Quality Improvement

Quality improvement addresses service needs

American Society for Quality defines quality as "A subjective term for which each person or sector has its own definition. In technical usage, quality can have two meanings: 1) the characteristics of a product or service that bear on its ability to satisfy stated or implied needs; 2) a product or service free of deficiencies. According to Joseph Juran, quality means 'fitness for use'; according to Philip Crosby, it means 'conformance to requirements'."Continuous quality improvement is the ongoing process to assess, anticipate and fulfill the stated or implied needs.

Regarding services and products, which are often the functioning of organizations. Quality improvement (QI) is an important topic in organizational development (OD). While OD is more strategic and handle organizational change for the best, QI focuses on optimizing processes and operations for better outcomes. All organizations should take effort for continuous quality improvement and promote organizational development. Both QI and OD rely on evidence-based approaches, which require routine collection and analysis of data.  

QI is for the improvement of systems and processes, regarding services or products. Human performance improvement (HPI) is relevant to QI since it is people who conduct activities in the systems and processes. QI considers human performance; however, it is more about optimizing the system and process for better outcomes.  

QI is critical for healthcare, which is deemed to deliver the quality of care, defined as the degree to which health service for individuals and populations increase the likelihood of desired health outcomes (WHO). Healthcare systems have built various quality measurement and improvement resources.

• National Quality Forum: Core Quality Measures Collaborative
• Centers for Medicare & Medicaid Services (CMS): Meaningful Measures Initiative 
• Agency for Healthcare Research and Quality (AHRQ): Talking Quality 
• Institute for Healthcare Improvement (IHI): Measures
  
• National Health Service (NHS) in London: Quality Improvement tools
• Healthy People 2030 Objectives: Objectives and Data 
  

Quality measurements in healthcare are complex, and require sophisticated frameworks. Here are a few.  

Three components of quality of care: structure, process and outcome

Resources  
Donabedian A. (2005). Evaluating the quality of medical care. 1966. The Milbank quarterly, 83(4), 691–729. https://doi.org/10.1111/j.1468-0009.2005.00397.x

Six domains of quality of care  

Resources  
Institute of Medicine (IOM). Across the Chasm: Six Aims for Changing the Health Care System,
http://www.ihi.org/resources/Pages/ImprovementStories/AcrosstheChasmSixAimsforChangingtheHealthCareSystem.aspx

Measures and Assessments for Healthcare Quality

HCAHPS

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care. HCAHPS serves as a national standard for collecting and reporting patients’ perspectives of care information. This national standard enable valid comparison among hospitals. The HCAHPS Survey, is also known as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey, or Hospital CAHPS. The Agency for Healthcare Research and Quality (AHRQ) is the agency that is in charge of Hospital CAHPS. The CAHPS program started in 1995.   

The HCAHPS Survey is composed of 29 items: 19 items that encompass critical aspects of patients' hospital experience, three items to skip patients to appropriate questions; five items to adjust for the mix of patients across hospitals; and two items to support congressionally-mandated reports. The assessed hospital experience of patients are:

• Communication with nurses
• Communication with doctors
• Responsiveness of hospital staff
• Communication about medicines
• Discharge information, care transition
• Cleanliness of the hospital environment
• Quietness of the hospital environment
• Overall rating of hospital
• Recommendation of hospital

The HCAHPS Survey can be administrated through mail, telephone, mixed (mail followed by telephone or active interactive voice response (IVR).

HCAHPS has included five-star quality ratings of the assessed patients' hospital experience. The Center for Medicare & Medicaid Service (CMS) has published HCAHPS Star Ratings on its Hospital Compare web site since 2015.  

Below is an example of a hospital's HCAHPS star ratings. 

Patient Safety Indicators (PSIs)

Patient Safety Indicators (PSIs) are measures related to potential in-hospital complications and adverse events following surgeries, procedures, and childbirth. The in-hospital complications and adverse events are potentially avoidable and are serious threats to patients’ safety. Therefore, these PSIs are critical measures for hospital care quality improvement. Below is the list of AHRQ’s PSIs.     

• PSI 02 Death Rate in Low-Mortality Diagnosis Related Groups (DRGs)
• PSI 03 Pressure Ulcer Rate
• PSI 04 Death Rate among Surgical Inpatients with Serious Treatable Complications
• PSI 05 Retained Surgical Item or Unretrieved Device Fragment Count
• PSI 06 Iatrogenic Pneumothorax Rate
• PSI 08 In-Hospital Fall With Hip Fracture Rate
• PSI 09 Postoperative Hemorrhage or Hematoma Rate
• PSI 10 Postoperative Acute Kidney Injury Requiring Dialysis Rate
• PSI 11 Postoperative Respiratory Failure Rate
• PSI 12 Perioperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) Rate
• PSI 13 Postoperative Sepsis Rate
• PSI 14 Postoperative Wound Dehiscence Rate
• PSI 15 Abdominopelvic Accidental Puncture or Laceration Rate
• PSI 17 Birth Trauma Rate-Injury to Neonate
• PSI 18 Obstetric Trauma Rate-Vaginal Delivery with Instrument
• PSI 19 Obstetric Trauma Rate-Vaginal Delivery without Instrument
• PSI 90 Patient Safety and Adverse Events Composite (Weighted average of PSI 3, 6, 8-15)

Below is an example of a hospital's PSI scores over 2017-2020.