Nursing Leadership &
Management
Patricia Kelly-Heidenthal
0-7668-2508-6
Delmar Learning
Copyright © 2003 Delmar Learning, a Thomson Learning company
Chapter 19
Managing Outcomes Utilizing
an Organizational Performance
Improvement Model
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Objectives
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Upon completion of this chapter, the reader should be
able to:
• Articulate major principles of performance improvement
(PI).
– Customer identification
– Need for participation at all levels
– Focus on improving the process, not criticizing individual
performance
• Describe how performance improvement affects the patient
and the organization.
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Objectives
• Identify how data is utilized for PI (i.e., time series data,
Pareto charts).
• Describe the difference in risk management and PI.
• Describe how the principles of PI are operationalized in the
organization.
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History of Quality Assurance
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Quality assurance (QA) emerged in health care in the
1950s as an inspection approach to ensure that
minimum standards of care existed in health care
institutions.
With its emphasis on “doing it right,” some thought
that QA was very punitive and did little to sustain
change or proactively identify problems before they
occurred.
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Total Quality Management
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Total quality management (TQM) began in the
manufacturing industry, when W. Edwards Deming
and Joseph Juran consulted with Japanese
corporations in the 1950s.
The end result of this method was to satisfy customers
rather than just “doing it right.”
This approach became integrated in the health care
industry in the 1980s.
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General Principles of Performance
Improvement
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Recognize customers and their needs.
Involve all organization members in the process.
Make decisions supported by data.
Continually do things better.
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Who Are the Customers in Health Care?
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A customer is anyone who receives the output of your
efforts.
Customers can be internal, within the organization.
Customers can be external, outside the organization.
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Empowerment of Everyone in the
Organization
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Each person must feel that he or she participates.
Each takes responsibility for the success or failure of
an organization.
Each takes an active part in developing new ways of
doing business and securing new customers.
Each trusts that his or her efforts are valued.
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Who Participates in the Improvement
Process?
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All staff members should be encouraged to
participate.
All those involved with or affected by a goal or
process should participate.
Staff can participate on individual, unit, or
organizational levels.
Participants should include point-of-service staff, i.e.,
those workers on the front line who do the direct work
involved in the process being changed.
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Improvement of the Health Care Process
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A process is a set of causes and conditions that
repeatedly come together in a series of steps to
transfer inputs into outcomes.
All processes have inputs, steps, and outputs.
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Improvement of the System
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A system is an interdependent group of items, people,
or processes with a common purpose.
Outcomes in a system can be improved by examining
not only processes, but also the relationships between
processes.
Correct gathering and interpretation of data is an
essential component of continuous improvement.
Shewart cycle: Shewart developed the concept that
improvement is a cycle; it is continuous because it is
linked to customer needs and judgments.
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Implications for Client Care
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Quality improvement for patient care can be measured
by the overall value of care.
Value is determined by outcomes and cost.
Outcomes can be clinical/functional (did the patient
live?) or related to patient satisfaction.
Cost can be direct or indirect.
Goal: increase quality outcomes, reduce cost.
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Methodologies for Improvement
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Plan-do-check-act (PDCA) cycle
FOCUS methodology
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Storyboard: A Method for Sharing Work
with Others
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It takes the major steps in the improvement
methodology and visually outlines the progression of
each step.
It can be displayed on a chart in a high traffic area of
the organization to inform other staff of the
improvement efforts underway.
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Problem Identification
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A clear, identified mechanism by which front-line
staff can suggest improvement opportunities they see
in their day-to-day work should be established.
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Improvement Strategies
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Benchmarking: measuring organization performance
with that of the best performers
Regulatory requirements: measuring organization
performance against standards from
regulatory/accrediting organizations
Sentinel event: an unexpected occurrence involving
death or serious physical or psychological injury to a
patient, requiring an investigation and possible change
to the organization’s process
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Balanced Scorecard
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In order to assure value in care, measurement of
progress has to be balanced.
Clinical value compass
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Patient Satisfaction Data
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Accumulated through questionnaires, focus groups,
and postcare interviews
Helpful if data can be compared/benchmarked against
data of similar organizations
Time series data
• Allows a quality improvement team to see change in quality
over time
• Time series chart used to look for trends, shifts, and unusual
data
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Charts
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Pareto
Histogram
Flow diagrams
Fishbone charts
Pie charts
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Principles in Action in an Organization
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Organizational Structure
• Encourage accountability.
• Maximize communication.
• Communicate and focus priorities at all levels.
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Organizational Process
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Process: the mechanisms used to accomplish the
organization’s mission and goals
Evidence-based plans of care, such as clinical
pathways, standardized protocols, and clinical
guidelines
Benchmarking tools
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Outcomes
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Outcomes are a measurement of the patient response
to structure and process.
Outcomes:
• Measure actual clinical progress
• Can be short-term or long-term
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Outcome data can be helpful in identifying
opportunities for improvement.
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