Applying Quality Management in Healthcare A Systems

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Library of Congress Cataloging-in-Publication Data

Names: Spath, Patrice, author. | Kelly, Diane L. Applying quality management in healthcare. |
Association of University Programs in Health Administration, issuing body.
Title: Applying quality management in healthcare : a systems approach / Patrice L. Spath.
Description: Fifth edition. | Chicago, Illinois : Health Administration Press ; Washington, DC : Association of
­University Programs in Health Administration, [2022] | Preceded by Applying quality management in healthcare /
Patrice L. Spath, Diane L. Kelly. Fourth edition. [2017] | Includes bibliographical references and index. |
Summary: “This book examines the real-world tools and techniques necessary for improving systems that affect
patient care outcomes. The author explains how to explore and modify interconnected systems to make lasting
changes that benefit the entire organization”—Provided by publisher.
Identifiers: LCCN 2021011255 (print) | LCCN 2021011256 (ebook) | ISBN 9781640552777 (hardcover ; alk.
paper) | ISBN 9781640552746 (epub) | ISBN 9781640552753 (mobi)
Subjects: MESH: Quality Assurance, Health Care—organization & administration | Health Services Administration |
Total Quality Management
Classification: LCC RA971 (print) | LCC RA971 (ebook) | NLM W 84.41 | DDC 362.1068—dc23
LC record available at https://lccn.loc.gov/2021011255
LC ebook record available at https://lccn.loc.gov/2021011256

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Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984. ∞ ™

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To the highlights of my life, Gracie and Ryan, my two great-grandchildren

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BRIEF CONTENTS

Preface.............................................................................................................. xv
Acknowledgment............................................................................................. xix

Part I Quality Management: A Systems Approach....................................... 1

Chapter 1 Quality Management Fundamentals................................. 3

Chapter 2 Role of Policy in Advancing Quality............................... 19
Chapter 3 Recognizing System Complexity and
Relationships............................................................ 35
Chapter 4 Understanding System Behavior.................................... 57

Part II Setting the Stage for Success.......................................................... 71

Chapter 5 Creating a Supportive Environment............................... 73

Chapter 6 Fostering Collaboration and Teamwork......................... 85
Chapter 7 Establishing System Direction...................................... 105
Chapter 8 Setting Improvement Goals in Complex Systems......... 125

Part III Achieving Quality Results in Complex Systems............................. 143

Chapter 9 Measuring Process and System Performance................ 145

Chapter 10 Using Data Analytic Techniques to Evaluate
Performance, with Naveen Kumar............................163
Chapter 11 Designing and Implementing Improvements............... 199
Chapter 12 Using Improvement Teams and Tools.......................... 223
Chapter 13 Making Healthcare Safer for Patients........................... 247

Part IV Practice Lab.................................................................................... 275

Exercise 1 Reflective Journal .......................................................277
Exercise 2 The Manager’s Role....................................................279
Exercise 3 Dynamic Complexity...................................................281
Exercise 4 System Relationships...................................................283
Exercise 5 Meeting Customer Expectations..................................285

vii
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viii B rief Co nte n ts

Exercise 6 Organizational Self-Assessment...................................287

Exercise 7 Improving a Performance Gap in Your
Organization..........................................................293
Exercise 8 Teamwork and Patient Safety.......................................301
Exercise 9 Improvement Case Study............................................305
Exercise 10 Systems Error Case Study and Analysis........................311
Exercise 11 Failure Mode and Effects Analysis...............................313

Glossary......................................................................................................... 317
Index............................................................................................................. 327
About the Author.......................................................................................... 349
About the Contributor................................................................................... 351

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DETAILED CONTENTS

Preface.......................................................................................................xv
Acknowledgment.......................................................................................xix

Part I Quality Management: A Systems Approach....................................... 1

Chapter 1 Quality Management Fundamentals............................. 3

Learning Objectives ..........................................................3
Why Focus on Managing Systems? .....................................4
What Are Quality and Safety?.............................................5
Creating a Common Understanding of Quality
Methods........................................................................7
Three Principles of Total Quality......................................11
Quality Continuum for Organizations..............................13
Leading the Way..............................................................15
Summary.........................................................................15
Companion Readings.......................................................16
Web Resources.................................................................16
References .......................................................................17

Chapter 2 Role of Policy in Advancing Quality........................... 19

Learning Objectives.........................................................19
External Stakeholders Affecting Quality ...........................20
Federal Health Policies and Oversight..............................22
Private Health Policies and Oversight...............................26
Summary.........................................................................29
Companion Readings.......................................................30
Web Resources.................................................................31
References........................................................................31

Chapter 3 Recognizing System Complexity and

Relationships........................................................ 35
Learning Objectives.........................................................35
Systems Thinking.............................................................36

ix
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x Det a iled C o n te n ts

Dynamic Complexity........................................................38
Visualizing System Relationships......................................43
Interconnected Systems Model.........................................44
Three Core Process Model...............................................46
Baldrige Performance Excellence Program
Framework .................................................................48
Summary.........................................................................51
Companion Readings ......................................................53
Web Resources.................................................................54
References........................................................................54

Chapter 4 Understanding System Behavior�������������������������������� 57

Learning Objectives.........................................................57
A Systems Metaphor for Organizations.............................58
Lessons for Healthcare Managers......................................59
Going Below the Waterline...............................................63
Summary.........................................................................68
Companion Readings.......................................................68
Web Resources.................................................................69
References........................................................................69

Part II Setting the Stage for Success.......................................................... 71

Chapter 5 Creating a Supportive Environment�������������������������� 73

Learning Objectives.........................................................73
Culture of Continuous Improvement...............................74
Culture of High Reliability...............................................75
Culture of Accountability.................................................77
Summary.........................................................................80
Companion Readings.......................................................81
Web Resources.................................................................82
References........................................................................82

Chapter 6 Fostering Collaboration and Teamwork�������������������� 85

Learning Objectives.........................................................85
Teams in Healthcare.........................................................86
Collaboration and Teamwork...........................................88
Mental Models Affecting Clinical Team Design................88
Mental Models Affecting Improvement Team
Design.........................................................................90
Mental Models About Work Team Differences.................91

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 D etailed C ontents xi

Collaborative Team Tools.................................................94

Summary.........................................................................97
Companion Readings.....................................................101
Web Resources...............................................................102
References......................................................................102

Chapter 7 Establishing System Direction��������������������������������� 105

Learning Objectives.......................................................105
Purpose..........................................................................106
The Purpose Principle....................................................110
Vision............................................................................117
Context..........................................................................119
Summary.......................................................................121
Companion Readings.....................................................122
Web Resources...............................................................123
References......................................................................123

Chapter 8 Setting Improvement Goals in Complex

Systems�������������������������������������������������������������� 125
Learning Objectives.......................................................125
Relationship Between Goals and Results.........................127
Setting Improvement Goals in Complex Systems............129
Types of Goal Statements...............................................132
Critiquing Goal Statements............................................134
SMART Goals and Complex Systems.............................136
Corollaries to Purpose and Goals....................................137
Summary.......................................................................138
Companion Readings.....................................................140
Web Resources...............................................................141
References......................................................................141

Part III Achieving Quality Results in Complex Systems............................. 143

Chapter 9 Measuring Process and System Performance������������ 145

Learning Objectives.......................................................145
Quality Measures and Their Uses...................................146
Selecting Performance Measures.....................................147
Choosing a Comprehensive Set of Measures...................153
Performance Measures and the Quality
Continuum................................................................156
Summary.......................................................................159

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xii Det a iled C o n te n ts

Companion Readings.....................................................159
Web Resources...............................................................160
References......................................................................160

Chapter 10 Using Data Analytics Techniques to Evaluate

Performance, with Naveen Kumar������������������������ 163
Learning Objectives.......................................................163
What Is Data Analytics?..................................................164
Introduction to Data Analytics Techniques.....................165
Types of Data ................................................................166
Applying Descriptive Statistics Techniques......................168
Graphical Methods.........................................................168
Numerical Summary Measures.......................................176
Using Graphical and Numerical Methods to
Analyze Process Performance.....................................182
Bundling and Unbundling Data According to
the User’s Purpose.....................................................187
Summary.......................................................................192
Companion Readings.....................................................195
Web Resources...............................................................196
References......................................................................196

Chapter 11 Designing and Implementing Improvements����������� 199

Learning Objectives.......................................................199
Systematic Critical Thinking in Designing
Improvements...........................................................200
Implementing Improvements.........................................209
Summary.......................................................................214
Companion Readings.....................................................217
Web Resources...............................................................217
References......................................................................218
Appendix 11.1...............................................................220

Chapter 12 Using Improvement Teams and Tools��������������������� 223

Learning Objectives.......................................................223
Charter Improvement Projects.......................................224
Performance Improvement Teams..................................226
Improvement Tools and Techniques...............................229
Summary....................................................................... 240
Companion Readings.....................................................241
Web Resources...............................................................242

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 D etailed C ontents xiii

References.....................................................................242
Appendix 12.1...............................................................244

Chapter 13 Making Healthcare Safer for Patients��������������������� 247

Learning Objectives.......................................................247
Systems Model of Organizational Accidents...................248
Reliability and Safety.....................................................252
Just Culture and Safety..................................................253
Measuring and Evaluating Safe Performance..................255
Designing and Implementing Safety Improvements.......260
Summary.......................................................................265
Companion Readings....................................................269
Web Resources..............................................................270
References.....................................................................270

Part IV Practice Lab.................................................................................... 275

Exercise 1 Reflective Journal..........................................................277
Exercise 2 The Manager’s Role......................................................279
Exercise 3 Dynamic Complexity.....................................................281
Exercise 4 System Relationships.....................................................283
Exercise 5 Meeting Customer Expectations....................................285
Exercise 6 Organizational Self-Assessment......................................287
Exercise 7 Improving a Performance Gap in Your Organization.....293
Exercise 8 Teamwork and Patient Safety.........................................301
Exercise 9 Improvement Case Study..............................................305
Exercise 10 Systems Error Case Study and Analysis..........................311
Exercise 11 Failure Mode and Effects Analysis..................................313

Glossary......................................................................................................... 317
Index............................................................................................................. 327
About the Author.......................................................................................... 349
About the Contributor................................................................................... 351

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PREFACE

A
t the start of the COVID-19 pandemic in 2020, supplies of personal
protective equipment and ventilators were inadequate. Many other
breakdowns in patient care systems became apparent as hospitals quickly
revamped processes to meet the critical needs of patients with COVID while
caring for patients with other conditions. It was a daily struggle to deal with
less-than-ideal systems. This book covers the concepts and techniques necessary
for improving the systems that are so vital to the daily work of clinicians and
the outcomes of patient care.
Anyone directly or indirectly involved in overseeing healthcare quality
and safety or improving processes involved in patient care will find this book
useful. The audience for this book includes senior leaders, department managers,
supervisors, and frontline staff. While the word manager is often found in the
chapters, it is not intended to narrow the audience or the purpose of the book.

Changes from the Fourth Edition

As in the fourth edition, the chapters in this edition are organized into three
parts. In part I, two chapters in the fourth edition (chapters 3 and 5) have
been merged into a revised chapter 3, titled “Recognizing System C ­ omplexity
and Relationships.” A new chapter 5 has been added in part II, “Creating a
Supportive Environment,” that consolidates and expands on topics previously
found throughout several chapters in the fourth e­ dition. In addition, a new
topic—accountability—has been added to this c­ hapter. The chapter on team-
work and collaboration immediately follows this new chapter instead of ending
part II as it did in the fourth edition. In all ­chapters, material has been updated
and new website resources and ­suggested readings added.
Part I provides managers with an overview of quality management and
how it applies to the systems of healthcare delivery. Chapter 2 covers the
many external forces influencing internal quality-management activities of
healthcare organizations. During the height of the pandemic, it became clear
that the systems of healthcare needed improving. This realization leads to the

xv
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xvi Prefa c e

discussion of systems thinking and management of dynamic complexity in

chapter 3. Changing systems of care requires an understanding of systematic
structure and managerial decisions affecting system behavior; these topics are
addressed in chapter 4.
Part II contains four chapters that describe the environment needed to
support quality improvements and the goal setting necessary to guide organiza-
tional activities. The new chapter 5 outlines three behavioral characteristics that
advance success: continuous improvement, high reliability, and accountability.
Teamwork and collaboration, covered in chapter 6, are two more characteristics
needed to support quality healthcare delivery. Chapters 7 and 8 explore how an
organization identifies its value and purpose and establishes improvement goals.
As in the fourth edition, part III contains the nuts and bolts of quality
management. Instructors will find much of the same material in this edition,
with some updates and additions. The basics of performance measurement,
assessment, and improvement are covered in chapters 9 through 12. Chapter
13 describes how these concepts apply to patient safety. The section on high
reliability previously in chapter 13 has been moved to chapter 5 to introduce
students to this characteristic earlier in the book.
Part IV contains practice exercises designed to help students apply,
evaluate, and synthesize the content of this book.
Health Administration Press offers educators the opportunity to build
custom textbooks comprising chapters from several different books. To accom-
modate this service, the chapters in the fifth edition of this book have been
written to stand alone as much as possible. Within each chapter, references to
material in other chapters have been minimized, or the concepts summarized
and repeated when necessary.

Resources
Listed at the end of each chapter are companion readings and web resources.
Instructors can expand students’ learning experience by assigning a companion
reading or directing them to explore one or more of the online resources. These
readings and websites are particularly useful in chapter 10, on data analysis
techniques, if instructors want to cover more than just basic concepts. The
web resources also provide instructors and students with sources of the most
current information on relevant quality management and patient safety topics.

Patrice L. Spath, MA, RHIT

President
Brown-Spath & Associates
Forest Grove, OR

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