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 an instructional outline and organizational format which drives an operating-for-quality dynamic throughout a facility - a foundation for discussing organizing and applied benefits. Figure 1 depicts a three-domain organizing-for-quality configuration. Conveying the message that healthcare quality is not a free-standing, unitary matter. Rather, it is best understood as a provider care activity (clinical care) which must be supported by organizational processes and personnel performing within distinct and interacting domains. Also, each domain has a specific mission that is supported by key behaviors, relevant decision-support techniques, and process improvement methods. Table 2 summarizes the mission, actions, and methods associated with each organizational element. Since Figure 1 is a conceptual configuration, it is relevant for any healthcare facility – from hospitals and physician clinics, to specialty entities and outreach services.

Figure 1 Three domains of organizing for quality 108 The Journal of Health Administration Education Winter 2017

Table 2 The three domains of quality

Mission/ Domain Purpose Concern focus Methods Customer To meet the Patient experience of care Studer training/people service customers’ Information transparency pillar needs Patient satisfaction Press-Gainey survey tools Employee satisfaction Focus group interventions Physician satisfaction Affinity charts Vendor participation Customer interviews Observation/intuition Surveys/ questionnaires Vendor/contract compliance Queuing theory applications Descriptive statistics Patient To mini- Adverse events Statistical process control safety mize the Error rates Data graphing – dash likelihood of boards harm Medication management Process design and flow Risk analysis Regulatory compliance Six Sigma intervention and reporting FOCUS-PDCA interventions Lean Six Sigma Failure mode/effects analysis Cause-and-effects analysis Clinical To maxi- Diagnostic accuracy Value-based purchasing care mize the Treatment errors Evidence-based training likelihood of the desired Sentinel events Target-focused interven- outcome Iatrogenic squali tions Information transparency Population health status Resource utilization/costs Time-driven activity incurred based costing Provider participation Measured value over time Provider peer review An instructional approach to healthcare quality 109

Customer service domain It is a given that once an organization declares a set of individuals to be a customer group, a defined, unavoidable obligation accrues to the facility. Specifically, each customer cluster has a well-defined, easily understood need that the organization is responsible for satisfying. It follows that the facility has made a commitment to use specific methodologies to identify and fulfill those needs – in concert with an approach to continuously ensure the intended outcome. A customer service culture is deemed an essential success factor (i.e., a quality foundation). Provider expertise, personnel competence, and technological sophistication cannot overcome the limitations of a diminished customer service environment. Further, the customer service domain is a foundational domain over which administrative, managerial, and non-physician personnel can exercise management control. Also, envisioning a distinct domain and expanding the definition ofcustomer beyond patients and patient family members fosters the continuous enhancement of a sensitive, responsive interpersonal organizational environment. Creating a customer service domain with a specific mission is instructionally helpful in resolving the dilemma over patient satisfaction as a proxy measure of healthcare quality (Cleary, & McNeil, 1988; Manary, Boulding, Staelin, & Glickman, 2013). Doing so fosters instructional opportunities to highlight an organization’s obligation to address patient needs throughout a patient’s experiences and within all nodes of interaction – not just at the bedside, in the exam room, or in the CT scanner. Such a service outlook amplifies the reality that a patient’s experience of care is the result of an organization-wide character and associated behaviors. Once created, this domain is a perfect arena for developing case studies that enable students to analyze the customer service lapse, apply the relevant methodology, and articulate a pragmatic solution. Such an instructional tactic illustrates the foundational role of ongoing customer service.

Patient safety domain The global intent of the patient safety domain is to continuously minimize the risk of harm. Creating a separate domain makes it possible to envision how customer service is foundational to patient safety. Customer-oriented personnel are motivated by the outlook, “I can minimize risk to patients within my sphere of responsibility.” This domain is also defined as an adjunct to the clinical care domain because it supports the provider-patient objective of 110 The Journal of Health Administration Education Winter 2017

“maximizing the probability of the desired outcome.” This is accomplished by supporting clinical processes and outcomes via the domain mission of minimizing the risk of harm to patients. The instructional and organizational implications of creating this domain underscores the clinical support role encapsulated within patient safety as distinct from the safety elements of direct clinical treatment. It is helpful to think of patient safety within this domain as activities of non-physician providers that augment and/or support the physician or mid-level provider’s care as delineated in the treatment plan. Separating these activities from the safety elements unique to provider-patient interaction amplifies the nature and extent to which non-physician personnel are accountable for the support features of patient safety (Gandhi & Lee, 2010; Radick, 2016; Birk, 2015). Since these responsibilities are treated as support, instructional delivery focuses on the assessment, process control, and performance improvement methodologies supporting the mission of “minimizing harm to patients.” This distinction eliminates the conceptual blurring between patient safety as a support activity and patient safety actions embedded in physician-patient interventions. The methodology emphasis is on Lean, Six Sigma, SPC using process improvement case examples with SPSS and/or Minitab software applications (Carey, 2003; George, Rowlands, Price, & Maxey, 2005; Arthur, 2011; Henderson, 2011).

Clinical care domain In keeping with the IOM’s definition ofquality of care, the clinical care domain is the arena in which providers interact with patients to ensure that healthcare services are delivered in a manner “consistent with current professional knowledge” for the purpose of increasing “the likelihood of the desired outcomes.” Creating a clinical care domain enables one to think in terms of the intended outcomes of provider interventions – however ¬outcomes are defined. Even though there are patient safety elements in the patient safety domain, working within a separate clinical domain allows for considerable instructional and applied flexibility. In this domain, patient safety is envisioned as inher- ent in the diagnosis, treatment, and outcome sequence of care. This view is consistent with Singh & Graber’s (2015) contention that diagnostic accuracy is the “next imperative for patient safety” because an accurate diagnosis is a priori to the desired clinical outcome (e.g., healthcare quality). Creating a clinical care domain as a distinct, free-standing organizational segment circumscribes provider-patient transaction as the ultimate care arena, especially in relation to oversight of diagnosis and treatment. In spite of the An instructional approach to healthcare quality 111 compelling forces of managerialism, commodification of health services, and challenges to professional dominance, physicians and mid-level practitioners retain and/or share responsibility for diagnosing and treating medical illness. Thus, those preparing to be healthcare administrators are reminded that they will have minimal (if any) latitude within this domain. Yet, they are responsible for ensuring quality-support performance throughout the organization and attesting the same to regulators and stakeholders. In response to this administrative reality, a distinct clinical care domain has a significant instructional advantage. It allows for a narrative regarding the historical, current, and emerging dialogue regarding technology advances, diagnostic errors, treatment selection decisions, outcome assessments, and outcome linkages to reimbursement. Even though no administrator will have direct service privileges within the clinical care domain, being conversant with quality issues impacting providers is an essential administrative obligation – an administrative customer service opportunity that supports the facility’s provider customers. This is especially true in relation to the conceptual and procedural difference between quality defined in process action terms andquality defined using value-patient-outcome language. This emerging and intensifying difference is readily incorporated instructionally by highlighting the conceptual differences and comparing the operational measurement approaches (Porter, 2010; Porter, Larsson, & Lee, 2016). Also, diagnostic errors are treated as a patient safety issue. However, when embedded in the clinical care domain, diagnostic accuracy is easily narrated as a clinical care matter because diagnosis is requisite to ensuring “the likelihood of the desired outcome.”

Domain-specific methods Table 2 catalogues performance improvement methods aligned with and supportive of each domain’s mission. Rather than teach quality as a strict methods course, the three-domain framework enables one to link methods to the decision-support role relevant to each domain’s mission. Creating this domain-mission-method alignment is facilitated by distinguishing between a deterministic and probabilistic view of the behavior of variables. It amplifies the importance of variability within a process (Pronovost, 2011). The domain-mission-method framework also envelopes specific methodologies within its most relevant domain (Brook, McGlynn, & Cleary, 1996). Once the mission and associated activities for each domain have been articulated, it is possible to focus exclusively on applications, measured outcomes, and performance improvement. Since methods are now embedded in a purposeful 112 The Journal of Health Administration Education Winter 2017

context, it is possible also to vary the level of rigor – even for SPC methods as well as queuing theory applications. Also, the factor and aspects of validity can be considered under an epistemological umbrella: “How do you know what you know?”

Summary Figure 1 and Table 2 support the argument that healthcare quality is best understood as the interaction of three distinct domains which individually fulfill a specific mission, yet cooperate to augment each other’s mission effectiveness. Figure 1 conveys this premise as a conceptual template and an organizational hierarchy, where hierarchy indicates that the customer service domain supports the mission of the patient safety domain just as the patient safety domain supports the clinical care domain’s ultimate mission.

Instructional advantages Even though a semester-long course has been abstracted in a short space, this format has advantages as well as improvement opportunities. One instructional question is, “How does this template apply throughout a semester-long healthcare quality course?” The global course outcome is accomplished at two levels – cognitive and organizational – and is supported by a focus on organizational design, cognitive structure, analytical positioning, applied relevance and, rigor flexibility.

Organizational design Independent of an organization’s service purpose, each domain: (1) has a defined mission to fulfill; (2) implements a set of mission-focused activities; (3) measures and assesses results; and (4) continuously improves performance using domain-specific techniques. To the extent that each domain fulfills its mission, each domain is able to support the mission of the domain above it. If the customer service domain is operationally strong, it is positioned to support the mission, activities, and methods of the patient safety domain. Equally so, if the foundational customer service domain is not effectively fulfilling its mission, the domains above it are weakened. This hierarchal organizational template posits that three organizational domains are necessary to support the IOM definition of quality: “the degree to which health services … increase the likelihood of desired health outcomes.” A solid customer service foundation supports the patient safety mission, An instructional approach to healthcare quality 113 thereby bulwarking that patient safety effectiveness redounds to an “increased likelihood of desired health outcomes” in the clinical care domain. An instructional advantage is the ability to minimize definitional uncertainty and enhance an understanding of key decision support methods. In addition, students have an opportunity to build a mental schema about healthcare quality that carries to on-the-job problem solving skill. Clarity about each domain’s mission leads to certainty about essential decision-support information – something that establishes certainty about appropriate methods. Once a deconstruction of quality operations into three distinct domains has been accomplished, it is easy to envision how the domains interact to provide reciprocal support for one another’s mission.

Cognitive structuring The three-domain template fosters administrative and clinical thinking. For example, Koven (2016) has argued that clinical providers are confronted with the dilemma of “struggling to ration … [their] time and emotional energy” in today’s care world of managerialism and commodification. The challenge is balancing corporate productivity requirements against time-consuming patient interaction expectations. This template fosters meta-thinking about the foundational importance of customer engagement and long-range clinical as well as administrative effectiveness. Such an outlook underscores the risk of being highly skilled clinically and operationally, yet being insensitive to customer needs. This is a vital sensitivity because health service management and care delivery are fundamentally interpersonal exchanges rendering clear thinking about quality as antecedent to effective execution and overall mission effectiveness. The three-domain template provides an experiential way of building a conceptual perspective that enables students and interns to analyze organizational dynamics. For example, in one assignment, interns are asked to narrate their understanding of how their site facility is organized for quality. Informal feedback and post-internship focus group data confirm that interns become sensitive to the structural and dynamic aspects of their placement organization. A further advantage is that the three-domain approach enables one to incorporate: (a) definitional nuances of quality; (b) evolution of quality definitions; and (c) implications of value as the quality frontier. This occurs without allowing quality complexities to frustrate understanding or decisions about methodology. This template is a perfect foundation for building applied problem-solving skills while incorporating changes and advances about healthcare quality. 114 The Journal of Health Administration Education Winter 2017

Analytical Positioning An instructional approach to methods is first conveyed by determining the position from which one is attempting to analyze a situation. There are three perspectives from which a situation may be addressed – retrospectively, prospectively, and concurrently. First, a quality situation, or adverse event can be assessed retrospectively, i.e., after the event has occurred. A post facto cause-and-effect analysis of a Joint Commission sentinel event is an example. The downside to a retrospective analysis is the after-the-fact aspect, especially when there is a negative outcome. As cause-and-effect methods are applied, an instructional question emerges: “How might this event been prevented?” Second, a Failure Mode/Effects Analysis (FMEA) approach assumes a prospective position because the analytic intent is the prevention of potential adverse events. Expert opinion presumes that a process, if applied as designed, could have negative consequences. Thus, a prospective analysis positions one to anticipate adverse events and respond accordingly. A third analytic position is concurrent, i.e., while the process is underway. The instructional narrative emphasizes the differences among one’s position – the advantages and limitations of the three analytic positions. This discus- sion is augmented by a review of the best methods for each domain and the associated analytical position.

Applied relevance Such an approach provides a template that limits uncertainty about mission, methods, and application. The customer service domain ensures a focus on the experiences of groups defined by the organization as customers. Doing so reduces the historical uncertainty regarding patient satisfaction as a proxy measure of quality. Further, since the domain’s intent is to satisfy customer needs, methods should focus on assessing customer experiences with the organization and continuously improving processes that enhance customer experiences. Table 2 shows that survey questionnaires, focus groups, listen- ing posts, and interviews are the most frequently used methods for capturing customers’ experiences. Also, since waiting time is a critical customer service variable, especially for patients, PDCA methodology is useful for ensuring continuous improvement. The overarching question is “How well are we meeting customer needs and in what ways can we continuously improve our measured results?” An instructional approach to healthcare quality 115

Rigor flexibility Since each domain uses methods accepted within U.S. health services, the three-domain structure enables students to analyze a situation objectively and design equally focused interventions. For example, within the customer service domain, it is assumed that customer’s needs do not change. Yet, there is no end to the extent to which methods can be applied along a continuum from basic to rigorous. For example, waiting time problems can be addressed by capturing and tabulating descriptive statistics followed by routine su- pervisory adjustments. The same concern can be addressed using Queuing Theory and adjusting processes accordingly, followed by assessment of patient perceptions of improvement. That is, once the conceptual consequences of a three-domain outline have been established, a healthcare quality course can be taught methodologically as an introduction or as a rigorous SPC/operations management skill builder. This is a valuable foundation for undergraduate students. Such an approach also enables master-level students to: (1) step back from the language flurry and methodological activity surrounding quality; (2) think through key elements of organizational activity; and (3) refresh/enhance their methodological tool box. Given the approach’s rigor flexibility, doctoral students have an opportunity to: (1) critically evaluate the quality literature; (2) execute well- designed studies incorporating unambiguous operational definitions; and (3) become conversant with legislative, regulatory, and administrative matrix in which healthcare quality is embedded.

Improvement opportunities A limitation or criticism is that the template is too simplistic and misleading because healthcare quality is far more complex than considered here. The U.S. health industry will never be able to model the safety record of commercial air services because healthcare, comparatively, is quite complex. This view is reinforced by the emerging acceptance of value as a comprehensive rubric for understanding and assessing quality, i.e., from a longitudinal outcomes view of care. However, this three-domain design and instructional approach is anchored in the principle of parsimony (Occam’s razor) as a concise way to think about organizational structure, domain mission, and relevant methods. A well-defined structure is actually a productive framework within which to edify and curtail the presumption of complexity’s capacity to dilute course competencies and experiential learning outcomes. An additional criticism is that patient safety and clinical care cannot mean- ingfully be treated as separate domains because both are integral components of quality. This challenge is addressed by creating a conceptually distinct 116 The Journal of Health Administration Education Winter 2017 clinical care domain to highlight the role of diagnostic accuracy and value as essential features of maximizing the probability of the desired outcome. Once conceptual and operational separateness has been established, defining the interactive support role among the domains is a natural nest instructional step.

Conclusion The core argument is that a three-domain mission-methods approach to healthcare quality provides instructional opportunities for strengthening student cognition about the elements of healthcare quality and the methodological tools of assessment and performance improvement. Deconstructing quality as a three-element organizational reality creates the conceptual freedom to visualize how achieving the desired clinical outcome is the direct and collec- tive support responsibility of the total organization. Thus, thinking about, organizing for, and managing quality are instructional and operating pre- requisites of healthcare quality success, realizations that are best established before students leave the academy!

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