Quality Management Integration in Long-Term Care Guidelines for Excellence By Maryjane G. Bradley, C.Q.M., C.Q.A., M.B.A., & Nancy R. Thompson, R.N.

Excerpted from the Preface for Quality Management Integration in Long-Term Care: Guidelines for Excellence by Maryjane G. Bradley and Nancy R. Thompson.

Copyright © 2000 by Health Professions Press, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

Preface

Prior to the late 1980s, “long-term care” was primarily a range of services that were offered to frail older adults living in institutions that provided health care, personal care, and rehabilitation services, usually for extended periods of time. The contemporary emphasis on health restoration and returning elders to noninstitutional settings (e.g., individual’s home, board and care home) forces facilities to respond to the growing expectations of health care professionals, regulatory and payer groups, family members, and residents. Quality management practices allow long-term care facilities to respond to environmental and industry changes, while enhancing responsiveness to customers. This responsiveness to change is a key factor in any facility’s success.

The term “total quality management” (TQM) represents organization-wide quality improvement and quality management for all employees and managers in all departments and processes. Some organizations call the TQM process continuous quality improvement (CQI), referring to the steady changes in work processes that improve resident care and an organization’s “bottom line.” The focus of both CQI and TQM is providing service to an organization’s customers by meeting their needs and requirements, delighting them with the services provided, and anticipating future needs. Because long-term care facilities vary widely in designating their quality management processes as TQM or CQI, we felt the need for a single designation — quality management integration, or QMI — that combines both philosophies and builds on their foundation.

QMI addresses quality management issues such as

• Who is involved in QMI and in what areas of the organization?
• When and how does an organization implement QMI practices?
• What is the best way to improve an organization’s work processes?
• What is the intended effect on customers?
• How does an organization set priorities?

The two primary questions that are addressed in this book are

1. How can we improve long-term care for each resident, while simultaneously becoming more effective throughout the facility as a whole?
2. How can we be more efficient and reduce the risk of error, yet maintain our focus on the customer satisfaction of each resident and his or her family?

Because the concepts and outcomes of TQM and CQI are so closely related, we developed the QMI model and its six core concepts. Each of the six concepts is founded on data collection and analysis, as described in Chapter 1 (see the QMI model at the beginning of each chapter). We stress integration in QMI because the core concepts and their reliance on data are integrated into the daily work of the entire organization and do not stand alone as a separate quality project.

Applying the six core concepts of QMI is vital for successful strategic planning, training/education, and implementation. Because we take a realistic approach to implementation, barriers and critical issues are identified and defined clearly, as are “real-world” suggestions on working through obstacles. Powerful QMI tools and techniques are detailed to ensure that teams and individual employees or managers will be successful, whether initiating strategic planning for quality improvement or improving an established process. The 3-phase quality management integration process (p. 15 and Chapter 3 show this process in detail) ensures that leadership activities, such as the organization’s quality council, are effective.

An actual case study in long-term care — Woodland Care Center at the beginning of its quality journey — is introduced and followed through the book. ( Woodland Care Center is a pseudonym that is used to protect the true identity of the facility. Most of the other mini-cases are synthesized from the authors’ combined experiences in long-term care.) Woodland ’s journey reflects many critical issues and barriers that must be faced by other LTC organizations and illustrates the QMI process.

Each chapter contains displays that highlight the human or practical aspects of QMI implementation in long-term care facilities. There are numerous illustrations of implementation procedures and various case materials are included.

Chapter 1 provides an overview of the six core concepts that are involved in implementing an effective QMI process and illustrates their reliance on data-driven decision making. These six concepts make up what we call the QMI model. Each core concept is described in detail and is accompanied by practical implementation guidelines for their integration in daily work. A number of key terms and techniques are introduced, including the 3-phase quality management integration process. This process is a guide through the quality journey.

Next, we describe the issues that are faced by the long-term care industry within the broader history of TQM and CQI. Chapter 2 examines the roots of quality management and its development in other service industries and in the health care industry. Successful techniques as well as potential pitfalls in introducing QMI to a facility are highlighted. Issues such as customer service; management’s role in implementing quality management processes; and data collection and analysis, or management by fact, are discussed. We include two mini-cases that demonstrate the implementation of QMI principles. The cases illustrate both the impressive cost savings and the customer satisfaction improvements that are possible through QMI.

In Chapter 3, we describe the application of the 3-phase quality management integration process at Woodland Care Center . The Woodland case also demonstrates the use of a number of successful techniques and tools that are critical to QMI implementation. Detailed examples are drawn from activities at Woodland . Instead of adding complex work systems, we explore how QMI can make work processes more efficient for staff, while improving resident and family satisfaction.

Chapters 4 and 5 are central to our discussion of quality management in long-term care: They help address the question, what barriers and critical issues within the facility and in the broader long-term care environment might you face as your organization implements QMI? Chapter 4 explores in detail the potential barriers and critical issues that are internal to long-term care facilities and strongly affect the success of QMI implementation in them. The potential roadblocks to implementing QMI range from short-term focus and resource limitations to turf wars and ineffective communication. The issues that are critical to successful implementation of QMI include the pivotal role of management, how to gain support from physicians, the family as a system, and the corporate or multifacility viewpoint about QMI.

Chapter 5 explores potential barriers and critical issues that are external to the long-term care facility. We examine powerful drawbacks of the current system, in particular the regulatory requirements and financial reimbursement structures in long-term care. We believe that the contemporary emphasis on meeting standards rather than exceeding them promotes quality assurance, not quality improvement, and inhibits cost-containment efforts unintentionally. In addition, we explore the decisive impact of financial reimbursement systems and regulatory requirements on policy and proposed process changes in health care.

A section in Chapter 5 focuses on integrated delivery systems (IDSs; e.g., networks, mergers, managed care organizations) and addresses the complexity of future health care systems. In many facilities IDSs have forced profound changes in systems and care processes. If problems exist in free-standing local facilities, imagine how those problems can be compounded in merged networks. The six core concepts of QMI and the tools of data collection and analysis enable managed care organizations to

• Limit risk
• Provide cost-effective services
• Measure customer satisfaction
• Track the success of residents’ long-term clinical outcomes
• Provide residents’ continuum of care across an integrated health care system

Chapter 6 covers the crucial role that data collection and analysis play in QMI and considers the data collected during Woodland ’s quality project and in several mini-cases. Tracking levels and trends in long-term care data and measuring both your work processes and your results are fundamental to management-by-fact QMI processes. Sets of key quality indicators and several mini-cases illustrate the application of QMI tools and concepts to everyday issues in long-term care facilities. There is an emphasis on analyzing and studying long-term data across multiple resident groups as well as on studying individual residents to monitor changes in clinical and functional effectiveness. The usefulness and interpretation of satisfaction survey data for both customers and employees also are considered.

Finally, Chapter 7 pulls together the quality management principles and issues that must be addressed to integrate QMI successfully into your organization’s daily work. Issues to be addressed by QMI leaders are detailed, and the training and certification of quality managers are discussed. Working with both internal and external quality consultants also is examined. Appendixes A–M provide QMI implementation tools and other reference materials.

We have combined two voices in this book, an internal and an external consultant. One of the authors is a vice president of organizational performance who works full time in a large, multifacility organization; the other author is an external consultant who supports long-term care organizations for a specific project or for a specified period of time, bringing an “outsider’s” fresh viewpoint and breadth of experience to the issues that surround a QMI process. Our tasks are very similar, even if our daily professional lives appear different: We both provide support and consultation to organizations that are struggling with the communication problems and critical issues that surround every QMI implementation in long-term care. Thus, our visions of the outcomes of successful QMI processes are parallel in most applications.

The variety of our professional experiences comes into use during each QMI implementation project as management and staff groups face QMI’s culture changes, the need for enhanced communication, and the shifts in job roles. We communicate the “win-win” benefits for every individual. Our confidence in QMI derives from seeing successful organizations transformed as they provide better service to their customers and clients and from working with organization leaders to develop efficient work processes and ever-improving employee satisfaction.