Great Minds Don't Always Think Alike
Charity C Hall
26 July, 2011
The world of healthcare in America today is a dynamic and fluid phenomenon. Change is inevitable, and quality improvement is a sector within healthcare that will see continual growth. With a diversified, large healthcare team with multiple personnel involved at both direct patient care and administrative levels, teamwork is a key component in initiating change and quality improvement processes within a healthcare organization. This paper will define quality improvement and its importance, and describe the process of change and the correlating significance of teamwork.
To define quality improvement, quality must first be defined. The term quality itself is multidimensional, described as "an unusually slippery concept, easy to visualize and yet exasperatingly difficult to define"(Garvin, 1988, p. xi).A more traditional definition is provided by Philip Crosby (as cited in Johnson & Foley, 2003, p. 41), author and founder of Philip Crosby Associates, who spoke of quality as "conformance to requirements," and a performance standard of "zero defects." Defined in Merriam-Webster dictionary, quality is "a degree of excellence" or "superiority in kind." Authors Johnson and Foley (2003), point out that if quality is excellence, who determines what is excellent? It has thus been concluded that quality and excellence are based on the customer and what the customer desires and expects. As defined by Evans and Lindsay (2011), quality is "meeting or exceeding customer expectations" (p. 17).
The individual customer's definition of quality is influenced by their perspective. There are judgmental, product-based, user-based, value-based, and manufacturing-based perspectives (Evans & Lindsay, 2011, p. 3). Most of these perspectives are self-explanatory, so user-based, product-based and manufacturing based perspectives will only briefly be defined here for the purposes of this discussion, as these terms will be mentioned again further on. A user-based perspective defines quality as providing the customer with what they want. A value-based perspective defines quality as giving the customer what they want at a competitive price. A manufacturing-based perspective focuses on providing the customer with a product developed according to certain specifications with reliability and consistency (Evans & Lindsay, 2011, p. 13).
With a foundational understanding of quality, quality improvement may now be defined. According to Juran (2001), a known quality Guru, improvement in this sense means "the organized creation of beneficial change; the attainment of unprecedented levels of performance" (p. 5.3). Juran (1998) identified that quality improvement is essential and "a permanent fact of life," claiming that "competition in quality has intensified" and the necessary reaction is to steadily increase quality improvement processes (p. 5.7).
This is particularly essential as it relates to healthcare, as competition in quality has unquestionably intensified in this arena over recent years. Dr. Reinertsen acknowledges that "Quality and safety are major foci in health care today" (cited in Feldman, 2006, p. 145). These are identified as important on an individual basis, say for the professional nurse or doctor, but also strategically important for entire health care institutions.Quality Assurance (QA) was the term previously used to identify the quality improvement process, indicating a focus on the outcome of individuals. Today the term Continuous Quality Improvement (CQI) is preferred as it places more focus on processes and systems of care as a whole. It emphasizes a multidisciplinary action plan with a focus on all aspects of patient care (Feldman, 2008). Feldman (2008) goes on to note that this forces health care institutions to "constantly evaluate and revise processes to better meet the needs of patients and stakeholders" (p. 145). Whether the term QA or CQI is used, the goal of both is to improve patient care and outcomes. Current and future trends indicate that further CQI is in order. One indicative example is the pay for performance and reporting systems that are currently in place and required of all healthcare institutions (Feldman, 2008). Pay for performance (P4P) programs have been established as a means of providing so called "incentives" to health care providers to ensure certain quality targets are met. Institutions are also now mandated to report certain information to both accrediting bodies and the general public, such as patient outcomes related to core measures in certain scenario based situations, for example the outcome of a patient who experienced a heart attack. According to the Agency for Healthcare Research and Quality (2006), this is "a strategy to improve health care delivery that relies on the use of market or purchaser power." This tactic in improving patient safety and quality in healthcare will propel physicians and health care institutions towards a further focus on CQI.
Initially, quality management efforts within healthcare were focused solely on the quality of a product. For years, modern medicine focused on outcome-based quality, as defined by the medical experts (Endres & Godfrey, 1994). This product based quality, with an emphasis on inspection, drove organizations to develop and incorporate what may be perceived by some as "elaborate" quality assurance procedures in order to review the outcomes and "assign responsibility for less-than-perfect outcomes" (Godfrey, 2001, p. 14.14). A product quality emphasis continues today, with recent clinical outcome research as an example. Researchers have expanded the more traditional definition of outcome to include more specific outcome markers, such as the patients' pain management, performance of ADLs (Activities of daily living), and ability to work (Godfrey, 2001).
With an increasingly educated and informed patient population, with data regarding the quality of healthcare at the public's fingertips via the internet, the media, and word of mouth, emerges a correlating increase in the expectation of quality health care. Healthcare improvements are now "widely publicized" and "expectations are high" amongst the public (Evans & Lindsay, 2011, p. 16). According to Evans and Lindsay (2011), these patient's perceptions of quality healthcare are product and user-based (previously defined above) perceptions. A manufacturing-based focus is also essential in rendering quality care as quality care expectations continue to raise. In translation, this means that health care organizations and professionals' goals should be focused on providing customers or patients with what they want, according to certain specifications with reliability and consistency, and at a competitive price!
Many different change processes or formulas exist. One change process described by Feldman (2008) involves four stages: visioning, planning, implementing, reviewing and learning. Regardless of the process or formula used, researchers and "quality gurus" seem to agree on the importance of integrating a team approach throughout the entire process. In a multidisciplinary field such as healthcare, where a multidisciplinary focus is placed on CQI, it only makes sense that teamwork be emphasized when initiating change. Furthermore, according to Juran (1998), most important projects are multifunctional in nature. Juran argues that improvement, especially for multifunctional problems, requires the incorporation of teams. "Experience has shown that the most effective organizational mechanisms for dealing with such multifunctional problems are multifunctional teams" (Juran, 1998, p. 5.32). Few people enjoy or embrace change; creating an attitude or culture of teamwork during this unpleasant process may eliminate potential barriers along the way. Author David Hutton (2000) recognizes that the individuals who are involved during each stage of the change process will respond differently, and in a positive manner, if they are provided the opportunity to "make this process their own" instead of being "herded through someone else's process" (p. 29). Hutton (2000) argues that if the participant is allowed to feel a part of the process rather than being directed through it they will develop a sense of ownership over the project and will "support and protect it as their own creation" (p. 29). Hutton also points out that an individual who feels pride and ownership in something will be more willing to work hard and overcome barriers that may be encountered during the project. An important aspect of a team approach is that each participant has clearly defined roles and responsibilities (Hutton, 2000). This may also work to the advantage of the team, eliminating potential obstacles created by unidentified roles. One of these essential roles is a process group leader, also known as a change agent. This may be at a management or non-management level, but at either level should maintain the role of leader. According to Dr. Deming (2003), an educated statistician and management expert, "the job of management is not supervision, but leadership" (as cited in Covey, p. 263). He goes on to emphasis the importance of demonstrated leadership at all levels as it will prove vital to the success of the change project. "Embedding total quality management in an organization involves culture change to a new set of beliefs, values and behavior patterns" (Lal, 2008, p. 172). It is critical that the team leaders lead by example, as they are restructuring crucial processes within an organization and to a certain degree re-shaping people's minds. While this role of leader is crucial, it is important to note that the goal of this role is to "facilitate rather than force change" (Feldman, 2008, p. 103). An effective team leader will be known as a "bridger in networks" who seeks to "weave people together" (Feldman, 2008, p. 103). A team leader should be open to the criticism of other team members' ideas and be respectful of their individual differences. The team leader should also prove trustworthy, reliable, honest, competent and credible, while at the same time maintaining effective listening skills (Feldman, 2008). Not only has a team approach been endorsed by researchers, but it is also recognized in well known methods such as Hoshin Planning and the Six Sigma approach. The Hoshin Planning Process is a strategic method which was developed in Japan in the 1950's. Its methodology stems from the total quality management philosophy. As a management planning tool, its overture was designed to eliminate the traditional top to bottom approach. The premise of the Hoshin Plan is the involvement of all employees ensuring their understanding of the process objectives. The idea is that at every organizational level "people provide input and agree to the goals that they are prepared to accept in support of the overall plan" (Hutton, 2000, p. 238). This method according to Hutton (2000) provides "closed loop improvement cycles" throughout the process (p. 51). The term six sigma refers to a "particular goal of reducing defects to near zero" (Pande, 2002, p. 4). The six sigma mission it to "reduce variation to achieve very small standard deviations so that almost all of your products or services meet or exceed customer expectations" (Pande, 2002, p. 4). This approach is used among healthcare institutions as a means of quantifying outcome data. For example, hospitals used the six sigma approach to determine the average number of hospital acquired infections (Pande, 2002). Six "critical ingredients" are identified in order to reach the six sigma status. Improvement and process focus are included in these key ingredients, with a team approach identified as a critical element. According to Pande (2002), "improvement and design teams are the time machines that foreshadow the future of the organization and the way it will operate at a six sigma level" (p. 21). Pande (2002) also identifies that teams alone cannot change structure, instead multidimensional involvement is necessary.Constant evaluation must be made of consumer satisfaction in order to make improvement, as quality-based success is determined exclusively by the customer's level of gratification. After examining the individual components that fashion true customer care, it is safe to conclude that teamwork is absolutely necessary for building a progressive foundation in the healthcare industry; however, patient care cannot be improved upon without the vision of a predesignated leader and the commitment of a qualified staff.
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