High Quality Toolset

Wrote Robert Townsend, "If it's not excellent, it won't be profitable. If it's not excellent, it won't be fun. And if you're not in business for fun or profit, what the hell are you doing here?" While lip service quality has always been present in American healthcare, organizations are finally doing the work of getting information systems in place, implementing standard clinical protocols, and dealing with the substantial problem employee issue which continues to exist. This Toolset will help you dig deep with its common sense logic and its power tools. The change manual organizes the work to be done under various Initiatives (in bold) and the specific Tasks they require (bulleted). Sample Task. Full Toolset available in Member Area.

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Toolset Manual Contents

Toolset Manual Contents

HQ.0 Change Module Assignments

• MAC Administration Instructions
• Executive Introduction
• Module Leader Instructions
• Initiative Team Instructions

HQ.1 Changes Addressed At Management Training

• HQ.1.1 Create A Hospital Map for Cycle Time Usage
• HQ.1.2 Present Summarized Hospital Strategic Plan Document
• HQ.1.3 Coordinate Strategic Planning Process with Budget Process
• HQ.1.4 Establish BHAG Councils for TUL Year Two
• HQ.1.5 Identify Top (10) DRGs & Work Action Groups
• HQ.1.6 Staffing/productivity Analysis for TUL Session V

HQ.2 Quality Improvement in Work Processes

• HQ.2.1 Create Departmental Quality Charts: Evaluate Quality Measures
• HQ.2.2 Flow Chart Each Service Line
• HQ.2.3 Conduct “Breakthrough Benchmarking” For Quality Purposes— Introduce Use of Additive Process
• HQ.2.4 Departments to Undertake & Complete One Quality Improvement Initiative Each Quarter
• HQ.2.5 Evaluate Organizational Responses To Errors In Patient Care
• HQ.2.6 Take Action on Trends in Errors in Patient Care
• HQ.2.7 Improve Physician & Clinician Protocols in the Transfer of Patients
• HQ.2.8 Take Action on Patient Treatment Delays, Risks & Liabilities
• HQ.2.9 Identify Critical Clinical Control Points & Install System Alarms

HQ.3 Quality Improvement in Physician Practices

• HQ.3.1. Physician Direct Variable Cost Management For Management Presentation
• HQ.3.2 Evaluate Physician Continuing Education
• HQ.3.3 Extend Broad Use Of Clinical Practice Guidelines
• HQ.3.4 Implement Computerized Diagnostic Systems As Second Opinion Check Tool For Physicians
• HQ.3.5 Evaluate Physician Peer Review Process

HQ.4 New Thinking In Quality Management

• HQ.4.1 Define New Roles Of CI Specialists In Quality Initiatives
• HQ.4.2 Identify Clinical Outcome Measures Used To Evaluate 100 Best Hospitals & Move Toward Them—Rapidly
• HQ.4.3 Boost JCAHO Standards of Performance in the Organization
• HQ.4.4 Evaluate NCQA or other Accrediting Body As Substitute For JCAHO Accreditation
• HQ.4.5 Restructure Quality, Utilization, Accreditation & Related Services Under One Department
• HQ 4.6 Study NCQA Standards & HEDIS Quality Information

HQ.5 Quality Development Opportunities

• HQ.5.1 Evaluate PC Availability & Software Training Needs For Quality Charting
• HQ.5.2 Evaluate Frequency of Quality Audits in All Service lines
• HQ.5.3 Abolish Isolation: Establish Networks & Webs of Best Practices Study Groups for Specialties among Organizations
• HQ.5.4 Identify Diagnoses Where Risk Of Complications Have Proven To Be Greatest In Your Organization & Make Changes
• HQ.5.5 Identify Diagnoses Where Risk Of Death Is Greatest In Your Organization & Make Changes
• HQ.5.6 Establish Quality Reading Standards & Applicable Discussions
• HQ.5.7 Mobilize Job Enrichment & Redesign without Layoffs

HQ.6 Quality Improvement in Operations

• HQ.6.1 Review Department Physical Layouts
• HQ.6.2 Review Patient Room Layout
• HQ.6.3 Review Visitor Waiting & Services Layout
• HQ.6.4 Assess Need for Management Engineering Professional
• HQ.6.5 Employ Vendor Knowledge/Assistance in Quality Initiatives
• HQ.6.6 Develop Inter/Intra Departmental Work Process Problem-Solving Decision Matrix
• HQ.6.7 Information Management Requirements
  

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Sample Task

Task HQ.4.6 Study NCQA Standards & HEDIS Quality Information

Priority: A
Timing: Begin following TUL Session V
Teamleader: Module Leader
Recommended Approach: DIG
Other Assignees: None
Interactions With Others: TBD

Work To Be Done: The National Council on Quality, and the Health Employers Data Information Set (HEDIS) are two sources of quality based statistical information that can be used to gauge your organization's quality performance, share quality initiatives and information, and watch for trends in quality and healthcare business in general.

The NCQA is intensively addressing quality issues and houses information on quality initiatives from all industries. Thus, this is a valuable source of information for quality best practices from the most excellent organizations as well as healthcare organizations.

HEDIS, on the other hand, is primarily interested in cost, quality outcomes, and most recently added to the list is their interest in Customer Satisfaction results from healthcare providers. Thus, knowledge of organizational performance statistics as housed by HEDIS provides you with competitive data—what you need to meet or exceed in order to remain or become competitive in your area. They are also rapidly becoming a powerful source of information for employer coalition negotiations for healthcare coverage, as well as a source of information for managed care companies who are negotiating contracts for the coming period of time.

Your Task is to find out how your organizational performance statistics compare with others in the HEDIS bank of information. Evaluate your comparative performance and set new, greater and higher standards of performance. If you cannot address all of the performance areas simultaneously, then choose those statistics that will have the greatest impact for the effort and begin work rapidly on those initiatives. Create a tactical plan to meet or exceed the HEDIS performance stats identified as being a priority.