CQI business as usual’ is no help for patient safety
Traditional approach weak on anticipating errors
Ever since a landmark report by the Institute of Medicine in Washington, DC, both health care quality managers and oversight agencies have been placing a greater focus on patient safety. However, observers say, addressing patient safety improvement with a traditional continuous quality improvement (CQI) approach may not be the way to go.
Some say the fault lies within CQI itself, while others blame inadequate implementation, but they all agree that "business as usual" is not the way to improve patient safety. "CQI mechanisms to control risks have not been entirely successful because CQI does not allow for human error," says Patrice L. Spath, of Forest Grove, OR-based Brown-Spath & Associates. "CQI expects people to be infallible."
"If we look at quality as it has been implemented in the past, we won’t be successful in reducing patient errors," adds Monica C. Berry, BSN, JD, CPHRM, president of the Chicago-based American Society for Healthcare Risk Management (ASHRM).
"The whole notion of quality in the past has become the idea of doing it, so it became an end rather than a means. In whole process of just doing it’ what has happened over time is that we have gotten lost in that process and fallen down in the implementation."
Spath asserts that in the health care setting there are two distinct aspects of CQI, each of which has its shortcomings. One affects the culture of the organization, the other relates to CQI project work.
On the cultural side, she says, organizational commitment is lacking. "What has happened is that a lot of administration leaders saw CQI as synonymous with Joint Commission requirements and pushed it down to people lower in the organization," she explains.
"They gave it to the quality manager, or perhaps to the risk managers, and expected individual managers in each department to improve their processes. Quality managers knew what to do; they had the ownership, but they didn’t have the power to effect organizational change like senior leaders do. Nor did they have the same power to make others accountable."
When it comes to actual process improvement, says Spath, a lack of training combined with an inherently flawed approach create a formula for failure. "Most of our managers are people who moved up into management from on-line positions and did not get the training they needed in how to improve processes," she declares. "Second, the solutions were not necessarily the best fixes in terms of improving patient safety; a lot of the focus was on improving the efficiency of process."
Any number of CQI projects have been undertaken to improve outpatient testing, or reduce waiting times, to improve patient flow in the organization, to get test reports out more quickly, or to improve customer service, Spath notes. "What we didn’t do is look at the mistakes that could be made in that superefficient model that can result in patients not getting the right test, for example," she offers.
"Let’s say an old lady comes into radiology for an IVP [intravenous pyelogram]. She’s checked in and she sits down. Another lady is scheduled for abdominal X-rays, and sits down without checking in. The radiology tech calls the name of the first lady, who doesn’t hear him, and the second lady stands up. The tech puts her in the dressing room, and does an IVP on the wrong person. So, one patient did not do what we expected them to, and the radiology tech did not check the patient’s ID. We didn’t ask What if?’ questions during the process, because CQI just doesn’t include that focus on human error."
So what CQI has given us, she concludes, are more efficient processes, but not necessarily error-resistant processes.
Effective or not, CQI and patient safety improvement are stuck with each other, says Berry. "Quality and risk management are joined at the hip," she asserts. "Neither one will be successful without a commitment to approach problems in a collaborative way."
Spath offers a number of suggestions for supplementing CQI to make patient safety improvement initiatives more effective. "There are techniques like reduced reliance on memory, simplifying the process — not something we have traditionally looked at," she says.
"The Joint Commission wants us to evaluate the culture of the organization as it relates to patient safety — to measure the commitment throughout the organization and then to take appropriate action. This is not something we did as part of [total quality management]."
Leaders must establish quality and safety standards and hold their people to them, Spath says. "The quality manager’s role should be that of facilitator; they should serve as an in-house consultant," she explains.
"They will gather up the data to see if standards are being met, to look at aggregate information to identify opportunities for improvement. They should generate ownership to provide a support function, but not to make it happen. By taking on all the responsibility for quality, everybody else in the organization relinquishes it. We can’t take on the responsibility for patient safety."
Rather, she advises, upper managers should build constant patient safety improvement into a list of performance expectations for all employees.
Berry would like to see the whole CQI process streamlined. "We’ve gotten caught up in the length of the process; it takes forever to get from phase one to that phase where you monitor the implementation," she explains. "That length of time is something we don’t have when it comes to changing patient safety initiatives."
How can we cut the project time down? "We need to look at things and develop a much more rapid cycle," Berry recommends. "I believe that was probably part of the Joint Commission requiring root-cause analysis to be completed within 45 days."
In the final analysis, says Spath, any CQI project must impact patient outcomes and satisfaction. "What this is really getting at is, are we really making the patient any healthier? That’s the real lynchpin between quality and risk," she says. "Leaders can no longer ignore their responsibility."
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