The roles of senior management in quality improvement efforts: what are the key components?
Medical errors (Prevention)
Health care industry (Management)
Bradley, Elizabeth H.
Holmboe, Eric S.
Mattera, Jennifer A.
Roumanis, Sarah A.
Radford, Martha J.
Krumholz, Harlan M.
|Publication:||Name: Journal of Healthcare Management Publisher: American College of Healthcare Executives Audience: Trade Format: Magazine/Journal Subject: Business; Health care industry Copyright: COPYRIGHT 2003 American College of Healthcare Executives ISSN: 1096-9012|
|Issue:||Date: Jan-Feb, 2003 Source Volume: 48 Source Issue: 1|
|Topic:||Event Code: 200 Management dynamics; 310 Science & research Computer Subject: Quality control; Health care industry; Company business management|
|Product:||Product Code: 9913300 Quality Control Management; 9911400 Management Development; 8060000 Hospitals NAICS Code: 622 Hospitals SIC Code: 8060 Hospitals|
With increasing attention directed at quality problems and medical errors in healthcare organizations, the ability of senior management to promote and sustain effective quality improvement efforts is paramount to their organizational success. We sought to define key roles and activities that comprise senior managers' involvement in improvement efforts directed at physicians' prescription of beta-blockers after acute myocardial infarction (AMI). We also developed a taxonomy to organize the diverse roles and activities of managers in quality improvement efforts and proposed key elements that might be most central to successful improvement efforts.
Results are based on a qualitative study of 8 hospitals across the country and included in-depth interviews with 45 clinical and administrative staff from these hospitals. The findings help identify a checklist that senior managers may use to assess their own and others' participation in quality improvement efforts in their institutions. By reinforcing their current involvement or by identifying potential gaps in their involvement in quality improvement efforts, practitioners may enhance their effectiveness in promoting and sustaining quality in clinical care.
The role of senior management in promoting and sustaining quality improvement efforts has been recognized since the earliest efforts to embed continuous quality improvement in healthcare. Berwick and colleagues (1990) have identified the support of management as one of the ten principles underlying successful quality improvement efforts. Experts on more recent innovations to enhance quality in healthcare (Arntdt and Bigelow 1998, Chassin 1998) also highlight the importance of administrative support in driving successful efforts.
Similarly, industrial experts in quality (Deming 1982, 1986; Juran 1986, 1989; Crosby 1992) have highlighted the critical role of management in effecting an organizational shift from quality control to quality improvement. The literature, both in general industry and healthcare, suggests that the role of senior management is paramount to successful quality improvement efforts (Arndt and Bigelow 1998; Chassin 1998; Deming 1982, 1986; Juran 1986, 1989; Crosby 1992; Feigenbaum 1991; Ishikawa 1985; Berwick 1996; Bigelow and Arndt 1995; Carman et al. 1996; Weiner, Shortell, and Alexander 1997). Consistent with this premise, several studies have reported "inadequate leadership" (Hughes 1992; Sullivan and Frentzel 1992) or "unclear vision" (Ancona 1990; Gann and Restucci 1994) as primary reasons for failed quality improvement team efforts.
The explicit objectives of this analysis were to (1) define the key roles and activities that comprise senior management's involvement in quality improvement efforts, (2) develop a taxonomy to classify such roles and activities, and (3) propose key elements of management involvement that might be most central to successful quality improvement efforts. We chose to examine a clinical process--the use of beta-blockers after AMI--because of the widely recognized challenges of applying quality improvement to clinical, rather than administrative, processes (Berwick, Godfrey, and Roessner 1990; McLaughlin and Kaluzny 1999; Longest, Rakich, and Darr 2000). Furthermore, typically underutilized in AMI care (Crockett et al. 1998; Krumholz et al. 1998), beta-blocker prescription after AMI is a quality indicator for the Center for Medicare and Medicaid Services (CMS). Hence, hospitals and physicians have ample opportunity and motivation to enhance this area of clinical practice.
METHODS Study Design and Sample
We conducted a qualitative study employing in-depth, open-ended interviewing of clinical and administrative staff during hospital site visits from March through June of 2000 (Bradley et al. 2001). Using purposeful sampling consistent with standard qualitative sampling methodology (Strauss and Corbin 1990; Crabtree and Miller 1999), study hospitals were selected to represent a range of sizes, geographic regions, and beta-blocker improvement rates over a three-year period. Changes in beta-blocker use rates at discharge were determined using data from the National Registry of Myocardial Infarction (NRMI) (French 2000) and calculated as the beta-blocker use rates during the follow-up period (April 1998 to September 1999) minus the beta-blocker use rates during a baseline period (October 1996 to March 1998) at each hospital.
After arraying all eligible hospitals by deciles according to their changes in beta-blocker use rates, we selected hospitals that represented a range of improvement rates in beta-blocker use. Thus, three hospitals were randomly selected from the lowest two deciles (representing declines in beta-blocker use rates ranging from -22 to -6 percentage points), the middle two deciles (representing increases in beta-blocker use rates ranging from 5 to 7 percentage points), and the highest two deciles (representing increases in beta-blocker use rates ranging from 19 to 35 percentage points). In two cases, randomly selected hospitals did not meet selection criteria (i.e., they did not differ in size or geographical region from others already selected) and thus were replaced with other randomly selected hospitals from the same deciles.
Additional hospitals were selected and visited until the point of theoretical saturation (Strauss and Corbin 1990; Crabtree and Miller 1999)--that is, until no new concepts were identified by the additional interviews. This occurred after the eighth hospital site visit and 45 interviews. The research team was blinded to hospital beta-blocker use rates until the completion of the data collection and coding. The characteristics and beta-blocker use rates in the study hospitals are presented in Table 1.
The investigators conducted in-depth interviews (McCracken 1998; Glaser and Strauss 1967) in person with physician, nursing, quality management, and administrative staff identified by the director of quality assurance or quality management as key staff involved with improving the care of patients with AMI. Four to seven individuals were interviewed at each hospital, for a total of 45 respondents. Respondents included 14 medical staff, 15 nursing staff, 11 staff from quality management or quality assurance departments, and 5 senior managers. Interviewers employed a standard interview guide with probes. The interviews opened with a grand-tour question (McCracken 1998) as is standard in in-depth, open-ended interviewing: "Would you tell us about the quality improvement activities your hospital has undertaken in the last three years?" Probes were used to gain additional detail or clarity about experiences the respondents described. Interviews were 1 to 1.5 hours in length and were typically conducted by at least two members of the research team, as recommended by in-depth interviewing experts (McCracken 1998). All interviews were audiotaped and transcribed by independent professional transcriptionists.
Interview data were coded and analyzed using the constant comparative method for analysis (Strauss and Corbin 1990; Glaser and Strauss 1967; Miles and Huberman 1994; Devers 1999). The code structure was reviewed three times for logic and breadth during its development by the full research team. Coded data were entered in NUD-IST 4 (Sage Publications Software) to assist in reporting recurrent themes, links among the themes, and supporting quotations. Further analysis was conducted to identify distinctions in management roles in quality improvement efforts between higher-performing and lower-performing hospitals using standard hypothesis-generating methods for comparing distinct groups based on qualitative data (Ragin 1987). For this analysis, higher-performing hospitals (a total of three) were characterized as those in which at least 65 percent of all AMI patients in the follow-up period were prescribed beta-blockers at discharge and in which beta-blocker use rates had improved at least 10 percent over the study period. Lower-performing hospitals (a total of five) were characterized as all others--those sampled from the middle and lowest deciles of performance.
Respondents' descriptions of the nature and level of management involvement and support for quality improvement efforts differed substantially among the study hospitals, yet several common roles and activities characterize these differences (see Table 2).
Personal Engagement of Senior Management
Several respondents described personal engagement of senior managers as paramount to the success of quality improvement efforts. Personal engagement was characterized by three dimensions: (1) advocacy for quality improvement efforts within the hospital and at the board level, (2) participation in quality improvement teams, and (3) dissemination of quality improvement data.
In some hospitals, senior managers advocated for quality improvement efforts with influential committees in the hospital and with the board.
Other aspects of personal engagement by senior managers were the degree to which they participated in quality improvement teams and were involved in disseminating clinical performance data.
In some hospitals, personal engagement of senior managers was quite limited. In these hospitals, respondents described the CEO as "distant" and the administrative involvement as only occurring at the middle-management level or lower In one hospital, clinical staff described the hospital's quality improvement efforts as "grass roots" and without any senior management involvement or knowledge.
Relationship with Clinical Staff
In nearly all hospitals, the relationship between senior management and clinical staff was described as influential in the success or failure of quality improvement efforts. Relationships between the senior managers and the medical staff differed widely, from cooperative and respectful to polarized and strained. Although most comments pertained to physician staff, some respondents described managers' relationships with nursing staff as important to the success of quality improvement efforts. The relationship with medical staff was characterized by two dimensions: (1) senior managers' understanding and responsiveness to physician needs and (2) senior managers' ability and willingness to negotiate with medical staff.
In some hospitals, the perception that managers understood, and often supported, the goals of medical staff was noted by physician and nonphysician respondents. In contrast, several respondents in other hospitals noted difficulties when medical staff perceived senior managers' goals to be divergent with their own clinical goals.
Respondents also focused on the ability of senior managers to negotiate effectively with physicians. Effective managers knew what they might be able to offer physicians in return for their participation and cooperation with quality improvement efforts.
Promotion of a Quality Improvement Culture
The promotion of an organizational culture of quality improvement was a third area in which respondents described managers' roles in improvement efforts. We observed three dimensions of organizational culture germane to quality improvement efforts and influenced by senior managers: (1) goal setting and the degree to which quality improvement was integrated into overall organizational goals, (2) norms regarding collaboration across departments and disciplines, and (3) innovation and risk taking within the organization.
Hospitals differed in the level of integration of their quality improvement efforts in AMI care with the overall organizational goals. In several hospitals, staff reported that improvements in quality of cardiac care were part of the organization's strategic plan and that quality progress was reported to the board or senior administrative team regularly. In these hospitals, senior managers highlighted quality as central to their survival in the marketplace and to their organizational mission. In other hospitals, although staff reported implementing several quality improvement efforts, they viewed these efforts as separate from the larger organizational goals. They voiced frustration at the lack of overall goals directed at AMI care.
Marked differences in norms regarding collaboration across departments or disciplines were observed. Some respondents described consensus and cooperation among diverse clinical and ancillary staff.
In other hospitals, staff described ongoing turf battles and interdepartmental conflicts related to quality improvement efforts. As examples, respondents said:
Finally, in terms of innovation and risk taking, some respondents described their hospital as always seeking a new or improved method for caring for patients. At these hospitals, administrative and clinical staff were perceived to be flexible and interested in novel approaches to care.
In other hospitals, staff reported their organizations as risk averse.
In one hospital, respondents noted that senior managers often avoided risks to maintain current departmental structures or embedded relationships with senior medical staff, who themselves were loathe to change practice.
Support of Quality Improvement With Organizational Structures
Nearly all respondents described the importance of organizational structures, typically created with senior management involvement, to guide and empower quality improvement efforts. Two dimensions characterized the diversity of such organizational structures: (1) whether multidisciplinary teams existed that were focused on AMI care and (2) whether quality improvement teams were linked to centralized decision-making bodies in the hospital.
Most hospitals had quality improvement teams that focused on AMI care, although some hospitals did not. Further, the degree to which quality improvement teams were linked to higher-level decision-making bodies varied among hospitals. In some hospitals, quality committees reported directly to senior administrative and clinical staff or influential committees. Illustrating this organizational structure, one respondent stated:
The manager further described that the quality management teams felt that they informed decision making at higher levels and that they were empowered to make substantial changes. In contrast, quality improvement efforts in other hospitals were decentralized, and teams' decisions were not always upheld at higher levels of the organization. For instance, respondents described issues that stymied quality improvement initiatives.
Procurement of Organizational Resources
Respondents in all hospitals discussed the issue of resource and budget constraints. Senior managers were viewed as playing key roles in procuring and allocating needed resources for quality improvement efforts. The common dimensions of this role were (1) staffing adequacy and (2) information technology (IT) capability.
In terms of staffing, respondents noted the critical role of management in approving budgets to procure necessary staff. Similarly, IT resources (including systems to capture, analyze, and summarize performance data) were viewed as essential for quality improvement efforts. Managers were charged with deriding on the resources allocated to centralized data collection, analysis, and reporting functions. Illustrating the lack of necessary staff resources, respondents stated:
Hospitals that performed particularly well reflected a mix of ownership types. Additionally, some of the higher performers were teaching hospitals, while others were not. The number of beds varied substantially among the higher-performing hospitals; however, the three highest-ranking hospitals in terms of improved beta-blocker use during the study period were also those with the greatest AMI discharge volumes.
Several features of management involvement and support described in Table 2 were apparent in the higher-performing hospitals (hospitals 7, 8, and 4 in Table 1) and were not apparent among the other hospitals. Specifically, differences were apparent in the areas of advocacy for quality improvement, relationships with clinical staff, norms regarding interdepartmental and multidisciplinary collaboration, and procurement of organizational resources.
First, in the higher-performing hospitals, the senior managers (the CEO or COO or both) were actively engaged in quality improvement efforts. This engagement included advocating for quality improvement efforts within the hospital and with the board, participating in quality improvement groups, and providing visibility for quality improvement data. In the lower-performing hospitals, managers disseminated quality improvement data from other sources but did not participate on teams and were not viewed as advocating widely for quality improvement in AMI care.
Second, in the higher-performing hospitals, senior management had positive working relationships with individual physicians and the medical staff as a whole. In one hospital, a physician respondent said, "He (referring to the CEO) understands physicians." In two of the higher-performing hospitals, the CEO was a physician. In all three, the CEO or COO was perceived as responsive to physician needs and able to negotiate effectively with physicians. In lower-performing hospitals, staff reported that senior management had poor relationships with the medical staff and did not understand or support the issues the clinicians cared about. In these hospitals, staff perceived management to be often more concerned with fiscal viability than with clinical improvement.
Third, while the organizational culture was described in lower-performing hospitals as "back-biting" and "finger-pointing," the organizational culture in the higher-performing hospitals was described as consensus driven--having shared goals and interdepartmental collaboration to improve quality. Respondents in these hospitals noted the lack of blame and policing of individuals for poor performance. Finally, in all hospitals, respondents described the quality improvement efforts as requiring enormous commitment of resources. Yet, in the high-performing hospitals, staff also reported being able to typically obtain needed resources to make and monitor improvements. In the lower-performing hospitals, respondents consistently stated that they lacked the resources (both people and information technology) to collect and disseminate needed data or to create new systems to improve care.
This study revealed five common roles and activities that captured the variation in management involvement in quality improvement efforts: (1) personal engagement of senior managers, (2) management's relationship with clinical staff, (3) promotion of an organizational culture of quality improvement, (4) support of quality improvement with organizational structures, and (5) procurement of organizational resources for quality improvement efforts. The multiple roles and activities that characterize management involvement suggest that hospitals cannot be easily characterized as either having or not having management support for quality improvement. Rather, management support is a multifaceted concept that encompasses a variety of aspects of administrative activities, roles, and interventions.
Our study found that some activities were more apparent than others in the higher- versus the lower-performing hospitals. Statistical differences could not be assessed because of qualitative study design and limited sample size. However, in the higher-performing hospitals we studied, senior managers were personally engaged in quality improvement efforts through active advocacy of such efforts within the hospital and with the board, had good working relationships with the medical staff, supported norms of interdepartmental and multidisciplinary collaboration, and ensured the availability of resources needed to conduct quality improvement efforts. These features were not apparent in the lower-performing hospitals. AMI volume was also greater in the three higher-performing hospitals.
The patterns in management roles found in higher- versus lower-performing hospitals generate credible hypotheses. For instance, the hypothesis that managers' personal engagement in quality improvement can promote success is consistent with writings by Deming (1982) and Crosby (1992) as well as recent findings in the dissemination of continuous process innovations in healthcare (Savitz 2000; Weiner, Shortell, and Alexander 1997). Further, management's role in promoting an organizational culture of improvement and organizational structures to support that culture, even before quality improvement techniques are fully realized, is consistent with the concepts of commitment and preparedness described by Savitz (2000) and Brailer (1998) and with the importance of group dynamics and culture in managing change described by Shortell and colleagues (1998) and Gist and colleagues (1987). However, larger-scale quantitative studies of these features and related performance outcomes are necessary to confirm or reject the hypotheses we proposed based on this initial study.
As a practical implication of our findings, this study highlights a limited set of roles and activities that managers might consider as they assess how supportive they are of quality improvement in their own hospitals. The dimensions of each role and activity might be included in a checklist for planning or evaluating one's own efforts in quality improvement, highlighting areas of administrative responsibility and influence. The five roles and activities illustrate potentially important, broad areas of administrative influence; their dimensions suggest more specific planning activities for managers.
Our findings also might promote better classification and measurement of managerial involvement in quality improvement efforts for future empirical studies evaluating the influence of such involvement. With some exception (Boerstler et al. 1996), the literature has noted the importance of senior management support in successful quality improvement efforts. However, the difficulty in measuring what management support comprises limits our understanding of this essential element of quality improvement. Better classification of this concept can facilitate more accurate evaluation of management interventions to improve quality in clinical practice. Such information can then provide the necessary science to promote evidence-based training and practice of healthcare managers in the skills of quality improvement.
Several issues should be considered in interpreting our findings. Although we believe the roles and activities we identified are applicable to other clinical process improvement efforts, our study focused on a single clinical process--beta-blocker use after AMI. Additionally, we focused on senior managers' roles and activities without full assessment of their interactions with other potentially confounding influences. With the exception of AMI volume, none of the organizational factors we collected (i.e., geographic state, bed count, ownership type, teaching status, or urban versus rural location) appeared to differ between the higher-versus lower-performance improving hospitals. However, additional organizational and cultural factors not assessed in this study may be important to consider. Finally, although the hospitals we studied were diverse in size, location, and beta-blocker use, our findings came from a select number of sites and may not fully reflect experiences in other hospitals. Although the qualitative methodology allows for a more in-depth understanding of management roles, our results remain exploratory.
Our findings can be used to support several important aspects of management development in this field. First, the findings suggest fundamental roles that senior managers play in clinical quality improvement and thus highlight curricular aspects that may be important for their academic preparation. Second, the taxonomy provides current managers with a checklist of roles against which they can evaluate their own performance as catalysts for and participants in quality improvement efforts in their hospitals. Finally, the study can enhance the quality of future research by more clearly articulating the management roles and activities that may be essential to the success of such initiatives.
This research was supported by the Agency for Healthcare Research and Quality, R01 HS10407. Dr. Bradley is also supported in part by the Donoghue Medical Research Foundation (02-102) and by a grant from the Claude D. Pepper Older Americans Independence Center at Yale University (#P30AG21342).
The authors are grateful to Peter Herbert, M.D., Katherine Littrell, William Kissick, M.D., Donna Diers, R.N., and Stephen Mick, Ph.D. for their comments on the manuscript. We also thank Emily Cherlin, Kinda King, Jen Fiorillo, and Kristin Mattocks for their research assistance in this project.
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Gayle Capozzalo, FACHE, executive vice president, Strategy and System Development, Yale New Haven Health System, New Haven, Connecticut
When quality improvement efforts in healthcare began in the 1980s, the importance of senior management involvement in the success of quality improvement efforts was not clearly understood. Many hospitals started "bottom-up" quality improvement efforts, while others focused on the "top-down" approach. Anecdotal quality improvement success was achieved using both approaches.
Since the late 1990s, however, senior managers have understood that their involvement in quality improvement efforts is essential to success. This study of Bradley and colleagues brings this awareness to the attention of the academic and clinical communities and identifies the roles and activities of managers that lead to successful quality improvement achievement. Although the study is directed specifically at the care of patients with acute myocardial infarction, the key senior management activities identified in the article--personal engagement in quality improvement, the relationship with clinical staff, willingness to promote a culture of quality improvement, creation of organizational support structures, and provision of resources--are applicable to all improvement efforts within the hospital.
Managed care payers and the Center for Medicare and Medicaid Services are beginning to tie provider payment to effective patient safety and clinical quality improvement initiatives and achievements. As a result, hospitals will need to provide consumers and payers with information regarding clinical quality and patient safety outcomes, forcing greater focus on improvement efforts. This national call for action to improve clinical quality and patient safety throughout the healthcare industry requires senior managers to create an organizational culture of quality improvement.
This article offered three dimensions of organizational culture germane to quality improvement efforts that were influenced by senior managers: (1) goal setting and the degree to which quality improvement was integrated into the overall organizational goals, (2) norms regarding collaboration across departments and disciplines, and (3) innovation and risk taking within an organization. Senior managers should take time to evaluate their performance as catalysts of quality improvement at their hospitals and to take stock of their organizational culture in the suggested dimensions. In addition, the education of future healthcare administrative and clinical leaders should incorporate the insights enumerated in this article.
For more information on this article, please contact Dr. Bradley at Elizabeth.email@example.com.
Elizabeth H. Bradley, Ph.D., associate professor, Department of Epidemiology, and Public Health, Yale University School of Medicine, New Haven, Connecticut; Eric S. Holmboe, M.D., associate professor, Department of Medicine, Yale University School of Medicine; Jennifer A. Mattera, assistant director, Yale-New Haven Hospital, Center for Outcomes Research and Evaluation; Sarah A. Roumanis, R.N., project coordinator, Yale-New Haven Hospital, Center for Outcomes Research and Evaluation; Martha J. Radford, M.D., system director, Clinical Quality, Yale-New Haven Health System, and associate professor of medicine, Section of Cardiovascular Medicine, Yale University School of Medicine; and Harlan M. Krumholz, M.D., professor of medicine and epidemiology and public health, Departments of Medicine and Epidemiology and Public Health, Yale University School of Medicine
"The one thing [the president] believed in very strongly was that TQM had to start at the president level and filter down. It must [also] start at the board level. The board, the vice president, the directors need to walk it, talk it. The team members--the doctors--will never catch on if it's not walked and talked and breathed at that level." (administrative director)
"We have [a new CEO]. He is exceedingly committed to quality. He wants report cards. He wants data out in front of everybody." (care coordinator) "We have what we call "wailing walls" where we show performance data. Each department has one. If you walk there, you'll see one on the wall. Every department has indicators that their team picked in service and outcome and costs." (administrative director)
"I went through a very difficult time with a vice president who was in charge of the heart center. To me, he was an obstruction. He was not a doctor. He didn't understand what we were talking about. Yet, he had the power to make decisions." (chief of cardiology)
"Our GEO says, `Look, heart is your baby. You handle it.' The money aspect of the heart is not my baby ... so I will have ... the VP or CEO ... handle the money aspect ... and we can work together." (chief of cardiology)
"It is very important that the goals of leadership in terms of performance improvement are brought down to the staff." (nursing manager) "We have our own personal goals that we're working on, but we have no input into the organizational goals for those [with AMI]." (care coordinator)
"You may see [the quality management department] approaching AMI a little differently than what cardiology is doing. But eventually, it all rolls in. And there's no tuff. If I go to my boss and complain about what Dr. so and so is doing or what nurse practitioner so and so is doing, guess who's gone? We have to work together." (senior manager)
"I screamed and yelled and hollered and said, `We're changing this.' The comeback was, `Well, nurses just have to get used to looking for the green and yellow.' [I said] take as many errors out of the system as you can. We finally worked it through, but it proved to be a battle, a very frustrating battle." (director of emergency medicine) "We still get a lot of defensive behaviors, and it is cumbersome to get a QI team together. I think once we make that better, and we get all the departments working together on a problem instead of pointing fingers, we'll do better [with QI efforts]." (nursing manager)
"We have done lots of things wrong ... and we are constantly learning. And it's a learning mentality ...; if something doesn't work, there's no penalty at the director level. [Senior administrators will] say, `OK ... Let's try something different.' So, you are not squelched to go outside the box and try something different." (director of quality management)
"I think the biggest [problem] is that we are scared to death.... Our culture has become [one that says], `Don't make a decision because that's safer than making one [that is] going to be wrong'." (director of quality management)
"We have quality teams in the department of medicine and all key areas report to our hospital-wide quality meeting, which is called our Performance Improvement Coordinating Group. They are scheduled to report on a regular basis." (quality improvement manager)
"The data project did not go through any official process. When I started collecting [data], I didn't have any formal reporting structure. It (the process) has not been part of the main quality department, which I think is a problem." (cardiovascular clinical nurse specialist) "This [CEO] was given ... authority to make decisions, being placed over the quality council, and ... the ball dropped. A department went out on a limb to make a recommendation [for improving AMI care], and the administration did not embrace that decision made at the lower level." (director of quality management)
"Over the last year, we've been so short-staffed that our goal was just to get the necessary things done." (cardiovascular clinical nurse specialist) "The hardest thing for me is not having the kind of data I want. We have several data systems; we've spent a lot of money on them; we've spent a lot of time on them. We need more." (director of physician quality management)
TABLE 1 Study Hospitals Change in Beta- Beta-Blocker Use Rate Blocker Use * Follow-Up Baseline ID/State Performance (% Points) (% of Patients with AMI) 7. CA Higher +30 73 43 8. OH Higher +22 69 47 4. FL Higher +12 68 56 3. CA Medium +7 46 39 1. NY Medium +6 67 61 6. AR Medium +6 35 29 5. MO Lower -16 47 63 2. MN Lower -30 45 66 Annual Staffed Ownership Teaching Geographic AMI ID/State Beds Type Status ** Location volume 7. CA 271 for-profit nonteaching urban 236 8. OH 428 nonprofit teaching urban 405 4. FL 629 nonprofit teaching urban 300 3. CA 263 governmental nonteaching urban 164 1. NY 231 for-profit nonteaching urban 49 6. AR 275 nonprofit nonteaching rural 182 5. MO 708 nonprofit nonteaching urban 132 2. MN 110 governmental nonteaching rural 41 * Beta-blocker use at discharge ** Has residency training approval by accreditation of Council for Graduate Medical Education TABLE 2 Management Involvement in and Support of Quality Improvement Role/Activity Dimension Range Personal Advocacy Garners support for quality Engagement improvement efforts within hospital and board versus does not support such efforts publicly or at higher levels Participation Active membership and attendance on teams versus nonparticipation Dissemination of Reports performance data to broader performance data audience in hospital and board versus does not get involved Relationship Perceived Has regular contact with and with Clinical understanding understands physicians; perceived Staff and as caring about clinical, not just responsiveness financial, outcomes to physician needs Negotiation Can find common ground and skills bargain versus gives ultimatums or avoids clinical staff Promotion of Goal setting Goals are consistent with QI and a Quality are shared versus limited role of Improvement QI and nonagreement in overall (QI) organizational goals Organizational Culture Norms regarding Consensus-driven and cooperative interdepartmental/ versus blaming and fault-finding multi- disciplinary collaboration Innovation and Seeks novel approaches and risk taking processes versus likes the old ways and is slow to change Support Existence of Teams to address AMI care present of QI with QI teams or absent Organizational Structures Linkages of QI QI teams report to executive teams to central committee or other senior group decision-making versus act in isolation without structures dear reporting Procurement of Staffing Clinical, quality management, and Organizational data-collection staff Resources IT capability Data-collection, analysis, and reporting capability
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