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Quality Improvement and Transformation of Healthcare

Introduction and Background

With spiraling medical costs and poor quality of health care services, government and private payers sought the need to improve the quality of health care delivery. In the early 1970s, the science of quality measurement and improvement first emerged as an organized field. Studies show a high rate of medical errors as well as a wide range of variations in health care procedures utilization unrelated to patients’ needs. Therefore, measures of processes and outcomes of care were developed to evaluate treatment offered to each patient along with the healthcare system within hospitals, health plans, and other providers (Miller & Gutmann, 2009).

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Traditionally, the performance of healthcare quality was determined solely by the performance of medical staff, primarily the physician (Miller & Gutmann, 2009). Transparency in the quality of care is a recent phenomenon with changes in the survey processes by the Joint Commission in 2004 (Miller & Gutmann, 2009). Controlling medical errors became a priority for healthcare researchers, who sought to reduce medical errors by applying continuous quality improvements for healthcare processes and delivery. Healthcare experts designed measures to evaluate processes and results of patient care not only in hospitals, but all areas related to healthcare. Low standards of care were severely penalized by a government with fines ranging from $5000 to $10,000 (Miller and Gutmann, 2009).

There were efforts to base payment on quality; however, quality performance and investment were not rewarded and poor performance was not penalized. The National Quality Forum (NQF) was created in 2000. Its main purpose was to generate reliable quality measures to create public transparency and enable market choices. NFQ developed a list of hospital-acquired conditions that should not occur. Later, Medicare and Medicaid center (CMS) announced its decision not to pay for hospital-acquired conditions followed by its initial pay for performance initiative (Miller & Gutmann, 2009). CMS launched the Consumer Assessment of Healthcare Providers and Systems Program (CAHPS).

The measures are available in CMS website permit, caparison among health care organizations. These measures evaluate eighteen key aspects which include: communication with nurses and doctors; responsiveness of hospital staff; cleanliness and quietness of the hospital environment; pain management; communication about medicines; discharge information; Overall rating; and recommendation of the hospital. By July 2007, CMS started to offer a financial incentive for hospitals that collected and submitted reports regarding quality and safety data and penalized hospitals that failed to do not (Miller & Gutmann, 2009).

The Pay-for-performance program became operational when hospitals started to be incentivized and reimbursed according to their performance. The adaption of the program was extended to the providers’ contracts and physicians.

History of Quality Improvement Movement in the United States

Developing practices

Until 1965, a board of directors’ only responsibility was to select physicians and they had no obligation to oversee quality. Each institution was regarded according to the physician who provides treatment, not according to the provided health care services. Taking into consideration the past incidents board of health care organizations focus on quality, direct financial incentives, gaining reputation, influencing customer choice, and impact market share. Currently, boards of directors have the data and tools to oversee quality (Miller & Gutmann, 2009). Although there are general standards for hospital boards of directors to fulfill their obligation to oversee quality, it differs from state to state

Joint Commission and NCQA

The Joint Commission standards emphasize that the governing body is responsible to maintain safe, quality care, and treatment for the patients, in addition to the federal statements which underlined the board’s responsibility to prevent organizational misconduct. With this changing environment, a Joint statement urges the board of directors to pay attention to their practices and to put quality as a priority. They are responsible for supervising patient safety and health care quality.

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It advises boards to be alerted and act accordingly whenever poor quality service is reported. Boards of directors do not have direct responsibility for quality; however, they can play a crucial role in improving quality. They can provide expertise and set benchmarks for high performance on quality. Most importantly, boards of directors can contribute to a culture that values high-quality performance ((Miller & Gutmann, 2009).

With open public reporting of measures in healthcare, board members now have open access to all areas of information related to performance about the medical staff which directly and positively impacts the quality of patient safety, patient care, and patient satisfaction. Technology and information systems are used to create databases for electronic medical records and barcoding in healthcare (Miller & Gutmann, 2009). This allows ease of access to board members and increases the institution’s ability to monitor administrative control and develop quality reports.

The government does not allow boards to investigate and identify the quality of patient care but boards are required to investigate problems related to poor quality and seek corrective measures for improvement (Miller & Gutmann, 2009).

Strong measures by the government to control poor quality coupled with a financial incentive for compliant boards is an encouragement for better quality patient care. Enforcement from state and federal governments has positively impacted healthcare boards to enhance activities related to governance through better literacy among board members, enhanced systems for identifying and reporting problems and enhanced answerability for professionals in senior managing positions. The collaboration between hospitals and physicians has improved the quality of healthcare in some hospitals of the United States (Miller & Gutmann, 2009).

The board of the hospital demonstrates a commitment to quality improvement in the organization and they also provide attention to provide resources to sustain quality. The board can consequently direct an effective mechanism to organize the internal resources to report quality of care. According to Jiang et al study, 80% of 567 responding CEOs stated that the governing boards initiated a strategic plan that improves quality and establishes a corrective plan for adverse events (hospital-acquired conditions) (Jiang et al, 2008).

Several other studies showed the boards of directors’ involvement in quality of care. The use of a dashboard has allowed board members to evaluate the institute’s performances. Most dashboards contain CMS Quality comparison measures. It has been proved that organizations that used dashboards with fewer measures and for two years or longer were associated with higher performance on quality improvement (Miller & Gutmann, 2009).

IOM report

The Institute of Medicine (IOM) (2001) calls for the improvement in healthcare as an essential aspect of safe quality care to patients. Government legislations identify hospital governing bodies and boards as primarily responsible for the quality of patient care. The Joint Commission reaffirms the board’s responsibility in being responsible for patient care. The results of the IMO survey report the active engagement of hospital boards in overseeing and tracking the performance of the institution. Reports confirmed that hospital governing bodies are aware of their impact and role in maintaining the quality of care and patient safety. Some changes recommended by the IOM report are:

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  • Effective communicating practices to all staff about written policy
  • Better involvement in agenda-setting
  • More time allocation to a quality item in board meetings
  • Inclusion of measure for enhanced patient quality care and safety in the CEO’s performance appraisals
  • Improvement of the quality of literacy of the board
  • Forming a board quality committee for specifically improving patient care outcome

The Institute of Medicine (IOM) published its report in 1999 describing the United States’ unacceptably and unsafe health care system. However, the report suggested a detailed strategy that could improve safety and quality of care delivery which would lead to error reduction by 50% in five years. In 2001, the IOM report titled ‘Crossing the Quality Chasm’ stated the six dimensions of quality that are necessary to achieve quality improvement goals.

The six dimensions are Safety, effectiveness, efficiency, patient-centered practices, timeliness, and equity. Today, the American health care system still used more than twice the amount spent in other advanced industrialized countries. Therefore, financial solvency was often prioritized over quality improvement. In addition, the financial burden shifted to the health care system by a growing population of underinsured and uninsured patients (Tubbs, Husby & Jensen, 2009).

Ways of improving practices

The Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) survey was initiated by CMS as a tool to measure and report patients’ experiences in hospitals. The HCAHPS is the first of its kind survey to be introduced to gain patient perspectives on the quality of health care provided by the institution. It is a national standardized survey reported publicly. The survey allows the collection of data through specific methods to measure the patient’s perceptions about their experience and quality of care at the hospital. The HCAHPS provides a national standard for comparing local, regional, and national hospitals concerning the quality of care and patient satisfaction.

Goals of the HCAHPS

The survey is created to collect and produce data about perceptions of patients about the quality of healthcare provided at the hospital. Data from this survey provides the objective and analytical comparison of hospitals.

Survey results are reported publicly which offers an incentive to hospitals to improve the quality of their care to patients since the survey involves patients themselves.

Public reporting of survey results also enhances the transparency in the quality of healthcare provided by hospitals thereby making increasing accountability.

Content and Questions

The HCAHPS survey is composed of 27 questions targeted at discharged patients about their experience with the quality of care in the hospital. 18 primary questions are targeted at the important hospital aspects such as communication with the hospital staff, their responsiveness level, cleanliness, silence, environment, pain management, medical communication and information, discharge information, overall hospital rating, and whether they would recommend the hospital (HCAHPS Fact Sheet, 2009).

The survey questions emphasize the following:

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  • Nursing – including courtesy, respect, listening, explanation, call-light responsiveness
  • Physicians – including courtesy, respect, listening, explanation
  • Environment – including cleanliness and noise
  • Pain control and medication information
  • Preparation for discharge (Tubbs et al, 2009).

The survey is administered randomly to discharged patients between 2 days to 6 weeks after they have been discharged. This new effort for quality improvement created new interest and commitment that drives quality transformation in the health care system. The U.S health care system is confronted with many challenges of poor quality and safety of care delivery, transparency in hospital performance, and growth of health care consumption which leads to a perilous future of health care industry unless the quality model changes to extensive, continuous, and sustainable paradigm. Several studies show board leadership in quality and the benefits of engaging health care providers in that board structure and the decision-making process.


SBAR (situation, background, assessment, and recommendation) is a tool that is used to communicate important information. This method was adapted from US Navy by M. Leonard and colleagues from Kaiser Permanente in Colorado, USA.

The SBAR is an effective communication technique that facilitates communication about patients’ health conditions, between members of healthcare teams. It is a mechanized system that allows healthcare professionals to frame simple questions in critical patient situations necessitating immediate attention. The use of SBAR allows for the flow of free and clear communication between healthcare team members thereby fostering teamwork and patient safety in healthcare organizations.

The SBAR Tool (Quality Tools in Practice, 2006)

S refers to the Situation. In the minimal period of about 5 to 10 seconds, the situation needs to be reported.

B refers to Background. The healthcare professional provides the background of the patient with a brief history in the context of the situation. The history is relevant to the context of the situation.

A refers to Assessment. Assessment of the patient’s situation allows healthcare professionals to offer their thoughts about the situation and conclusion.

R refers to Recommendation. Healthcare professionals identify in brief their needs to control the situation within a specific time frame.

The SBAR tool has a set of 4 standard sections with questions. These allow staff members to share information in a precise and concise manner. Healthcare professionals can engage in effective and assertive communication using this tool since it reduces the need for misunderstanding or repetition. The SBAR tool is comprised of 2 documents. The first is the SBAR Guidelines for communicating with physicians using the SBAR technique. The second is the SBAR worksheet for reporting to a physician about a critical patient or situation (Quality Tools in Practice, 2006).

SBAR offers structured communication that allows all stakeholders to have the same expectations regarding the situation. Additionally, it helps improve communication which encourages assessment skills. As a result, recommendations can be based on the right level of detail and assure the best solutions (NHS, 2008).

Catholic Medical Center Health Care System (CMC)


The Emergency Department at Catholic Medical Center Health Care System consists of 30 beds and has 39,000 visits per year, 25% of which result in hospital admission. The CMC Emergency Department was using paper-based medical records. Therefore, clinician documentation was insufficient; charging for services was under-valued and slow to process. In conclusion, the emergency department was losing money. The hospital realized that better data measures would help the hospital generate revenue into the system.


The Catholic Medical Center Health Care System (CMC) is a not-for-profit, tax-exempt, and a 330-bed full-service community hospital. This sophisticated acute care hospital provides services to residents of the Greater Manchester area and throughout New Hampshire. It is not only serving some of the most critically ill patients in the state but also meets the needs of the community’s vulnerable and medically underserved individuals (CMC, n.d). However, CMC provided $87 million in support to care for the patients.

Measures for Quality Improvement

A committee was created by bringing the hospital finance group on the board. They collaborated with all departments including medical records, billing and compliance to determine the nature of the charges and take appropriate decisions. By effectively breaking down inter-departmental walls they were able to create a better workflow by using the ED PulseCheck system. The system gave them access to data and information about the bottlenecks in their hospital which was causing delays and problems.

Using this data, they were able to achieve enhanced patient care and satisfaction by improving the quality to departments, areas, and procedures which needed attention. They implemented a system called the LYNX E/Point through which they were able to achieve a better than expected ROI in a matter of 54 days.


The Catholic Medical Center Health Care System achieves success with providers’ involvement in the decision-making process. The hospital’s respectable reputation is that of including physicians in every decision. The hospital wanted to replace the paper-based system with an electronic medical record system to decrease spending time for documentation, improve the charging process, and share information with other physicians in CMC. The ED PulseCheck system was implemented in the hospital.

However, the system alone did not solve the problem. It was realized by the ED manager that cross-departmental collaboration is needed and providers’ input is crucial. It was decided that timely collection of patients’ data and efficiently charged capture were prioritized. Physicians and nurses along with other departments such as HIS, medical records, billing, finance joined the ED team. As a result, each stakeholder in this team shares her/his interests and needs.

It was noticed that clinical cooperation reflected in the patients’ data collection and ED workflow. The ED had a doctor champion who learned the new system and was able to convey the knowledge to his co-workers. It enabled the ED team to confidently specify areas that needed improvement. CMC was also successful in choosing the right vendor that has experience and knowledge regarding emergency department work flow and what data is needed to capture the lost charges and increase patient satisfaction.

Intermountain Healthcare System

The Intermountain Healthcare is a Utah –based, highly integrated system with multiple nonprofit hospitals, 155 clinics, home care, hospice, and a renewed clinical research institute. Also it owns and supports 17 community and school-based clinics for uninsured and low-income population (Carroll & Edwards, 2011).

Since 1988 Intermountain Healthcare’s goal was to reduce cost and improve quality. Over two years the Intermountain team studied practice variations that focused on details of care for transurethral prostatectomy (removal of prostate), cholecystectomy (removal of gall bladder), total hip replacement, community-acquired pneumonia, and cardiac pacemaker implantation. The team found massive variation in physicians’ practice. Not even one physician’s practice that follows best patient care. Although none of the physicians were providing optimal care, each doctor had something to learn or something to teach.

Intermountain team used an important tool that connects the improvement of the quality with the reduction of medical cost. They focused on the processes of care delivery that led to certain treatments. Dr. Alan Morris, the head of pulmonary intensive care medicine at Intermountain, and his colleagues generated evidence based clinical practice guideline that used to treat acute respiratory distress syndrome (ARDS). Then they included this guideline to the flow of the clinical work so each physician did not have to remember what the guideline is for treating this disease. Therefore, using the guideline became a normative default.

By applying this method the variations in care delivery among physicians reduced from 59 % to 6 % in four months, especially in treating the most extremely ill patients with ARDS. This method is called ‘shared baseline’ which is used to measure and control practice variation. Additionally, this method also reduced the total cost of hip replacement from $12,000 to $80,000 per case in two years.

Another method also improved clinical care by reorganizing its delivery. This method is called clinical leadership dyads. Simply, this clinical dyad contains part-time physicians with full-time nurse administrators in the same region who meet monthly to review data for the clinical, cot, and delivery outcomes for each care delivery group. Following that was the clinical leadership dyads meeting from across the entire Intermountain system which discussed the improvement opportunities and disseminate constructive results.

By applying clinical leadership dyads to Obstetrics and Gynecology care delivery, successful outcomes were documented. Induction of early labor according to appropriateness criteria reduced unplanned cesarean section and reduced the high utilization of newborn intensive care unit. This new protocol decreased the rate of unplanned surgical delivery. The Intermountain rate of cesarean section delivery was by 21% while the national rate is 34 %. It was estimated that the Intermountain new protocol of elective early labor induction could lower the health care cost in state of Utah by about $50 million per year.

Lessons Learned / Recommendation

Role of Government

With the introduction of quality measures and public reporting, governments now have access and tools to monitor quality in healthcare (Miller & Gutmann, 2009). Surveys from the Joint Commission are an effective tool for identifying deficient facilities in healthcare. The Joint Commission should collaborate with state governments to monitor data on the quality of care in institutions where standards are extremely low.

Board performance duties of care, loyalty and mission are overseen by attorney generals who should have the power to question or even replace members of a board of directors in institutions severely lacking in quality care for patients, putting them at high risk. Government interventions in foreseeing and controlling the quality of care to patients should focus on the evaluation of board members’ duties for enhanced outcomes inpatient care. Board leaders of institutions should be held accountable for serious issues and continual problems in healthcare. Government intervention should seek data related to the persistence of the problem and attempts made by board leadership to control it for enhanced quality outcomes (Miller & Gutmann, 2009).

Physicians who are involved in the quality improvement process can affect the results and improve the outcome of patient care. Physicians with their medical backgrounds can help in the application of research and clinical guidelines. Clinicians can improve the quality of care by implementing well-structured guidelines implementation programs. They can lead some corrective strategies, such as continuing medical education, audit and feedback of clinical information, provider reminder and computer support systems, and financial incentive programs.

These strategies rely to some degree on a clinical champion who influences the clinical behavior and eventually improves the quality of care (Morris, McLaughlin, Asinger & Gobel, 2000). Many health care organizations seek to adopt these clinical practice guidelines, pathways, and protocols to manage care effectively. These guidelines are used to evaluate performance for ongoing monitoring those other physicians can learn and which can be used to perform education and corrective action.

Risk management indispensably affects physicians. Since risk management is concerned with clinical mistake avoidance and management of malpractice issues, physicians’ involvement and support for these activities are essential for the success of this program implementation (AMA, n.d).

However, the improvement of clinical care leads to a reduction in medical expenditure. Therefore, leaders should invest in education, workflow improvement, and new data system that enable the improvement and decrease the chances. For example, the physician team in Intermountain applied about 840 changes to the guideline regarding treating ARDS patients for the first four months. Now, there are only one or two minor changes every month (James & Savitz, 2011)

Each health care organization should choose a few priority areas and they do not have to start from scratch for data collection. The facility can use its existing system for data collection to measure the outcomes. Then they can test new care processes and build them into daily protocols. This strategy leads to standardizing and simplifying processes that can be followed consistently and easily (Carroll& Edwards, 2011).

Another lesson that can be learned from the Intermountain experience is the ability to move the patient between health care settings. Coordination between the hospitals and outpatient clinics can be facilitated through an integrated system. The hospital does not have to own an outpatient clinic. it can be done through a partnership that can ease the continuum of care. For instance, Intermountain healthcare has a partnership with community practices in the neighborhood that improves care transition and reduces avoidable readmission (Carl & Edwards, 2011).

The implications health care leaders

Providing high clinical quality is the core of the organization’s strategic plan. The quality of medical services has become the social focus. Therefore, an active comprehensive quality improvement approach is necessary to monitor the comprehensive treatment process. Quality improvement programs that investigate the results of each treatment are not effective. However, the recent approach that focuses on the quality of the treatment process is a cornerstone of quality improvement. It has been proven that by implementing this approach in health care settings, positive outcomes have been documented.

Variances management which is known as clinical pathways is adapted for quality improvement. The clinical knowledge should be used to control and optimize medical behaviors. Some of the clinical pathway activities such as laboratory tests and medication are integrated into the organization’s information system. This information forms the heart of clinical pathways formation and will enable practice workflow monitoring. Then the quality of treatment will be improved and controlled based on medical knowledge (Yang et a, 2012).

Several studies show that information systems play a critical role in the quality improvement process in health care organizations especially if they improve the efficiency and the effectiveness of the organization as a whole. The service process in general is crucial. If the operating system is poor the perceived quality of services is poor as well. (Verboom, 2004). Storing data in the information system helps health care providers and leaders to improve the quality of the services. As a result, medical expenditure will decrease.

For example, the Intermountain Healthcare system used information systems that are designed to monitor quality. Nearly $2 billion was invested in infrastructure. Most of it was invested in health information systems (HIS) and electronic medical records (EMR) to enhance communication and make use of the data stored in the system for research and quality purposes. Since the mid-1990s, extensive internal data reporting regarding clinicians’ performance add to the transparency of Intermountain healthcare (Carol & Edwards, 2011).

Hiring physicians who have leadership potential is necessary to bring other physicians along. physician leaders are an important factor for embracing the hospital measurement and reporting philosophy (Carl & Edwards, 2011)

Resident’s participation in the quality improvement initiative could affect the patient outcomes including quality in the curriculum (Carl et al, —-)

In conclusion, health care organizations are under pressure to improve. Each organization has to increase its competitive advantage for the long term, its governmental compliance, and its patient satisfaction and decreases its medical expenditure. In the past, the American health care system was a system full of errors; today with a change in the physician’s role and internal structure of the organization, quality health care delivery improved.

The clinician’s role was expanded from medical practice-oriented to applying knowledge of delivering care in a management position. This combination initiates a new generation of healthcare providers that can alter the future of the U.S healthcare system. This paper has proposed one solution for improving persistent quality issues by including health care providers in the quality improvement process. This model has revealed success that can be applied to similar health care settings.

Today, the health care providers are performing professional activities and excel in administrative activities such as the Intermountain team. They are contributing and taking part in Accountable Care Organization (ACO) and Patient–Centered Medical Care (PCMC) models that are on the cutting edge of changes occurring now (Mastal & Levine, 2012). The discussed recommendations can offer a roadmap to leaders and managers to utilize health care providers’ knowledge and skills in the pursuit of leading transformation and advancing health


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