A Health Administration Instructional Approach

An instructional approach to healthcare quality 103 TEACHING TIPS & TOOLS Thinking about and Organizing for Quality: A Health Administration Instructional Approach Asa B. Wilson, PhD, DHA Abstract The language community surrounding the phrase healthcare quality that pervades regulatory standards, infuses academic publications, and drives operating practices is argued to be a difficulty. More recently, the term value has emerged as a quality synonym, yet it conveys a significant definitional and applied transition from earlier meanings. This challenging language environment has been further intensified by the emerging linkages between quality assessment and alternatives to fee-for-service reimbursement. Thus, an array of regulatory, practice, and academic approaches creates health administration instructional challenges. A course outline is presented that: (1) is anchored in a concise definition of healthcare quality; (2) encourages an administrative conceptual schema regarding quality; and (3) deconstructs quality into three separate-yet-interacting organizational domains. This framework is augmented by an emphasis on a methodological inventory of domain-relevant decision- support techniques. A three-domain organizational framework minimizes current quality language difficulties and incorporates quality’s definitional evolution – all without undue confusion. This instructional format creates a balanced approach to thinking about quality, envisions organization design strategies, and defines appropriate method applications. Please address correspondence to: Asa Wilson, Health Administration Division, Central Michigan University, 208H Rowe Hall, Mt. Pleasant, MI, 48859. Phone: (989) 774-1735 Email: [email protected] 104 The Journal of Health Administration Education Winter 2017 Introduction Healthcare quality is an enduring priority throughout the U.S. health industry and within academia. Regulatory agencies, insurance companies, academic departments, advocacy organizations, legislatures, professional membership groups, and accrediting bodies are generating a growing number of pro- nouncements on the topic. An array of regulatory and advocacy agencies has increased the volume and intensity of materials on every aspect of healthcare quality – efforts resulting in a vast policy, research, and practice literature (Casalino et.al, 2016; Berwick, 1996). Quality as a healthcare language problem A linguistic meta-analysis of these publications will fail to distil a generally accepted definition ofquality , especially one that specifies quality improvement activities within the nation’s health system (Blumenthal, 1996). This linguistic arc ranges from quality understood only in the “eye of the beholder” (Spath, 2009) to the position that value expressed as clinical “outcomes achieved relative to the costs” is the emerging frontier of quality (Porter, Larsson, & Lee, 2016). One also finds language viewing healthcare quality as a complex – if not an impossible-to-define – feature of care delivery. It is possible to find language that is somewhat dismissive of prior operational definitions or process-based quality monitors and argues for long-term outcome measures under the rubric of value for patients (Porter, 2010). Additional considerations question what elements should be included in a definition of quality. A debate exists over the degree to which patient satisfaction measures are a proxy of quality (Cleary & McNeil, 1988; Manary, Boulding, Staelin, & Glickman, 2013). Also, Nigam’s (2012) content analysis of the quality literature from 1975 through 2009 captures the extent of “changing [healthcare quality] paradigms in academic medicine”. This review identified three distinct evolutionary periods: (a) peer review period, (b) policy reorienta- tion period, and (c) quality improvement period. Each has a different origin, focus, definition, and approach to quality. In addition, the sequence of periods represents a transition from quality as a physician-driven endeavor to quality as the province of an expanding group of non-physician participants. Compounding this linguistic fog is a concern over which profession or what segment of the health industry should be responsible for leading a reso- lution of the quality problem (Chassin & Loeb, 2011; Becher & Chassin, 2001; Chassin, 1996). There are questions also over the role physicians have had and will play in future quality improvement initiatives, especially in relation to addressing the of diagnostic accuracy (Singh & Graber, 2015; Nigam, 2012). An instructional approach to healthcare quality 105 Instructional Difficulties The existing language dynamic and resultant methodological uncertainty about quality generates instructional uncertainty considerations. In the academy, one can hear arguments that healthcare quality should be taught as a strict statistical process control (SPC) methods course, or that quality is best understood in data analytic course content. Another approach posits the need for a “handbook” course which covers an inventory of vision, strategy, definitions, and tools – all linked to or reflective of quality. Others pose that students should secure a Six Sigma Green Belt certificate as a course requirement since quality is a process improvement activity. There is an instructional tendency to encapsulate Lean applications within hospitals and not extend course content to outpatient settings (Gandhi & Lee, 2010; Arthur, 2011). A corollary tactic is to treat quality as a component of organizational strategy by designing a course emphasizing quality’s strategic planning and reimbursement support role in a value-based environment (Shoemaker, 2011; Lee, 2010). Even though agreement exists about the importance of quality as a care delivery priority, the language community bugling this concern is not as uni- form. However, the academy’s applied obligation is such that it must prepare graduates to understand the language nuances of quality, yet be prepared, upon graduation, to work effectively within the resultant policy and operations environment. Equally so, undergraduates are to have a preparatory foundation for graduate work. Purpose The purpose of this paper is to present a course outline that: (1) is anchored in a concise definition of healthcare quality; (2) deconstructs quality into three separate and mutually supportive organizational domains; and (3) fosters an administrative outlook regarding organizing and managing for quality outcomes. Such a framework prepares students to master a conceptual view of healthcare quality and acquire a working knowledge of methodological approaches. This structural and content format supports scholar-practitioner research skills, applied administrative competencies, and advanced degree pursuits. Organizing for quality The following course outline has the overarching goal of establishing conceptual clarity about quality by creating an outlook that has academic and applied relevance. The starting point is a working definition ofhealthcare quality and is the foundation upon which to build the remaining course content. 106 The Journal of Health Administration Education Winter 2017 The Institute of Medicine’s (IOM) (2000) definition of healthcare quality was selected for this purpose because of its definitional clarity: “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Subsequently, this definition is deconstructed into four distinct and interdependent elements. Each element is linked in turn to an operational definition and sources that are well accepted within U.S. healthcare. Table 1 summarizes the four definitional elements and identifies examples of operational components associated with each element. Table 1 Elements and operating advantages of IOM’s definition of quality Definition elements Operating advantages A. Health services - Specificity of definition - Uniformity of coding - Accepted procedural language - Common communication base B. For individuals and populations - Minimal uncertainty of focus - Identify disease states - Specificity of demographic groups - Assess health status of population gains C. Increase likelihood of desired outcomes - Fosters retrospective research - Likelihood is readily quantified - Allows for continuous improvements - Able to incorporate value assessment D. Consistent with professional knowledge - Reliance upon evidence-based Rx - Objective assessments of Rx - Define role for meta-analysis - Continuous improvement cycles - Meta-analysis of contradictory findings The IOM definition creates a point of reference or benchmark from which to develop instructional materials aligned with this framework. It also creates a consistent language community and clear methodological linkages. This definition can be used also as a benchmark from which to compare other definitions of healthcare quality, especially those promulgated by regulatory, An instructional approach to healthcare quality 107 accrediting, and advocacy agencies. This four-element framework does not contradict historical or emerging quality-value definitions. Rather, it facilitates an understanding of the dynamic nature of historical quality perspectives and those emerging within the industry. Finally, this deconstructed definition becomes a conceptual template questioning how best to organize for quality. A three-domain organizational template Deconstructing IOM’s definition is

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