaders to educate themselves, their staff and the vulnerable public on the use of new systems, processes, and programs. This article provides foresight information about the future challenges healthcare leaders will face and suggestions to help them overcome.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Healthcare rising costs As more people strive to live longer, healthier and more active lifestyles, healthcare concerns increase and so does the costs. Research reveal healthcare costs and spending often rise at rates exceeding inflation, and is expected to increase in the future. The Society for Human Resource Management present that the Office of “1 the Actuary at the Centers for Medicare and Medicaid Services estimates that aggregate health care spending in the United States will grow at an average annual rate of 5.8 percent from 2015 through 2025, or 1.3 percentage points higher than the expected annual increase in the gross domestic product.” This causes a huge concern for leaders as they seek to provide coverage for their employees. Leaders must find alternative methods to combat the rising costs of care. They must do the research to find funding, grants and contributors to help them conduct research, set up programs and implement processes at the pace of change. The Health Services Research Information Central (HSRIC) provides a list of “grants, funding and fellowships” leaders might consider helping them train staff members, open up public information sites or labs for processing paperwork and other initiatives.2NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Healthcare regulatory challenges Healthcare has taken center stage in the political arena under the Trump administration. As tension and uncertainties mound regarding Trump’s threats to repeal and replace Obamacare, insurance and medical executives scramble to determine “what business is going to look like in the years ahead” (Gomes, 2016). Larry Levitt, a senior executive with the Kaiser Family Foundation emphasized any transition from one program to the next will require time for insurers to adjust to the “reverse disruption” and “overhaul to how individuals buy policies” (Gomes, 2016). Healthcare leaders must inform themselves, and staff on how to handle the changes in coverage. Currently, there is a “noticeable gap between the belief that change is necessary and actual support for specific reform plans designed to achieve that change” (Wood, 2011). Leaders will be challenged to counter frustration and confusion from Americans, once deemed otherwise uninstallable, who have formed a sense of security their current coverage, argues Wood (2011).NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Regulatory challenges drive up the cost of providing services and care. As the Trump administration strive to regulate Medicare and Medicaid eligible healthcare providers are overwhelmed by regulated “changes and new reporting requirements” (Brown, n.d.). Research provide that healthcare leaders are further burdened to comply with a variety of newly revised standards including the Health Insurance Portability and Accountability Act (HIPAA), Centers for Medicare and Medicaid Services (CMS), and Joint Commission on Accreditation of Healthcare Organizations (JCAHO). To combat these challenges, the healthcare provider needs actively engage in awareness and information sharing regularly. Studies suggest leaders must implement document control programs, compliance training, routine audits and address non-conformance incidents immediately utilizing integrated healthcare platforms.3NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Medicinal and technological advancement challenges The practice of medicine and technology has created opportunity and challenges in the way providers practice medicine today and in the future. Today’s health organizations are facing physician shortages and need “low-cost alternatives to office visits” and in-patient care (Austin, Beethoven, & Chait, 2016). Five to ten years from now, leaders can expect more of a shift from the traditional office visits and prescribing in favor of virtual and cyber doctor patient interactions. Sanicola (2016) argue “medicine” – the use of “electronic communication” such as “two-way video, phone, email, wireless tools, and other forms of telecommunications technology.” Telemedicine “works well for treating common conditions such as colds, flu, pink eye and sprains” and “more easily manages patient care for chronic illnesses that require daily interventions” adds Sanicola (2016). The rapid change requires leaders to acquire and develop methods for maintaining and accessing private sessions and data of patients. Saslow (2016) argue the pressure and “growing influx of patient data, legal requirements for strict privacy and security, rapidly advancing clinical technology increases costs, and other factors. At a minimum, leaders should explore innovative ways to manage and store the information adequately adds Saslow (2016). Heathfield, Pitty and Hanka (1998) posit leaders must “understand and predict the behavior of systems and provide important knowledge to inform further developments.” Once the leader understands the system, they can prepare training strategies for the staff and the patient. The leader’s training efforts must be a continuous initiative to keep up with the continual change of technology and medicine in the future.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Training and education challenges Professional development is the key. Healthcare leaders must take steps to assess, develop and fine tune key personal and professional skills to remain proficient (Northouse, 2013). Most training initiatives, per Dunn (1995) remain centered around “traditional clinical interview with its focus on acute illness,” but healthcare providers will be challenged to change that dynamic. The future will require healthcare leaders to take more of a hands-off approach; involve patients more in personal care; offer alternatives to current practice and make themselves and staff available to forms of communicating with the patient without a trip into the office (Gomes, 2016). Ethical challenges Ethical challenges in healthcare is a big deal. Recent news stories support this claim with headlines about ethical violations of healthcare providers. In 2016 the British Broadcast Center (BBC) reports Dr. Paolo Macchiarini, was accused of providing misleading medical research which led to the deaths of seven patients (Kremer, 2016). More recently an Olympics Physical Therapy doctor, Larry Nassar was found guilty and sentenced for sexual misconduct. These incidents hurt the character and trust of the medical leaders. In addition, it creates legal costs and rise in malpractice insurance coverage for the agency.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Giving the very serious ramifications, healthcare leaders must ensure their behavior and their employees are above reproach. Bruning and Baghurst (2013) suggest “reform requires ethical decision-making from leaders” because these leaders influence “various relationships” and “creates fundamental successful changes in healthcare.” Sound “ethical principles to transformational leadership improves healthcare relationships and alleviates stress and tension produced by change” (Bruning & Baghurst, 2013). Leaders must understand the success of the organization; heavily rely on their ethical behavior. Building trust earns money and funding and reduces unnecessary liability costs for the agency.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Conclusion Healthcare managers must be able to provide direction and guidance to organizations about roles, responsibilities, and functions (Gomes, 2016). The leader must devise and revise strategies everyone can understand and follow. Thompson et al. (2011) argue “decisions made by healthcare managers not only focus on ensuring that the patient receives the most appropriate, timely, and effective services possible, but also address achievement of desired performance targets.” Ultimately, decisions made by an individual manager affect the organization’s overall performance (Northouse, 2013). Leaders should not take on the many challenges “posed by complex health care systems” therefore, it takes “a shared, distributed, or collective approach to address complex problems with diverse perspectives, talents, and skills” (MacPhee et al., 2013). Leaders must build a collaborative environment whereby everyone is involved in the process of developing strategies to help overcome the challenges as they arise. Staying abreast of the changes and implementing a plan of action will create successes for healthcare leaders and their organization for years to follow.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Why Quality Improvement in Healthcare is Important? Healthcare, safety, efficiency and equability are few of the concerned facts which every human must remain aware about. With the improvement of technology and science, improving quality in healthcare has become important. The institutions dedicated to medical practices need to give high effort for healthcare services. Implying specialized methods for healthcare settings, the doctor office need to stream measurable improvement in the quality of healthcare services. As said, quality improvement is meant for enhancing safety, effectiveness, and efficiency which is achieved by deploying various methods. Both qualitative and quantitative healthcare improvement has become imperative. Healthcare features are becoming complex with time and the requirement of new and enhanced methods is becoming inevitable. This would reduce costs as well offer access to new technology.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Changes in Healthcare System Would Improve the Level of Performance The main reason behind the quality improvement of healthcare is that, if the healthcare practice institutions are stuck with the traditional concepts with no further enhancements, it will fail in generating better results. Streamlining the changes into the system, a new level of performance can be achieved. Replacing the inefficient parts of the structures with new inventions can prove to be worthy. For the proven efficiencies, improved methodologies are implemented in healthcare on a global scale. Digital version of patient’s health record or simply the EHR- Electronic Health Records software renders real-time records that are patient-centered. The EHR contains medical and treatment histories of a patient. EHR system is prepared at the doctor office that goes beyond standard clinical data and features a broader view of the health standard of a patient.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper What Are The Aims Of Healthcare Improvement? Safety- It renders a protective shield that avoids the patients from injuries for the care. Effectiveness- Basing on the knowledge of science, the healthcare services are rendered as would be beneficial for the patient and avoid the services that are not profitable. Patient-Focused- The provided health-care is as per preferences of any individual patient. The requirements and values of healthcare ensure the patients with precise clinical decisions. Real-time- Quality improvement in healthcare reduces the time of lingering which may sometimes are harmful when delayed. Efficiency- It avoids certain wastes that include effort, idea, supply as well as equipment. Equability- Basing on personal characteristics, the rendered healthcare quality mustn’t differ. Benefits of Continuous Quality Improvement (CQI) Continuous Quality Improvement (CQI) is a systematic approach to achieving ongoing improvements in a product or service. CQI users define the problem, map the process, identify improvement opportunities, implement the improvements and continually monitor the results for improvement opportunities. There are several benefits of using CQI.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Use of data CQI uses quantitative information (e.g., output, defects) instead of subjective information to improve the process. Monitoring the data identifies ongoing opportunities for improvement. Improved morale The use of CQI helps improve employee morale by not blaming the employee for the problems in the system. Instead, it focuses on the problems in the process, not the people performing the process. Better customer service Because CQI focuses on continuously improving the organization’s performance and removing problems from the system, customer satisfaction increases. Increased productivity Removing errors from the process results in fewer errors and less repeat work on the part of the employees. Less repeat work means increased productivity. Increased revenue By removing errors and increasing customer service, the organization has the opportunity for increased sales.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Principles Of Quality Improvement In Healthcare Principle 1: Promote hands-on improvement projects. High-level strategy discussions and ideas aren’t enough to promote quality improvement in healthcare. Hands-on work aids the adoption of quality improvement projects because staff and physicians can see the direct impact in real-life situations. It also incentivizes internal teams when the organization identifies an area that needs improvement, and encourages staff and physicians to play an active part in the strategy. Principle 2: Get buy-in on what “quality” means. Part of the difficulty in defining quality improvement stems from the word “quality” itself. It’s subjective, and organizations sometimes suffer from internal clashes on how to characterize those seven letters. It’s important to get buy-in across the organization on exactly what quality means so you can objectively determine if it’s improving. However you decide to define quality, it should be measurable and revolve around patients. Healthcare organizations are guided by a mission to improve the lives of patients, so your definition of quality should overlap with how you care for them.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Principle 3: Focus measures on improvement vs. accountability. Since quality improvement in healthcare revolves around the patient, performance measures should focus on improvement rather than accountability. When accountability is overemphasized, the needs of the patient are superseded and quality improvement can’t be applied. For example, a typical accountability measure might collect data on the percentage of ER patients who waited more than 30 minutes, and hold management accountable for keeping wait times under 30 minutes. A better tactic would focus on the system and collect actual wait time data in minutes to measure performance, instead of just focusing on the person who’s held accountable for those wait times. By taking this approach, a process can be improved. The concept of quality has been contemplated throughout history and continues to be a topic of intense interest today. Quality presently is addressed in numerous academic and trade publications, by the media, and in training seminars; it is perhaps the most frequently repeated word among managers and executives in contemporary organizations. In a recent survey, executives ranked the improvement of service and product quality as the most critical challenge facing businesses [1]. Quality has been described as “the single most important force leading to the economic growth of companies in international markets” [2]. Quality in healthcare is also a determinant issue as healthcare accomplishes a work of life perpetuation and quality in healthcare sector is getting thorough attention. So far, different approaches have been introduced to improve healthcare service quality. Therefore, this research aims at reviewing the methods and approaches with their improvement models used for service quality improvement in a healthcare and gives alternatives insights for further research in the area.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper The need for service quality improvement Both public and private organizations exist to serve their customers. The service quality particularly in the public sector has become ever more important in improving customer satisfaction. Organizations, especially in the public sector agree that customer satisfaction is one of the most vital factors that contribute establishment of reputation and credibility among the public. The public complaint of long queues, poor service delivery and insufficient physical facilities affect the image and level of service quality in the public sector. Service quality that customers receive must be reliable, responsive and emphatic involving service product, service delivery and service environment. Service quality has been documented as one of the key driving forces for business sustainability and is crucial for firms’ accomplishment. Hence, research on service quality has been carried out worldwide.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Earlier studies have focused on service quality construct by Paranormal et al. [3-5]. The development of the original 22-item SEMIQUAVER instrument signifies one of the most extensively used operation of service quality. It has provided researchers with the possibility of measuring the performance-expectations gaps composed of five determinants namely, reliability, responsiveness, empathy, assurance and tangibility. Existing studies focus on measuring the service quality level by these five dimensions in a holistic manner without considering the independent focus that should be given for each dimension through prioritization and their integrated impact to other improvement activities.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper The apparent reluctance of service organizations to utilize quality improvement based strategies and practices are difficult to understand, especially in light of the increased significance of the service industries and the demand of customers. The trend signifying the increasing importance of the service sector is expected to strengthen in the foreseen future. This trend, coupled with an increasing emphasis on the customer-focus strategic orientation makes the reluctance of some service organizations to implement quality improvement initiatives difficult to fathom. Some attribute this apparent reluctance of service organizations to implement quality improvement initiatives to the difficulties associated with defining service quality. Despite apparent difficulty, some practical research has attempted to practically address issues related to service quality in different service operational settings such as rapid asses

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