Quality Management System for a Hospital

by Ann L. Wiley, STC Fellow, QPI SIG Founder

Hospitals have a range of activities focused on ensuring and improving safety, efficiency, effectiveness, timeliness, access, and satisfaction. A quality management system ensures comprehensive and integrated effort leading to desired results. Such a system is highly dependent on data, reporting, documentation, and continual learning. This article describes selecting and implementing a quality management system in a hospital and includes the following:

Key elements of a quality management system
Why select a particular quality management system?
Basic steps in adopting a quality management system
Areas covered by the Joint Commission standards
Relevance to the daily work of treating patients
Case studies
Key elements of a quality management system
Dr. Robert Burney, Director of Quality Improvement in the Office of Medical Services of the U.S. State Department, in an April, 2006 presentation to the Rochester ASQ Section, identified the key elements of a quality management system:

Measurable goals for the organization
Documentation of processes to achieve those goals
Periodic assessment of processes and goals
Periodic review of results by management
Action planning to correct problems
Why select a particular quality management system?
An organization may have these elements with any quality management system or with no system at all. When the organization follows a system that has these elements and provides external oversight, the elements are most likely to be put in place and sustained.

Hospitals can follow the ISO 9001:2000 standards, the criteria for the U.S. Baldrige National Quality Award or for one of the state quality awards, or the standards of the Joint Commission on Accreditation of Hospitals.

For information about state and local quality award programs, visit http://www.networkforexcellence.com Links for resources on ISO, Baldrige, and the Joint Commission are found in this article.

Basic steps in adopting a quality management system
Regardless of the system selected, the basic steps in adopting a quality management system are the same. The main steps are summarized here based on the “Steps to Accreditation” by the Joint Commission (http://www.goldsealofapprovalvideo.org/ September 17, 2007). Detailed steps are identified here as applicable for adopting the ISO or Joint Commission standards or the Baldrige Criteria.

Obtain a copy of the standards or criteria you want to use.
Hospital Accreditation Standards, http://store.trihost.com/jcr/product.asp?dept_id=24&catalog_item=767
Comprehensive Accreditation Manual for Hospitals, http://store.trihost.com/jcr/product.asp?dept_id=24&catalog_item=767
ANSI/ISO/ASQ Q9000-2000, http://www.asq.org/quality-press/display-item/index.html?item=T2100&author=ANSI/ISO/ASQ Q9000-2000 Series
Baldrige Health Care Criteria for Performance Excellence, http://www.quality.nist.gov/HealthCare_Criteria.htm
Develop and write (or identify and make available) a policy, a manual or manuals, procedures and work instructions; and identify the relevant records. Establish these as controlled documents. For ISO Registration, work with the Registrar beginning at this point.
Write the policy to tell the broad objectives, much like a detailed mission statement.
Write the manual or manuals to identify the processes that will ensure meeting the objectives and goals.
To document procedures, make a flow chart of each process; write down what is done at each step. Dr. Burney suggests drawing a diagram of what patients experience beginning at the registration desk.
Have the people who do the work write the work instructions, telling where to find needed items, what to do with them, and how to report and act on the results.
Make a list of the records created as each procedure is done, to identify the evidence of conformance to the quality management system and attainment of outcomes. Be sure there is a procedure for identifying, storing, protecting, retrieving, retaining and disposing of the records.
Conduct a self assessment
The Comprehensive Accreditation Manual for Hospitals has a self assessment grid.
Baldrige has a quick self assessment tool for the criteria, http://www.quality.nist.gov/eBaldrige/Step_One.htm and others for the Organizational Profile, Are We Making Progress? http://www.quality.nist.gov/Progress.htm and Are We Making Progress as Leaders? http://www.quality.nist.gov/Progress_Leaders.htm
For a comprehensive self assessment against the Baldrige Criteria, you can conduct a “retreat” in which a small group does the assessment based on existing knowledge. You can also form an investigative team, and have the team organize to perform the asessment, investigate, and evaluate the status of the organization using the Baldrige scoring system.
Assign at least two people to investigate each category, based on their expertise and the importance of the item to their departments. If necessary, have team members investigate multiple related categories, such as Measurement, Analysis and Knowledge Management, and Results.
Have team members list documents to review, people to interview, questions to ask, and analyses to perform. Your time frame determines the scope of the investigation.
Write the Organizational Profile first.
You may want to write responses for “Focus on Patients, Other Customers, and Markets” before responses for “Strategic Planning.” Otherwise write responses in the order the criteria are presented.
List the areas for improvement and develop an action plan. Use the Baldrige Sel-Analysis Worksheet found in the criterian booklet.
Implement the action plan.
The Joint Commission requires complying with the standards in daily work for at least four months prior to a survey.
Implementation includes determining the needed competencies and conducting any needed training.
At this time all personnel must learn the relevance of the quality management system to their work, and of their work to consistently achieving desired outcomes.
Obtain, complete, and submit the application along with the fees.
After the application is submitted, the Joint Commission provides performance improvement services and an Account Representative to help the hospital through the process.
Once Joint Commission accreditation is achieved there is an annual fee each year of the three-year accreditation period.
There are application and site visit fees for the Baldrige Award.
There are fees for the review by the ISO Registrar who certifies compliance for registration to the standard; renewal is required every three years.
Host the site visit or survey.
Maintain compliance.
Publicize accreditation or the award won.
Areas covered by the Joint Commission standards
Regardless of the quality management system selected, the areas assessed are similar. All hospitals that have won the Baldrige Award to date are accredited by the Joint Commission with the Gold Seal of Approval. For reference, the Joint Commission standards cover the following (http://www.jcrinc.com/13519/%20September%2017,%202007):

Section 1: Patient-Focused Functions
Ethics, Rights, and Responsibilities
Provision of Care, Treatment, and Services
Medication Management, Surveillance, Prevention
Control of Infection
Section 2: Organization Functions Improving Organization Performance
Leadership
Management of the Environment of Care
Management of Human Resources
Management of Information
Structures with Functions
Medical Staff
Nursing
Relevance to the daily work of treating patients
Often a quality manual or award application is written in the language of the standard or award criteria. Typically there is some industry- and organization-specific information in each re-stated standard element or criteria item. Quality manuals and even award applications may seem abstract. Therefore it’s difficult for people to see exactly how each standard or criteria item relates to their work. To overcome this problem, involve everyone in stating how each standard will be implemented or criteria item applies. Here are specific things to do to establish relevance.

Name the groups who are the customers.
Tell the role of each employee in assessing and meeting the needs of customers.
Show how the elements of the standard or criteria items apply to each step of a procedure (clinical guideline) for situations such as outpatient treatment, or diseases such as diabetes.
Identify the records created during each procedure, and when and why they are reviewed.
Ensure procedures cover all phases of an activity, such as prescribing, dispensing, and administering medication and that the standard is applied to each procedure.
Identify the reviews and the outcomes assessed in each review.
Tell the specific records and reports that are reviewed, for which outcome, by whom, and at which exact review.
Tell how specific measurements show that the needs of customers have or have not been met, and that services are safe, efficient, effective, timely, accessible and satisfactory to customers.
Link improvement plans specifically to measurements and tell how results are used to develop improvement plans.
Tell how results of reviews are communicated to ensure that everyone with an interest in a particular measurement learns the outcome.
Show specifically how all types of resources: infrastructure, work space, equipment, labor and support, are deployed and re-deployed to eliminate waste and maximize results.
Case studies
The profiles of the winners of the Baldrige Award in Health Care provide useful case studies.

2006: North Mississippi Medical Center, Tupelo, Mississippi, http://www.quality.nist.gov/PDF_files/NMMC_Profile.pdf

2005: Bronson Methodist Hospital, Kalamazoo, Michigan, http://www.quality.nist.gov/PDF_files/Bronson_Profile.pdf

2004: Robert Wood Johnson University Hospital Hamilton (New Jersey), http://www.nist.gov/public_affairs/RWJUHH_PDF_final.pdf

2003: Baptist Hospital Inc. Pensacola, Florida, http://www.nist.gov/public_affairs/baldrige2003/Baptist_3.3.04.pdf

2003: Saint Luke’s Hospital of Kansas City, Missouri, http://www.nist.gov/public_affairs/baldrige2003/St.Lukes_3.3.04.pdf

2002: SSM Healthcare (SSMHC), St. Louis, Missouri, http://www.nist.gov/public_affairs/releases/ssmhealth.htm

Ann L. Wiley is president of Ann L. Wiley Consultants Inc., specializing in development of processes and the communications and training needed to implement processes and sustain improvements. Ann has a Ph.D. in instructional development from Syracuse University. She is the founder and immediate past manager of the Quality and Process Improvement SIG of STC and an STC Fellow.

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