Introduction
Management of risk in health care institutions seeks to reduce any potential negative occurrences to all stakeholders such as patients, staff and, generally the entire organization (Lighter and Fair, 2000). This is done by engaging the nursing department to identifying quality improvement initiatives in nursing. One of the initiatives could point out the potential health hazards, threats, and lead to coming up with a way of eliminating them or reducing their effect as much as possible. Quality management on the other hand is more of a competitive strategy (Lighter and Fair, 2004). Sure, a safe health environment will be a preference to many but to retain a competitive edge, an organization needs to offer more than that. It needs to offer services that are of high quality standard of excellence.
Healthcare organizations should come up with ways of providing service excellence when pandemics, disasters and mass casualty occurrences take place (Kraus, 2000). Healthcare management need to identify and address a quality improvement initiative in nursing that will deal with internal risks adequately and at the same time doing the best they can to reduce external risks open to their patients and staff (Porter, 1985). By successfully identify the social, cultural, political, and healthcare needs of their patients as well as staff; they will also have succeeded in identifying potential dangers and threats (Stamatis, 1996).
For this to be effectively achieved, the healthcare managers need to understand the service population within their ambit. Thus, a clear plan and guideline will be essential to provide a framework on the ways to reduce risks, implementing the plan, reevaluating it, and taking corrective measures. Quality management is more of subjective rather than objective and so to understand the service population is crucial to identification and elimination of risks involved in the provision of healthcare (Walburg, 2006).
Quality and Risk Management Strategies and Theories
It has been proposed that measuring healthcare quality can be done by observing its processes, structure and outcomes (Casmir, 1994). Healthcare providers concern process measures with delivery of services while structure measures assess availability and accessibility of healthcare services and the quality of their resources. Outcome measures on the other hand shows the ultimate result of the services offered influenced by the environmental and behavioral factors (Kelly, 2003). Later, the Total Quality Management (TQM) model was put forward which came with the view that for an organization to achieve best results, it must be committed to improving quality of the organization in its entirety rather than in segregation (Flew, 2004).
Apart from TQM, Continuous Quality Improvement (CQI) has also been in used with an aim to develop clinical practices (Youngberg, 1998). This model is premised on the principle that there is always an opportunity for development and improvement for every situation and process (Kavaler and Spiegel, 2003). Many hospitals have put in place Quality Assurance (QA) programs to deal with issues that have already been identified by the relevant regulatory organizations. This may include such issues as reviewing the reports and responsibilities of oversight committees, analyzing documentations, and studying credentialing processes (Caroll, 2009).
Other strategies have been proposed to improve the clinical practices. For example, there have been discussions that Clinical Practice Improvement (CPI) is more of a multidimensional outcome methodology to be directly applied to clinical management of every patient (Horn, Hickey & Carrol, et al, 2002). CPI as an approach was developed by clinicians as an attempt to understand the complexity of delivery of healthcare services, and in teams, a purpose is formulated, data collected, findings assessed and then translated into practice changes (Scott 2005). These models have portrayed that commitment of clinicians coupled with proper management are paramount to a successful implementation of change. Also, other quality management strategies have seen the need for management to believe in the importance of the project, to effectively communicate the purpose as well as empowering the staff to be able to achieve the goal (Gould and Kolb 1964).
In the recent past, most methods of quality improvement have emphasized on the need to identify a process that has less-than-ideal outcomes, which measures the main performance attributes and uses a thorough analysis to develop a new approach and in the process, integrating the newly devised approach with the process while at the same time reevaluating performance to ensure that the change process becomes successful, (Shojania, McDonald, Wachter, et al, 2004). Furthermore, other quality improvement methods have been established such as the International Organization for Standardization ISO 9000, Six Sigma, Zero Defects, Toyota Production System, Baldridge, etc. writer have argued that the choice made on the Quality improvement strategy to be adopted depends on the nature of project subject of quality improvement.
Acceptance and subsequently, the adoption of quality improvement methods in clinics has been majorly hampered by the unavailability of scientific health services literature, (Blumenthal & Kilo, 1998), though new research and studies are now emerging in the field. Critics have asserted that a project o quality improvement is more of a research if it involves a practice change, affects the patients by assessing their outcomes and generally exposes the patients to more risks or burdens (Coplan and Masuda, 2011). Either way, individuals need to be protected through promoting respect for participants, providing them with informative materials and promoting scientific value (McGee and Wilson, 2005).An organization that intends to undertake a project or studies with an intention to positively impact on healthcare processes so as to attain desirable outcomes can use any of the following models discussed below:
Plan-Do-Study-Act Model; this method has been commonly used in healthcare institutions as an effective way of attaining rapid cycle improvement (Bulau, 1990). Its most favorable characteristic is its cyclical nature in assessing and impacting change. It is most effective if it is done in small and frequent phases as opposed to large and drastic measures, (Berwick, 2003). It is mostly concerned with establishing a functional link between process changes and the outcomes. The goal of the project has to be identified as well as the way to get there and standards to be measured against. The changes to be made are then determined and implemented and incase of any deviation from the expected results, corrective measures are undertaken.
Six Sigma Model: this is another method that can be adopted. It involves improving, designing and following up on the process so as to reduce or completely eliminate wastage while at the same time increasing the desired outcomes (Flew, 2004). Process capability is used in measuring the improvements achieved by comparing the circumstances before the improvement and the situation after implementing the new changes (Kelly, 2003). The first thing is to identify the project by analyzing data that was previously collected in the area and from that, the goals and objectives are defined. Then standards are set and any potential variation taken into consideration and then the project is implemented. Thereafter, measures can be developed to determine the new process capability.
This method considers planning ahead, to improve the level of service in case of emergencies. However the approach, would find the quality improvement initiative in nursing to reduce future internal and external risks for both the patients and staff challenging. At a small scale it could be possible for the nursing department to plan for internal risks ahead, but by large the external risks may be difficult to measure.
Collecting the data overall for possible future external risks could be challenged by the dynamic nature of external health risks that require emergency care.
Toyota Production/ Lean Production System: this method has been commonly used in manufacture of cars by Toyota (Sahney, 2003). It involves identification of customer needs first and then improving the processes by identifying the non-value-added activities and eliminating them from the process. It is based on identification of errors and then improving quality so as to prevent the occurrence of similar errors. Healthcare organizations have managed to improve the safety of their patients as well as quality of their services through this method by first defining the problem, then coming up with the expected objectives and then eliminating the bottlenecks and allocating tasks (Coplan and Masuda, 2011). It has been shown that this method proved to be successful by determining the needs of each patient, deciding who should do what and signals that should be used to ensure that the project is going well and the corresponding steps to take are right. For it to be successful, unnecessary activities that do not contribute to the final outcome of the project should be eliminated.
Root Cause Analysis: it is commonly found in engineering field. Its main focus is on identification and understanding what the underlying causes of a problem are and the potential outcomes that would have been realized and then embarking on solving those problems (Krans 2000). It is used to identify the trends and assessing the risks when error is suspected to have occurred and is based on the understanding that it is the system as opposed to individuals who contribute to most problems, (Institute of Medicine, 1999). It can also be applied after an undesirable event has occurred and then information is collected on the main cause of the outcome and then solved. It is more of a reactive rather than a proactive strategy where it only comes in after an event has occurred and trying to identify the root of the outcomes. A team may require to be mandated with the task of identifying the root cause as it is a labor-intensive process to make findings. It may involve questioning the individuals involved in addition to analyzing the systems. Then recommendations are made based on the findings as to how to solve the problem or how to avoid such an outcome in the future. Errors caused by the system should be differentiated form errors that were caused by irresponsibility or negligence of individuals. Individuals found to be lacking should be engaged in a development plan.
Failure Modes and Effects Analysis: this is a method that is used to identify as well as eliminate potential failures and problems or errors of a system that are known to us and therefore prevent them from actual occurring (Kavaler and Spiegel, 2003). It is based on predicting and evaluating potential failures and then coming up with steps to proactively reduce or totally eliminate future failures. The extent of the failure will also be identified and the most effective steps developed and implemented with the main aim of preventing errors from occurring. A multidisciplinary team will normally be responsible in identification of these errors and making recommendations on the best way to handle the situation. A system should be put in place to monitor deviations overtime and well-established measures put in place to provide information on how effective the process is. A Joint Commission mandated in 2001 that all accredited healthcare providers should come up with proactive risk management activities to predict the weaknesses of a system and adopt measures to minimize the possible harm to patients (Adachi & Lodolce, 2005).
Requirements to Implementation of a Quality Improvement Strategy
For effective implementation of a quality management, strategy effective leadership is crucial. Strong leadership goes hand in hand with consistent commitment and involvement to continuous improvement. Effective leadership ensures that the scarce resources are efficiently allocated ranging from providing competent human resources to allocating enough time schedules to each team for the project (Porter, 1985). Leadership is also crucial to make patient safety the main focus for all the stakeholders and in formulating the strategies and to provide a platform for developing periodical patient safety goals in every organization and creating accountability for patient safety outcomes. Also, it is important to help reduce resistance to change within the organization.
An improvement process has to engage all the stakeholders and aim at obtaining their commitment if it is to succeed. This will ensure that they understand that the purpose of the project could be achieved with few adverse effects and maximum benefits. Feedback should also be obtained from the stakeholders and should be used appropriately to affect the outcome of the project (McGee and Wilson, 2005). Effective communication is also an important aspect of the project. Proper communication channels should be devised across the entire organization and utilized adequately. These provide a mean through which individuals can voice their concern as well as giving their opinions which might be very important to the outcomes of the project. It will also keep everyone informed about the expected outcomes of the project as well as carrying out interim evaluations. It also provides a means of problem-solving in case of conflicts.
The organization should also ensure that the stakeholders and team members remain motivated throughout the project period. This may be through recognition and rewards for good performance as well as punishment for poor performance (Lighter and Fair, 2004). Also, all the stakeholders should be involved in the project from the executive to the employees. Others include implementation of protocols addressing patient needs. Different approaches need to be tested too. The individuals should be organized in teams. Team leaders should be chosen by the team members and not the executive. The team leaders chosen should act impartially and without bias when dealing with each member. Teams need to meet regularly to decide on how to go about their common goals.
Conclusion
Healthcare is a very complex field and therefore quality improvement in the area is a very dynamic and challenging topic. But this is made better by the fact that studies have continued to be done in this area and a body of knowledge is slowly coming to being for the betterment of the services. A range of quality improvement methods have continued to be in use since the publication of Donabedian in 1966, (Donabedian, 1966), but until recently, the Six Sigma methodology has never been used and even where it was used, it was not totally integrated as an independent whole but was used in isolated components.
Largely due to the undeniable importance of quality improvement, though mostly driven by external forces, many efforts have been undertaken to improve quality performance and are very much in place. Thus, researchers as well as clinicians should focus on determining which areas need to be published on so as to improve this field. Researchers should collaborate with other organizations as well as service providers. More research should be conducted on what tools work best as well as enlarging our understanding of quality improvement science.
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