Creating A Culture of Excellence
Ulises Ruiz
José Simón
This chapter examines how the existing systems of healthcare fall short of what their quality should be, what the evolution of the concept of quality in healthcare has been. It also outlines what approaches are available for creating a culture of excellence that allows for improvement of the quality of care, patient safety, and risk management, through a renewed management approach focusing on the patient as primary customer. The existing challenges for creating a new culture and implementing new approaches are discussed. Integration of approaches for a comprehensive journey toward excellence is advocated.
THE NEED TO IMPROVE THE HEALTH SYSTEM MANAGEMENT FOCUS ON PATIENT SAFETY
There is evidence of an ever-increasing incidence of adverse events in healthcare delivery in many countries. The facts show an alarming reality.
A 1991 Harvard study in the United States found that 4% of patients suffer some kind of harm in hospital: 14% of the incidents lead to death and 70% of the adverse events result in short-lived disability.
In Europe, an “Atlas of Avoidable Death 1985-1989” following healthcare services intervention, carried out by the European Community Working Group on Health Services, was published in 1997. The atlas counts the existing cases of “unnecessary disease and disability and unnecessary untimely deaths” as measures of the quality of medical care. An excessive number of such unnecessary events was taken as a warning signal of possible shortcomings in the healthcare system which warranted further investigation (1).
In the year 2000, the Hospitals for Europe Working Party on Quality of Care found 10% of adverse events as a result of hospital admissions.
In its The World Health Report 2000, Health Systems: Improving Performance, WHO analyzes the deficiencies of health systems around the world and when dealing with The Potential to Improve it states that: This report finds that many countries are falling short of their potential…. There are serious shortcomings in the performance of one or more functions in virtually all countries (2).
Along this line, the scientific literature has shown the existence of so-called medical errors and how they can be prevented. A large study found that adverse events occurred in 3.7% of hospitalizations, leading to death in 13.6%. Over half of these adverse events resulted from errors that could have been prevented (3,4).
Basic considerations about errors in medicine, comparison of the aviation model to the medical model, and offering system changes to be implemented following the Total Quality Management approach can be found in Leape’s Special Communication: Error in Medicine (5). The number of deaths associated with adverse events was also quantified (6).
Facing the problem, the Institute of Medicine (IoM) sponsored a National Roundtable on Health Care Quality, which stated among its conclusions that: .. Serious and widespread problems exist throughout American medicine. … Very large numbers of Americans are harmed as a direct result. Current efforts to improve will not succeed unless we undertake a major, systematic effort to overhaul how to deliver healthcare
services, educate and train clinicians, and assess and improve quality (7). Similar findings about the gaps in US healthcare were published as a Final Report to the President (8).
services, educate and train clinicians, and assess and improve quality (7). Similar findings about the gaps in US healthcare were published as a Final Report to the President (8).
These findings about patient safety in US medical care prompted the IoM to examine this issue through a Committee on Quality in Health Care in America, which released its landmark report To Err is Human: Building a Safer Health System in November 1999, establishing for the first time the results of an in-depth study that names medical errors as the nation’s leading cause of death and injury. The report indicates that medical errors kill more than 44,000 people in US hospitals each year, which is more deaths than from motor vehicle accidents [43,458], breast cancer [42,297], or AIDS [16,516], and the total national costs of preventable adverse events are estimated between $17 billion and $29 billion.
The IoM report states in its conclusions that the current rates of injury from care are inherent properties of current system designs rather than poor performance by individual providers and that safer care will require new designs, outlining a four-pronged approach to prevent medical mistakes and improve patient safety (9).
Following a direction by the U.S. Presidency, the Quality Interagency Coordination Task Force (QuIC) developed the report Doing what counts for patient safety: Federal actions to reduce medical errors and their impact, stating the strategy of identifying prevalent threats to patient safety and reducing medical errors. It provided an action plan to implement the administration’s initiative designed to help prevent mistakes in the Nation’s healthcare delivery system (10).
A second report of the IoM’s Committee on Quality in Health Care in America, Crossing the Quality Chasm: A New Health System for the 21st century, addressing additional quality problems focuses on how the healthcare delivery system as a whole can be designed to innovate and improve care in all its quality dimensions for all Americans, considering a basic premise: The purpose of the healthcare system is to reduce continually the burden of illness, injury and disability, and to improve the health status and function of the people of the United States.
The Committee proposed six aims for improvement: (a) safety, (b) effectiveness, (c) patient centeredness, (d) timeliness, (e) efficiency, and (f) equity. However in assessing the capacity of today’s US healthcare system to achieve these six aims, the Committee considers that: In its current form, habits and environment, American health care is incapable of providing the public with the quality health care it expects and deserves. It also states that The current care systems cannot do the job. Trying harder will not work. Changing the system of care will (11).
Studies conducted in the past decade in several countries discovered the magnitude of such problems in developed countries. The percentage of adverse events attributed to hospital admissions is similar in the different countries: Australia 16.6%, Britain 10.8%, Canada 7.5%, Japan 11%, Denmark 9%, New Zealand 12.9%, and Spain 9.3%.
Consequently, patient safety has become a global issue, much of which is being aimed at designing new approaches for improving healthcare systems worldwide: IoM (USA) report of the Quality Interagency Coordination, to the president, February 2004, WHO: the International Alliance for Patient Safety launched in October 2004, European Union: patient safety as a specific theme within the UK’s and Luxembourg’s 2005 EU Presidencies, and a Patient Safety Summit in November 2005.
All around the world, the performance of healthcare systems is being questioned and approaches to improve their design and performance have recently been directed outside the health sector. This is so, even though traditionally the authority to define and interpret the meaning of healthcare practice has been located solely within the healthcare professions where, for a long time, the knowhow of other industrial and service sectors has been considered not applicable.
QUALITY OF CARE—A LASTING ISSUE IN HEALTHCARE
Historically, quality of care has been a major concern for leading healthcare givers. In the Hammurabi code (2000 BC), the physician causing the death of a wounded warrior would have the fingers of his hand amputated. The Hippocratic Oath (IV c.b.c) established standards for medical ethics. In the Middle Ages, throughout Europe physicians and surgeons were organized as guilds and needed recognition to act as such. In the United States, authorization to practice medicine appeared in 1760 and the first medical association, the Medical College, was founded in 1787.
In the modern ages, Florence Nightingale’s observations for improving the quality of care in military hospitals during the Croatian war in the 1860s, where varied outcomes puzzled her, are the first attempt for improving hospital care.
The Flexner report in 1910 established standards for medical education, and Codman, a surgeon at Massachusetts General Hospital, introduced the concept of End Result Follow-Up in the decade of 1910. The American College of Surgeons was funded in 1913 to translate Codman’s idea into a Minimum Standard for Surgical care and established a Hospital Standardization Program by 1917.
The Joint Commision on Accreditation of Hospitals originated out of this program in 1951, now known as the Joint Commission (TJC), which revised, expanded, and updated the previously established American College of Surgeons standards of care in hospitals.
In the 1960s, both Donabedian and Williamson introduced each in their own way, approaches in healthcare similar to those used in industry for product quality assurance.
Avedis Donabedian established a common denominator framework for both explicit and implicit inspection, defining structure, process, and outcome for care (12). In the early seventies, researchers started investigating the reasons for the large variation found in the process of care among the practitioners, the hospitals, and the geographical regions (13). In the late seventies, research by the Rand Corporation established an experimental design for evaluating the effect of different healthcare insurances on the processes and outcomes of care (14,15).
Also in the sixties, John W. Williamson introduced his Health Accounting approach. Unfortunately, it was not well known and not recognized as a valid approach to managing quality in healthcare.
Aware of these changes, the Joint Commission changed its policy and its approach through the Agenda for Change in 1986, establishing criteria beyond the Donabedian framework and looking for the effects of healthcare on the customers (16).
In the early 1980s, a European Community (EC) Concerted Action Project on Health Services and “Avoidable Deaths” initiated research on results from a series of conditions for which mortality is considered largely avoidable, given timely and appropriate medical intervention.
More recently, using developed information systems, data bases have been established where individual professionals and healthcare organizations can search for resources utilization and adherence to care protocols. Reaction of professionals to these data has been mixed. A successful use of this kind of information system has been reported by Wennberg (17).
It is noteworthy to mention that all these key issues are a common rallying point in modern quality improvement approaches and are being considered as such in the socalled Excellence Models (Baldrige and EFQM) and more recently in the 2008 version of ISO 9000.
TJC is applying the same key issues in its approach, but differs in the methodology and tools applied implementing it as organizational criteria. Paul M. Schyve, Senior Vice President, TJC states: “Successful mechanisms are also likely to provide more detailed information about performance … while creating evaluation processes … through incorporating aspects of the Baldrige and EFQM approaches … likely to create a special focus on the safety of care, incorporating aspects of the ISO 9000 approach to quality management” (18).
For the past two decades, the industrial and service sectors have been looking for new managing paradigms in order to improve their performance, and their methods and techniques are being increasingly translated and used in the health sector. At present, patient safety and risk management are the priority issues for all these approaches.
HEALTH PROFESSIONAL, QUALITY OF CARE, AND ORGANIZATIONAL QUALITY
In the past, errors in medicine were considered the responsibility of caregivers rather than addressing underlying system design faults. The blame and punish approach to errors has been prevalent and still is being considered valid in many health systems, services, and organizations. Licenses are lost and health professionals are sued for error-induced injuries. Yet only rarely are these so-called medical errors due uniquely to the carelessness or inappropriate conduct of an individual health professional.
In the health services sector, services provided by healthcare professionals to individuals are central to the professional responsibility of the staff in the provision of care/service. However, responsibility for care and responsibility for running the organization should be clearly differentiated, as well as the dual role of physicians when they are both care givers and administrators of their own clinical service as a unit of the whole organization. Thus, the traditional professional bureaucracy approach currently employed by most hospitals in the developed world is shifting to focusing on organizing rather than on organizational structures.
However, the traditional hospital’s dual authority structure may represent a source of tension, stemming from a difference in cultural perspectives between hospital administration and medical staff.
The administrative arm of a hospital is built upon a bureaucratic structure and is therefore more mechanistic in nature, encouraging conformity and efficiency through standardized rules and regulations. The administrator’s allegiance is to organizational goals and he/she prefers a proactive approach and long-term goal setting (19, 20, 21).
The medical profession, on the other hand, is founded on collegiality. It thrives on clinical autonomy and selfregulation, adopting a more reactive, independent problemsolving approach, with a preference for immediate outcomes. The medical staff possess a strong allegiance to their patients and their profession. Their orientation is more technical in that it is rooted in the natural sciences. As a result, the medical culture has historically tended to resist administrative constraints (19, 20, 21).
There is a need to break down the traditional boundaries that separate physicians, hospital administrators, pharmacists, technicians, and nurses by shifting away from a culture of blame and by working together to systematically design safer, more effective, and efficient systems.
Today’s healthcare centers and services are complex organizations where the work of each professional is part of a system that has to be constantly in perfect running condition, ensuring an efficient, effective, and safe operation for the benefit and safety of the patient who enters such a system, looking for care (22).
Healthcare professionals, both caregivers and administrators, have been confronted for two decades with a most perplexing issue on how to improve the quality of the healthcare system without losing traditional roles and responsibilities (23, 24, 25), while facing an increasing recognition that healthcare providers have to respond to the preferences and values of the patients as their customers (26,27).
As a result, two different perspectives for quality issues in healthcare, currently considered complementary, developed. First was the classical Quality Assurance approach cherished by healthcare providers (28) and second, the more recent approach of Total Quality Management imported from the industry and service sectors (29). The healthcare organization continuous quality improvement trade off (CQI) reconciles both approaches through participation and active commitment of both managers and caregivers in the search of quality (22,30).
The service perspective for health systems as a nuclear concept for CQI has been, for the past decade, the focus of extensive quality research studies (31). Factors such as customer satisfaction (32,33), return behavior (34), recommendations to others (35), choice behavior (36), and interactions with employees (37) have been considered when analyzing quality in health systems.
In the health sector today, approaches such as Quality Control (QC), Quality Assurance (QA), Business Process Reengineering (BPR), Continual Quality Improvement (CQI), Total Quality Management (TQM), and tools/techniques such as ISO 9000:2000, Six Sigma, and Balanced
Scorecard (BSC) are complementary methodologies to achieve what is considered Organizational Excellence as per models such as the Baldrige model in the United States, the EFQM model in Europe, and the Deming model in Japan.
Scorecard (BSC) are complementary methodologies to achieve what is considered Organizational Excellence as per models such as the Baldrige model in the United States, the EFQM model in Europe, and the Deming model in Japan.
Presently, it is recognized that assuring the quality, safety, and social justice of the care provided to patientcustomers is a requirement for both public and private health services, beyond the basic public health measures. Therefore, a new healthcare system has to be designed for the 21st century (11,38), recognizing that criteria set in some of the oldest European public health services are also falling short of their expectations.
This urgent call to action for healthcare entities to reengineer their work processes, placing safety as a paramount institutional objective, requires a marked change in healthcare sector thinking, since no substantive enduring changes can be made without successfully remaking the existing organization’s culture and reshaping the way members think, behave, and approach their work (39,40).
Culture and Organizational Change
Recognition is growing among healthcare leaders of the need for a culture change within their organizations. Culture change is not a program with a completion date, nor is it a quick fix. It is an ongoing journey—a journey that requires leaders to understand the current state of the organization, establish a clear vision, align behaviors, and instill accountability.
Organizational culture is considered as a manifestation of internalized assumptions or “taken-for-granted” understandings that are shared by an organization’s members on such matters as the interactions between humans, institutions, and their environment; therefore, members must find meaning in their professional and personal existence (21). These assumptions are expressed through the values, beliefs, attitudes, behaviors, language, customs, goals, policies, and operations of an organization (39,41).
Historically, in the healthcare sector, a “safety” culture has been one that integrates the Hippocratic maxim of “first do no harm” into the very fiber of its identity, infuses it into the norms and operations of an entire organization, and elevates it to the level of a top priority mission enshrined in formal corporate statements as a guiding principle that governs the work and is applied to its day-to-day practices.
Even though the “patient safety movement” is now clearly underway as generally accepted, “Improved safety must be our specific, declared, and serious aim, beginning at the top of our organizations” (42). It has to be emphasized that culture is at the very heart of an organization and plays a key role in helping organizations respond to the many challenges they now face when searching for a culture of safety as an organizational priority (43, 44, 45). Specifically referring to the historical healthcare institutions accreditation culture, safety initiatives cannot be viewed just as a means of complying with yet another external mandate, but must be perceived by the entire membership as being integral to the organization’s mission and vision.
Safety must be the dominant characteristic of all high-risk industries, including healthcare. The manner in which a healthcare organization balances the issue of safety with other organizational priorities will shift its culture toward or away from a safety orientation. Safety cannot be treated as an adjunct to the strategic decision-making process. As a general concept, a safety culture is what emerges as a result of a concerted organizational effort to move all cultural elements toward the goal of safety, including an organization’s members, its systems, and work activities; it must be front and center and implemented at all levels of the organization (46,47).
To this end, the organization must set safety goals and objectives that apply across the institution and down to the departmental level. Patient safety issues should appear as regular agenda items for discussion and implementation at all levels of the organization in order for safety to be sustained as a priority. Given the sweeping changes that will be necessary to bring about organizational safety in healthcare institutions, now more than ever, good leadership from both clinical and nonclinical arenas is an essential prerequisite to transforming an organization’s culture. According to experts in the field of organizational change, no substantive transformations will take place within an organization without the skill, visible commitment, and guiding example of a recognized leadership. Effective leadership sets the expectation and tone for an organization by articulating the institutional vision through empowering messages and by reinforcing “doing the right thing” as a corporate priority (45).
However, healthcare organizations have unique structures and are subject to societal expectations that must be accommodated within an organizational value system. But actually, they share many common challenges and objectives with large corporations in the industrial and service sectors. They all hire people with goals and ambitions, and with expectations as to how they will be treated, accepted, rewarded, and promoted.
All too often, however, employee expectations and those of the organization are not fully aligned. This may be true despite what the organization professes as its objectives. For employees, it is the culture of the organization that is the reality, not the mission statement that hangs on the wall.
Leaders must redefine the meaning of shared responsibility and accountability. Organizational cultures and the training and socialization of the numerous professional groups in healthcare also add to the considerable heterogeneity of value systems within healthcare organizations. These contribute to another challenge confronting healthcare managers—competing or conflicting values within a unit or the entire organization.
Four key elements of values-based leadership are required for healthcare managers who seek to develop as values-based leaders: (a) recognize your personal and professional values; (b) determine what you expect from the larger organization and what you can implement within your sphere of influence; (c) understand and incorporate the values of internal stakeholders; and (d) commit to values-based leadership.
A culture that is quality and safety oriented is characterized by a strong, broad-based working alliance that shares ownership of the organization’s vision. The alliance is strengthened by the collaboration of “centers of power” within the organization, represented by critical segments of the hierarchy, including executive and medical staff.
The greater the solidarity and sense of ownership across the organization, the greater the willingness to
share responsibility and accountability for achieving the vision of safety (48).
share responsibility and accountability for achieving the vision of safety (48).
Everybody in the organization has a task, and all tasks can be considered as being a “process”; “process thinking” defines the new management paradigm.
Process Thinking
Modern health services constitute integrated processes. Care is delivered through core processes that follow the patient from the time of referral/request until after the discharge, including follow-up. Core processes, however, depend on a number of vital inputs in the form of supporting processes. Furthermore, achieving an integrated process approach is critical for assuring efficient healthcare risk management.
The identification of processes, their interaction, and their control and applying a system of processes within an organization are referred to as “the process approach.”
A process is a unique combination of people, tools, methods, and materials that add value to an input to attain an output in goods and services.
Regardless of what their end products or services are, the concept of “process” can be applied to each and everyone.
When used within a quality management system, such an approach emphasizes the importance of:
Understanding and meeting requirements
The need to consider processes in terms of added value
Obtaining results from process performance and effectiveness
Continual improvement of processes based on objective measurement
Tasks (processes) link together to form systems that are aimed at achieving an end goal whose quality is prescribed in specified requirements and the goal of customer satisfaction. An individual task will have its own set of specified requirements to satisfy. Every task can be analyzed into the constituent elements that it needs or supplies.
The quality of task output depends as much on the quality of the inputs received at the workplace as it does on how well the task is actually performed or, as one might say, how well the process is system controlled. This basic fact has often been forgotten and people have been blamed for results not within their control.
In order to function effectively and efficiently, an organization has to identify and manage different linked activities where the output from one process becomes the input to another one.
The application of a system of processes within an organization, together with the identification and interactions of these processes, and their management, referred to as the “process approach” is the required foundation for establishing a quality management system.
Quality Management Systems
Quality management systems are the basis for the successful operation of an organization; it allows for systems control and systematic management, and process thinking is the nuclear concept for assuring its implementation.
The concept of a quality management system in healthcare emerged in the last century as a new paradigm in the healthcare improvement arena, where concepts such as quality of care, adverse events, cost of care, cost management, customer satisfaction, patient empowerment, and evidence-based practice established a new glossary for healthcare professionals.
Therefore, in the health services sector, requirements for quality management have to be interpreted differently than in industry and other types of business for the following reasons:
Healthcare services are characterized by the physical and mental involvement of the patient in the process of care provision. Thus, the provision of care is based on the continuous interaction between healthcare professionals (providers) and customers.
The customer may have little knowledge of the professional aspects of the service delivered. The relationship between the patient and the professional is an unequal one considering the professional input; choices will be highly influenced by the professional.
Commonly, the purchase and the receipt of health services are separated (so-called third-party payment). Thus, the provider may have to satisfy different quality demands from its two main customers: the patient and the purchaser.
Healthcare services are characterized by complexities such as relations and interactions between patients, healthcare professionals, health suppliers, insurers, industry, and governmental bodies. In addition, health services are subject to constant change introduced by evolving technologies.
Nevertheless, by the use of a quality management system, processes that are directly or indirectly related to the health services provided can be controlled to meet these requirements.
This new approach to healthcare management has required finding an acceptable methodology for measuring, assessing, and comparing organizational performance through valid standards and recognizing self-assessment and accreditation results, and has been, consequently, a high priority in technically developed countries (49).
Even though the efficacy of quality management as a strategic orientation of the organization that impacts on the immediate and future performance and sustainable competitive advantage appears important, more data are still needed; the findings of a study on small and large hospitals in the United States has reinforced past anecdotal claims of success (50).
Furthermore, the realization of total quality management in everyday practice required the availability of preexisting technologies, standards procedures, and numerical representations on where to anchor the new “customer”-oriented focus culture that confronts the traditional medico-scientific “patient” concept of quality healthcare (51).
Healthcare is more than a decade behind other high-risk industries in its attention to ensuring safety, and safety is the first critical step in improving quality of care considering management of risk a priority.
Patient safety has become a priority issue after the IoM report, and it appears that sectors such as that of aviation
can be a good benchmark for safety and risk management within the healthcare sector (52). It seems, therefore, that healthcare organizations can benefit from learning from other sectors that have implemented risk management in an integral approach toward a continuous improvement culture. Management of risk should be an integral part of any healthcare sector reform.
can be a good benchmark for safety and risk management within the healthcare sector (52). It seems, therefore, that healthcare organizations can benefit from learning from other sectors that have implemented risk management in an integral approach toward a continuous improvement culture. Management of risk should be an integral part of any healthcare sector reform.
Risk Management in Healthcare
Traditionally, risk management in healthcare has been driven by insurance and litigation rather than the “holistic” approach that has evolved since the mid-1950s out of the manufacturing and insurance companies. This more formal approach to effective risk management is being accepted as a required management practice both in the private and public sectors and has led to the development of professional risk management associations in many countries (53).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
