The Quality-Cost Connection: Surveyors looking for well-designed processes
The Quality-Cost Connection
Surveyors looking for well-designed processes
How to prioritize process improvement projects
By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR
The Joint Commission on Accreditation of Healthcare Organization’s performance improvement standard requires that organizations do an effective job of designing new processes. New processes may be those that have been revamped in a way that makes the process dramatically different or new services/activities that never existed before in your organization. According to the standards, process design activities should include consideration of:
• your organization’s mission, vision, and plans;
• the needs and expectations of patients, staff, and others;
• up-to-date sources of information;
• process performance and outcomes in other organizations.
Joint Commission surveyors will want to see that your organization has followed a systematic process development approach. For example, the activity of redesigning the medication administration process should proceed as follows:
1. The quality council (or other oversight group) confirms that redesign of the medication administration process is consistent with the organization’s mission, vision, and business plan. If patient safety improvement is a goal of the organization, then reducing medication errors through process redesign will definitely be a worthwhile endeavor.
2. A team of people who are involved in or affected by the medication administration process is formed. The team is charged with achieving specific process improvement goals based on an understanding of what’s not working well in the current process as reported by patients, staff, and others.
3. Team members identify important medication administration tasks that need improving. At this point, team members review outside sources of information about methods known to improve the process. Team members may visit other facilities to learn about their process and identify "best practices." Books and journal articles on the subject of medication administration are reviewed. Vendors of software designed to improve the safety and efficiency of the medication administration process might be invited to speak at team meetings.
4. Finally, the medication administration process is redesigned to meet the goals of the organization. Timing, location, specialization, technology assistance, sequencing of the work, and current literature recommendations are considered when designing the ideal process.
5. The proposed new process is shared with others in the organization to obtain their input into factors such as safety, environment, process reliability, measurements, and documentation standards.
6. Before implementing the new medication administration process, the team selects measures of success. The team also determines how often progress toward the goals will be measured and when they will meet again to assess performance.
Survey hot spots’
Surveyors are interested in how the organization prioritizes process improvement projects and how effective the activities have been. While your organization has the leeway to select any process for improvement activities, it is likely that surveyors will be looking for projects that focus on issues that are currently receiving national attention, such as patient safety improvement, reduction of restraint use, protection of patient rights and confidentiality, and improved pain management practices. Of course, if your organization’s comparative ORYX measurement data reveal significance variation from other facilities, surveyors will expect that a project was undertaken to examine the cause of the variation and necessary actions initiated.
Surveyors may not ask, "Have processes been designed well?" but they will look for evidence that clinical practice guidelines were used in the design of new patient care processes. For example, if your medical staff have undertaken a project to improve care for patients who have had heart attacks, process redesign activities should include an emphasis on timely administration of anti-thrombolytic therapy and appropriate use of beta-blockers. Surveyors will expect to see that information published by groups such as the Institute for Safe Medication Practices and the Food and Drug Administration was used in re-designing the medication administration process. Where appropriate, you should able to show how patient satisfaction data and input from staff and community members helped guide process design activities.
Be sure that your organizationwide quality management (QM) plan defines the process improvement steps used by people in your facility. These steps should include a statement that the design of new processes is based on several factors, including the needs and expectations of customers, professional standards and practice guidelines, and best practices identified in the literature. Your QM plan also should identify who has responsibility for ensuring that new processes are well-designed. This may be the quality council for processes that cross departmental boundaries and the department director for intradepartmental processes. The checklist shown below can be used to determine if processes are being well designed. A similar checklist could be added as appendix to your QM plan.
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