The Journal for QualiTy & ParTiciPaTion April 201912

Having a quality management system model can provide

a solid foundation for healthcare organizations, but

ongoing self-assessment of what gaps exist and how they

should be addressed offers a way to ensure improvement.

How Well is Your Healthcare Quality

Management System Performing?

Grace L. Duffy, Susan Peiffer, and Pierce Story

A Hospital-Based Healthcare Quality Management System Model1 was

released in April 2016 by a team of practitioners from the ASQ Healthcare Technical Committee, who represented the Society’s Healthcare and Quality Management Divisions. That model is described in a detailed monograph available at: http://asq.org/2016/04/ quality-management/a-hospital-based- healthcare-quality-management-system- model.html. Figure 1 illustrates the model and its associated sidebar, “A High-Level View,” summarizes the model’s design.

Since then, this quality management system (QMS) model has spread quickly across the globe and attained wide accep- tance. Feedback for the initial monograph

indicated that additional information related to the way healthcare organiza- tions could apply the model to improve patient outcomes was needed.

The QMS model offers a systemic structure that enables healthcare orga- nizations to meet both quality and value-based goals. Each organization needs to understand its current situa- tion and determine the actions that are required to raise its performance to the necessary level and sustain that high performance on an ongoing basis. Self- assessment is a proven approach for achieving these results.

The current maturity of each organiza- tion’s QMS is one factor that influences the model’s potential application.

www.asq.org/pub/jqp 13

Organizations that are begin- ning to develop a QMS (or that just have recognized the need to develop one) tend to have different questions regarding the model’s use than those that have a well-established QMS. Providing self-assessment meth- ods that could satisfy a broad range of circumstances was the impetus for the recently released second monograph and is the focus of this article.

Organizational Assessment as a Driver of Improvement

The QMS model incorporates integrated continual improve- ment and innovation to attain exceptional quality, safety, and patient outcomes. Continual improvement changes pro- cesses so that they increase the effectiveness and efficiency of activities. Innovation is far more transformational; it brings healthcare organizations closer to their visions of a far better delivery system, addresses unmet customer needs, and improves patients’ lives.3

“An organizational assessment is a systematic process for obtaining valid information about the performance of an organization and the factors that affect performance. It differs from other types of evaluations because the assessment focuses on the organization as the primary unit of analysis.”4

Organizational assessments fall into two pri- mary categories—third-party assessments that are conducted by specially trained external examin- ers and self-assessments that are conducted by members of the organization. In both cases, the assessments usually are based on a comparison of the organization’s performance against an estab- lished framework or specific set of criteria.

In a review of healthcare organizational assess- ments, the researchers noted, “As healthcare organizations look for ways to ensure cost-effective, high quality service delivery while still meeting patient needs, organizational performance assess- ment is useful in focusing improvement efforts. In addition, organizational performance

Figure 1: QMS Maturity Model

Patient identi�cation

and assessment

Leadership commitment, planning, and review

Feedback loops

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an d

su pp

or t re

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Mana gem

ent

of inf

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on

Communication, education, and training

Risk management

M anagem

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of change

Te am

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Com pli

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with re

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ment s

Delivery of care

Transition of care

Development of treatment

plan

Exceptional quality, safety, and

patient outcome

Indicates continual improvement and

innovation

Legend: Interactions

assessment is essential for ongoing management decision-making, operational effectiveness, and strategy formulation.”5

Both third-party and self-assessments offer substantial benefits that can help healthcare orga- nizations understand their performance gaps and develop specific plans for addressing them. Self- assessments provide an opportunity for leaders and other members of the organization to introspec- tively evaluate processes and results. In some cases, self-assessment instruments are fairly simplistic and utilize short questions whose answers are based on opinions and decisions. Other self-assessment instruments, however, may have more complex frameworks that require the use of facts, data, and analyses to answer the questions. There is much value to be found in the process of capturing diverse perspectives into a consensus-based decision. The process of reaching the consensus involves discus- sion—and sometimes debate; however, the end result is a decision that all participants can sup- port without trepidation. When conducting an organizational self-assessment, the ultimate con- sensus-based decisions are significant, but often the

process of understanding and resolving the initially different perspectives may be even more important because it builds common insights and a unified approach for moving forward.

The use of a well-designed self-assessment tool that is based on a recognized framework can be especially beneficial—particularly to organizations that are in the initial stages of implementing the associated criteria. For instance, consider the positive results that have been reported about using self-assessment in association with the Baldrige Performance Excellence Program criteria.

Baldrige-based self-assessment has been such a prev- alent practice that instruments have been developed by many academics, consultants, and practitioners in an effort to provide options for organizations that have differing intentions for the evaluation process.

The Impact of Maturity on the Self- Assessment Process

Research on the efficacy of self-assessment has confirmed that another factor—organizational maturity—impacts the value of framework-based evaluations. One study examined the use of the

The Journal for QualiTy & ParTiciPaTion April 201914

core of the model. Of course, the 10 critical quality system elements represent the operationally focused essence of the QMS model from the perspective of a daily management system. They provide for the operational environment, attributes, and activities that make up the patient experience, enable or con- strain change, and lead to intended clinical results. Poor performance of any of these elements may lead to the failure of the entire healthcare system and its ability to meet expectations. The related activities and services associated with each of the elements may apply to one or more of the four key components of care delivery affecting the patient experience. This is true because setting up the ability to serve patients must happen strategically before actually engaging with the individual patient.

The Overlay The integration of continual improvement and inno- vation is critical throughout all the other aspects of the model to ensure that better patient care and business efficiency are achieved. By superimposing these two essential approaches over the three con- centric circles, the model makes it clear that they must be applied to all of the previously described parts. By determining, measuring, and analyzing the results of the organization’s core processes, continual improvement and innovation are possible. Without this critical foundation, the model and any advances it cultivates may become static and fail to allow for future change. The difference between these two approaches is discussed in more detail in the original monograph.

A High-Level Summary

The Inner Circle The core of the model delineates the results that are expected—exceptional quality, safety, and patient outcomes, the primary and secondary driv- ers of exceptional patient and family inpatient hospital experience (defined as care that is patient centered, safe, effective, timely, efficient, and equitable), as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey’s “willingness to recommend” the hospital.”2

The Middle Circle This circle details four key components of the patient’s care delivery—identification and assess- ment, development of a treatment plan by all primary and ancillary services, delivery of care, and transition of care to the next level or dis- charge. These components represent the patient’s typical experiential path through the care-delivery process. They are described in more detail in the first monograph.

The Outer Circle The 10 critical quality system elements that provide the infrastructure and framework for sup- porting and influencing achievement of exceptional quality, safety, and patient outcomes are the process and structures needed for overall business effectiveness and efficiency, and they have an interactive relationship with each other, the four key components of care delivery, and ultimately the

www.asq.org/pub/jqp 15

• Integration. How do your processes align with your current and future organizational needs? How well are processes and operations harmo- nized across your organization?”7

Healthcare organizations are complex, and their efforts to integrate a QMS take time and involve varying approaches. Factors such as the services they provide, size, etc., impact their processes and results in all the ways described by the Baldrige scoring system. Because research has shown that organiza- tions require different assessment information to support decision making, it makes sense to com- bine the concept of a maturity model with a proven scoring system, such as the one used for Baldrige self-assessment.

QMS Maturity Model Figure 2 illustrates a straightforward maturity

model that reflects a typical organization’s jour- ney for deploying the QMS model systematically and comprehensively. This illustration indicates when the organization should shift from self- assessments that are based on the generic QMS model framework to the specific organizational construct. The areas that are shaded in red represent the periods of less maturity when the organiza- tion is more dependent on the basic QMS model. Blue-shaded areas show that the organization has customized the QMS model into a framework that specifically fits its situation and should be used for performance evaluations.

The X-axis reflects four operational stages that represent the organization’s growing understanding of the QMS model, as follows:

• Initial awareness. The organization becomes familiar with the QMS model and seeks to determine if its existing processes for attaining exceptional quality, safety, and patient outcomes are directionally appropriate.

• Increased understanding. The organization begins to delve more deeply into connecting the four key components of the patient’s care delivery and the 10 quality system elements.

• Metric-based application. The organization estab- lishes clear metrics with targeted performance levels for all QMS elements. Operational defini- tions exist for each metric and include sampling plans, reporting frequencies, and distribution.

• Integrated application. Data associated with per- formance metrics is collected and analyzed.

Baldrige and the European Excellence models, con- cluding, “It is suggested that the original models might still be a useful guide to improvement but only for organizations whose conformance qual- ity is poor. More advanced organizations should choose their own relevant dimensions and weight- ings rather than use any standard one-size-fits-all model with more attention being paid to the pro- cesses by which their own business models and strategy are developed.”6

In other words, as an organization becomes more mature in its conformance to a QMS, its self-assess- ments need to move away from generic frameworks and focus more on determining compliance with the organization’s specifically designed approaches. The use of facts, data, and analyses to substanti- ate self-assessment findings would appear to be a necessity at this point in an organization’s journey.

The degree of deployment often is used as the basis for maturity models. This approach was used to develop the QMS maturity model, where the deployment levels were based on an organization’s ability to master progressively advanced levels of the QMS model based on the competencies of indi- viduals and the organization as a whole to learn new concepts and their systematic application.

The wide acceptance of the Baldrige criteria—not only in the United States but also as the founda- tion for many other state and country’s quality award programs—supported the use of its scoring methodology for the development of the QMS application maturity model. Scoring for Baldrige- based assessments uses two dimensions—process and results. Both the strategic approach and the degree of deployment, as well as improvement (called learning), and integration are considered in the process scores, as summarized below, but much more detailed information is included in the actual scoring documentation:

• “Approach. How do you accomplish your orga- nization’s work? How effective are your key approaches?

• Deployment. How consistently are your key pro- cesses used in relevant parts of your organization?

• Learning. How well have you evaluated and improved your key processes? How well have improvements been shared within your organization?

The Journal for QualiTy & ParTiciPaTion April 201916

Results for the metrics associated with the

QMS elements are considered leading indica-

tors. Correlation/regression analyses are used to

determine how well those metrics predict perfor-

mance for the lagging indicators associated with

the four key components of the patient’s care

delivery, as well as the lagging indicators related

to the processes for attaining exceptional quality,

safety, and patient outcomes. Results of these

analyses are used to drive continual improve-

ment and innovation.

The Y-axis reflects six deployment stages that

represent the organization’s growing understanding

of the QMS model, as follows:

• Stage 1—QMS model adoption. The organization officially adopts the QMS model as the relevant framework for its system.

• Stage 2—Alignment of existing processes against 10 QMS elements. The organization determines how its existing processes align with the 10 QMS ele- ments, where there are redundant efforts, and where gaps exist.

• Stage 3—QMS pilot. The organization selects a department, function, clinic, location, or other subsidiary work units as a pilot site for imple- menting the complete QMS model. Applicable existing processes are improved or supplemented as necessary to fulfill the QMS model’s intentions completely. Initial metrics and performance

Stage 1: QMS model adoption

Stage 2: Alignment of existing processes against

10 QMS elements

Stage 3: QMS pilot

Stage 4: QMS expansion

Stage 5: Consistent application of the com- prehensive QMS model

Stage 6: Understanding QMS drivers and

interdependencies

Generic self-assessment Organization-specific self-assessment

Initial awareness

Increased understanding

Metric-based application

Integrated application

De pl

oy m

en t

St ag

es

Operational Stages

Figure 2: QMS Maturity Model

www.asq.org/pub/jqp 17

targets are adopted to track results. Learnings from the pilot are used to improve the QMS model’s application in the initial work unit.

• Stage 4—QMS expansion. The organization develops a comprehensive expansion plan that applies the QMS across all work units. Processes associated with the 10 QMS elements are cus- tomized as appropriate to meet specific patient and business needs. Appropriate metrics and performance targets are adopted to track results for each work unit. Learnings are monitored and used to improve the QMS model’s application in each work unit.

• Stage 5—Consistent application of the comprehen- sive QMS model. The organization’s focus moves beyond determining if means and proportions of processes’ adopted metrics are on target. More attention is given to consistent application by monitoring variances of the metrics.

• Stage 6—Understanding QMS drivers and interde- pendencies. The organization’s comprehension of relationships among the QMS model’s levels are understood deeply. Continual improvement and innovation efforts associated with the 10 QMS elements not only enhance attain- ment of target performance (for both means/ proportions and variances) but also ensure sustainable performance of the organization’s highest-level outcomes.

It is very important to note that the time required to complete each of these stages varies among orga- nizations. The level of leadership commitment is a key indicator of the speed associated with moving through these stages. Because this is the case, self-assessments may not be conducted on a specifically recurring basis, such as quarterly or annually. Each self-assessment should be adminis- tered when the organization’s leaders believe that the stage has been completed or substantial prog- ress has been made. This approach ensures that the deployment process can be revised based on the results of the self-assessments to keep it moving forward optimally.

Self-Assessments Based on the Generic QMS Model

The more mature the organization’s applica- tion of the QMS model is, the more it needs to switch from the use of a generic framework to one

that is customized to fit its specific situation. Initial self-assess- ments, however, are intended to help the organization iden- tify its strengths and opportunities related to alignment based on the generic QMS model. In other words, at the beginning of its journey, the organization focuses more on assessing whether or not it has processes in place to fulfill the 10 qual- ity system elements and how well the processes it is using are performing. Later as the organization becomes more mature in its application of the QMS model, its self-assessment becomes more sophisticated, focusing on how well the processes associated with the elements combine to generate organization-wide results that can be predicted and controlled so that patient and business outcomes are achieved on a sustainable basis.

Detailed descriptions of the self-assessment pro- cesses associated with each of these stages have been developed to clarify the changing approaches used as organizational maturity increases. Worksheets also have been developed for each self-assessment stage of the maturity model. They are not intended to be used exactly as presented by every organiza- tion that conducts a self-assessment, but they offer a starting place for planning the self-assessment process. The online supplement to this article includes the entire set of supporting documenta- tion and more detailed explanations of their usage.

Summary The application of the generic QMS model is

useful for healthcare organizations of all types. It establishes a fundamental framework for ensuring that patient and business outcomes are attained consistently on a long-term basis.

The use of self-assessments provides an afford- able means for organizations to evaluate the state of their quality efforts and determine required improvements and innovations. The self-assess- ment process, however, needs to be modified as the QMS implementation progresses. By adjust- ing the self-assessment instruments used to fit the organization’s QMS maturity, the findings will be more appropriate and actionable, supporting

The Journal for QualiTy & ParTiciPaTion April 201918

Susan Peiffer

Pierce Story

Grace L. Duffy

Susan Peiffer is the performance improvement specialist for the Hospital Sisters Health System, Western Wisconsin Division. Peiffer has more than 30 years of hospital experience and served as director of a variety of hospital departments including clinical laboratory, infection control, radiation oncology, and palliative care. She is a past-chair of the ASQ Healthcare Division and current member of the ASQ Board of Directors. Her email address is [email protected]

Pierce Story, is co-founder and vice president of concept development at Capacity Strategies, Inc. A healthcare innovator and speaker, he is the author of many articles, blogs, and several books including Optimizing Your Capacity to Care: A Systems Approach to Hospital and Population Health Management; Developing a Poly- Chronic Care Network, and Improving Nurse Satisfaction and Retention Through Capacity Optimization. Contact him at [email protected]

Grace L. Duffy is president of Management & Performance Systems where she provides services in organizational and process improvement, leadership, and quality. She has authored numerous books and articles on quality, leadership, and organizational performance. Duffy is an ASQ Certified Quality Auditor (CQA), Certified Quality Improvement Associate (CQIA), Certified Manager of Quality/Organizational Excellence (CMQ/QE) as well as a Lean Six Sigma Master Black Belt. She was named Quality magazine’s 2014 Quality Person of the Year. Contact her at [email protected]

the organization’s ability to meet or exceed its objectives/goals even as changes are made to the surrounding environment. In other words, the self- assessment processes described in this monograph are fairly robust, and they will work for most healthcare organizations regardless of the condi- tions that are affecting their operations.

More Online To learn more about how to conduct a self-assessment at

each maturity level, including process maps and worksheets, go to the online supplemental article, “Healthcare QMS Self- Assessment Based on a Maturity Model,” at www.asq.org/ pub/jqp. A second online supplement, “The Impact of Human Factors on a Hospital-Based Quality Management System,” presents a different perspective on how the QMS relies on and engages people in achieving critical outcomes. The complete monograph discussed in this article is available at http:// asq.org/2019/03/quality-management/assessing-your- healthcare-quality-management-system.pdf.

References 1. Tania Motschman, Christine Bales, Larry Timmerman, Grace L. Duffy, Pierce Story, and Gregory Gurican, A Hospital-Based Healthcare Quality Management System Model, ASQ Healthcare Technical Committee, http:// asqhcd.org/hbok-99-001/.

2. Institute for Healthcare Improvement, “Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care,” http://www.ihi.org/resources/pages/ ihiwhitepapers/achievingexceptionalpatientfamilyexperi- enceinpatienthospitalcarewhitepaper.aspx.

3. Peter Merrill, “Expert Answers: Integrating Quality, Innovation,” Quality Progress, July 2015, pp. 8-9.

4. Katrina Rojas, “Evaluating the Performance of an Organization,” BetterEvaluation, http://www.betterevalua- tion.org/en/theme/organizational_performance.

5. S. G. Leggat, L. Narine, Lemieux-Charles, J. Barnsler, G. R. Baker, C. Sicottet, F. Champagnet, and H. Bilodeau, “A Review of Organizational Performance Assessment in Health Care,” Health Services Management Research, http://journals.sagepub.com/doi/ pdf/10.1177/095148489801100102.

6. A. Williams, B. Bertsch, A. Van der Wiele, J. Van Iwaarden, and B. Dale, “Self-Assessment Against Business Excellence Models: A Critique and Perspective,” Total Quality Management and Business Excellence, http://www.tandfonline.com/doi/ abs/10.1080/14783360600753737.

7. National Institute of Science and Technology, “A Focus on Improvement,” https://www.nist.gov/baldrige/ about-baldrige-excellence-framework.

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