Introduction
Marshfield clinic is non-profit healthcare institution that has been operating for almost one hundred years in the US. The clinic was founded by the six doctors in 1916. The clinic is currently domiciled in Marshfield. The current paper related detailed Quality Management Plan (QMP) and the scope of QMP in Marshfield clinic. It also contains analysis of mission statement and compliance of the goals of Quality Management Plan with mission of the healthcare institution. A significant part of the paper relates principles of Quality Management Plan and reporting of Quality Management Plan activities.
Mission Statement
Mission of Marshfield clinic is to provide quality services for the patients through main values of the organization including stewardship, leadership, integrity, compassion, respect, service, and excellence.
Purpose
The Quality Management Plan is a part of Project Management Plan. The purpose of Marshfield clinic Quality Management Plan is to assure if the mission of the organization is fulfilled and to describe the process of monitoring the quality of the services provided by the organization. The Quality Management Plan includes procedures and processes to ensure quality planning, quality assurance, and control to be conducted within the project. The Quality Management Plan consists of four stages, namely: ensuring that quality is planned, defining how quality will be managed, defining quality assurance activities, defining quality control activities, and defining quality standards.
Goals and Objectives
The main goal of Marshfield clinic Quality Management Program is to monitor the quality of the services provided to the customers. The objectives of the Plan are divided into three parts as follows: maintenance of comprehensive Quality Management Plan, ensuring high level of customers’ satisfaction and assessment of appropriate healthcare services, and developing programs aimed to improve health outcomes of the patients (McLaughlin and Kaluzny, 2006).
The first stage is to meet standards of Federal and State entities, such as Joint Commission on Accreditation of Healthcare Organizations (JCAHO) when maintaining Quality Management Plan. The program is supposed to be evaluated annually (Joint Commission International, 2002). In order to ensure continual high level satisfaction by the services provided Marshfield clinic managers have to monitor patients’ complaints, appeals, and grievances. The monitoring will give an opportunity to identify areas that need improvement on an ongoing basis. Monitoring of customers’ satisfaction with the help of external agencies, such as Systems Surveys or Consumer Assessment of Healthcare Providers will give an opportunity to identify the areas that need improvement. Monitoring with the help of external agencies will help control compliance to Federal and State requirements (Joint Commission International, 2002).
External control includes a set of the following measures: implementation and monitoring of interventions in the areas that need improvement; reporting the results of monitoring of customers’ satisfaction and assessment of appropriate healthcare services to the Quality Committee and to the Board of Directors yearly. It is also recommended to maintain collaborative relationship with the providers of community entities (Bialek and Duffy, 2009).
The third stage includes promoting early detection of disease and preventive services. This goal can be achieved with the help of educational and management programs. Also, promotion of self-management of chronic diseases through educational programs will help improve healthcare services. Monitoring of individual health outcomes with the help of the case management programs will contribute to the quality of services as well. Monitoring of overall health outcomes with the help of Information Set data and Healthcare Effectiveness data, aiming to meet the requirements of Federal and State controlling agencies, and reporting results to Quality Committee and the Board of Directors yearly are the measures that can help enhance customers’ satisfaction by the healthcare services provided (Harris, 2010).
Total Quality Management Plan is outlined in Appendix 1.
Scope of Quality Management Plan
Total Quality Management Plan consists of several components. The components of Quality Management Plan are outlined in Appendix 2. Individual performance is integral in achieving organizational goals. The most significant results can be obtained using synergy. The Quality Management Plan must be integrated into operations departments. There four key areas that are subject to monitoring according to the requirements of the Quality Management Plan as follows: services utilization, customers’ satisfaction, clinical services, and administrative services. Clinical services include disease management, case management, patients’ health education, and quality improvement projects. Integration and monitoring of these areas help provide quality healthcare services and efficient cost utilization (Novick, Morrow and Mays, 2008).
Utilization of services includes monitoring of utilization of services. This monitoring is coordinated by Medical Management Team (MMT) and Healthcare Assessment Committee (HAC). Customers’ satisfaction is monitored according to Quality Management Plan principles (Goldsmith, 2008). Multiple methods are used for accomplishment of this monitoring including Systems Surveys and Consumer Assessment of Healthcare Providers. Customers’ complaints, appeals, and grievances are also monitored (Rouse, 2010).
The next component of the Plan is clinical services. Clinical services include disease management, customers’ health education, and quality and performance improvement projects. The MMT and the HAC take part in accomplishment of such projects (Safavi, 2006).
Disease management is also included in Quality Management Plan of Marshfield clinic. It is supposed that Chronic Disease Improvement Program (CDIP) can be maintained within the scope of Quality Management Plan based on the S-P-O model (Brosnan, 2012). The program is supposed to be based on the principles of Chronic-Care-Model that conforms to federal and state regulations. The Quality Management Plan also includes prevention guidelines, case management, data analysis on on continuing basis, tools for evaluation of cost effectiveness, tools for individual goal setting, interdisciplicary team, and clinical practice quidelines based on evidence. The goal of the program that aims to reduce occasions of acute condition of chronic diseases. The program is also suggested to decrease healthcare costs spent on treatment of chronic deseases, self-managemnt of chronic deseases, provision of resources to the customers to manage chronic deseases, and ensuring compliance with treatment plans. The aspects of CDIP are provided in coordination with the MMT and HAC (Hillestad and Berkowitz, 2010).
Customers’ health education is an important component based on health literacy and cultural awareness. Customers’ health education includes preventive education and disease specific health education. These could be such methods as sending e-mail messages regarding individual health issues, quarterly newsletters regarding specific cases related individual health condition, targeted mailings related health condition, case management, individual and group classes (Hillestad and Berkowitz, 2010).
The primary goal of any healthcare institution is to improve the health of the patients. All healthcare quality improvement plans aim to comply with regulatory requirements. The healthcare plans must be bases on relevant data collected with the help of reliable and valid methods. Improvements can be based on both external and internal data, for example, data provided by Systems Surveys and Consumer Assessment of Healthcare Providers (CAHP). Other data provided by Health Outcome Survey (HOS) and Healthcare Effectiveness Data & Information Set Measures (HEDIS) can be also used for analysis. Data is reviewed by the Assessment Committee and is reported to the Quality Committee (Safavi, 2006).
Monitoring within the scope of Quality Management Plan includes additional clinical services, such as mental health program, maternity care, preventive care, newborn care, and many other programs. These additional services are monitored by MMT and HAC. Data collected and analyzed by MMT and HAC is also reviewed by Assessment Committee, and further reported to Quality Committee. Administrative services include monitoring of procedures and policies as well as operations issues. This monitoring is accomplished in cooperation with MMT, HAC, and Procedure Committee (Novick, Morrow and Mays, 2008).
Principles of Quality Management Plan
As it can be seen from Appendix 1, the structure of Quality Management Plan is based on the three principles, namely: functional definition of quality, ensuring accountability, and clear differentiation of responsibilities. It is obvious that an effective Quality Management Plan (QMP) must be based on functional definition of quality. Accountability must be ensured at all levels of QMP implementation. Responsibilities must be clearly differentiated between clinic leading team and Quality Management Committee (McLaughlin and Kaluzny, 2006). The quality process includes a number of elements, such as mission, strategy, and values. Quality should be defined before it can be assessed and improved. Quality-related activities are focused on design, implementation, monitoring, and improvement of the process of providing healthcare services. For example, quality can be defined as the degree of excellence of the clinic processes (Harris, 2010).
The definition of quality as well as QMP must be approved by the Board of Directors because accountability begins with the Board of Directors. QMP must be reviewed every three years or more often if there are any substantial changes in regulation or clinic policy. The Board of Directors appoints Quality Management Committee (QMC) which is to monitor the ongoing effectiveness of the clinic and to communicate the issues to the Board of Directors. QMC has to hold meeting each month. The main responsible person for quality and safety is CEO of the clinic. Operational responsibility rests on Director of Quality who is reporting to CEO. QMC is reporting to the Director of Quality. Chief Medical Officer is accountable to CEO for the performance of staff, safety and quality of clinical program, quality improvement, and performance assessment (Goldsmith, 2008).
In many clinics the effectiveness of QMP depends on leadership. Leaders are responsible for effectiveness of QMP. Usually, responsibility rests on executive staff, heads of divisions, and department managers. Thus, the Quality Council includes staff with authority and leadership responsibility. Quality Management Committee is comprised of the employees, such as medical assistants, health educators or front desk staff, who do not have leadership responsibility. Thus, the effectiveness of QMP is responsibility of leadership (Harris, 2010).
The leaders are supposed to accomplish the following tasks for effective quality management: selection of monitoring metrics and setting performance goals for each department, determination of performance thresholds for metrics, ensuring data quality supplied to QMC, management of improvement activity, and identification of quality and safety problems (Hillestad and Berkowitz, 2010).
Quality Council might consist of several leaders, usually, from five to seven executives appointed by CEO for approximately one year term. The primary goal of Quality Council is to develop, support, and operate Quality Management Program. The Quality Council is supposed to have monthly meetings, to be chaired by the Director of Quality, and to report to the CEO. QMC is expected to monitor quality management activity and report on it. The goal of QMC is to ensure monitoring of chosen metrics, ensuring quality of data collected, metrics do not exceed established thresholds, quality improvement is carried out, and quality-related issues are resolved (Brosnan, 2012).
The most important issue in quality management in any healthcare organization is to establish clear separation of responsibilities between the leaders and QMC. For example, QMC cannot be responsible neither for overseeing QMP, nor for solving quality-related problems. Leadership should operate the overall quality program ensuring the results of quality improvement activities. The role of QMC is to monitor the quality program regularly reviewing metrics. QMC should consist of five to seven front-line employees appointed by the Director of Quality. It should be a cross-functional authority and holds meetings monthly. The primary function of QMC is to monitor QMP within the area of its responsibility. QMC is reporting on results, issues, and effectiveness of the program.
Role of Clinical Providers
The most essential part of quality management is to ensure quality of the services provided on the level of clinical providers. Clinical providers are the professionals who are authorized to write prescriptions. The main goal of clinical providers is to give excellent care and ensure that the services provided by them are of the highest quality possible. Quality of services is assessed through monitoring, processes improvement, performance and decisions improvement, and human interactions. The quality-related activities are managed by FTCA and apply to “licensed independent practitioners” according to the definition of The Joint Commission (Joint Commission International, 2002).
The quality-related activity is regulated by the four main managing structures, namely: clinical guidelines, peer reviews and clinical audits, providers’ performance improvement activity, and quality management programs. Providers identify and adapt clinical guidelines based on evidence. These activities include prevention of diseases, health promotion, and metrics of clinical outcomes. Clinical guidelines are usually based on national standards. There are many sources for the guidelines based on evidence, including National Guideline Clearinghouse by the Agency for Healthcare Research and Quality (AHRQ). Peer Review Audit is conducted and scheduled by the Chief Medical Officer. The goal of audit is to assess the quality of the services provided. Audit is based on data collected from patients’ records and evaluation of data. The representatives of QMQ are appointed by CMO. The CMO is responsible for resolving clinical problems and constantly performing quality improvement. The assessment of each clinical provider is integrated into QMP under leadership of CMO. Normally, clinical quality activity is reported to QMC (Bialek and Duffy, 2009).
Components of Quality Management Plan
The QMP consists of the three fundamental components as follows: quality assessment, quality improvement, and tracking improvement activity (reporting on the effectiveness of a program). QMC must be charged with metrics of quality and safety for monitoring. Under metric a defined program measure is meant. A metric should be continuously reviewed (measured and monitored) in order to determine the level of performance of each department or individual. Leaders and staff provide QMC with metrics for monitoring based on evidence. Performance measurement is based on S-P-O model (Hillestad and Berkowitz, 2010).
The sources for metrics could be the materials of National Quality Forum (NQF), NCQA hides measures, BPHC recommendations, or the material of Joint Commission National Patient Safety Goals (Joint Commission International, 2002). NQF and NCQA HEDIS can provide health and business plan requirements, metrics developed by peer reviewed organizations and metrics developed by professional societies. BPHC recommendations include patient satisfaction, quality assessment, social environment, health status, and economic measures (cost, productivity, etc.) (McLaughlin and Kaluzny, 2006). Standard metrics relate performance, processes, health outcomes, quality of decision, and satisfaction of the patients. Appropriate metrics should reflect the uniqueness of the clinic. For each category one metric should be adopted aiming to add other metrics later showing the progress in quality evaluation and performance measurement. It could be responsibility of Quality Council. Leadership can also establish a performance threshold. Data is collected on a regular basis, analyzed, and reported routinely. The aim of data analysis is to identify trends and assess performance level suggesting the opportunities for improvement. Data analysis is based on the benchmarks and techniques of statistical control related quality evaluation (Safavi, 2006).
QMP is to document the improvement methodology that is used in the clinic. The most frequently used methodology consists of the three steps as follows: process improvement, re-engineering, and analysis of the roots of causes. A team must be appointed for each stage of the program. The Director of Quality is responsible for appropriate training of the staff of the clinic and provides necessary support. There a number of improvement methodologies, but for quality improvement at Marshfield clinic S-P-O Model had been chosen. This model is useful in assessing of healthcare because it measures organizational characteristics, such as hospital services, staffing, and the number of beds (Brosnan, 2012).
Re-engineering team is appointed to create innovative approaches to the quality improvement process. Any team participating in quality improvement process can be assigned to use new reengineering techniques. Root causes analysis helps better understand the processes. This is an in-depth analysis of adverse incidents and is often used for uncovering the roots of causes (Bialek and Duffy, 2009).
Tracking improvement activity and reporting data related quality management is carried on a regular basis and includes internal reporting – metrics identification, specific metric measurements, initiating improvement activities, and providing ongoing results of quality improvement process.
Conclusion
Quality improvement process affects all levels of quality control and measurement. In the current Quality Management Plan there were several significant points discussed in details, including analysis of mission statement and purposes of the clinic, and the scope of QMP. The main principles of QMP were outlined and the role of clinical providers was assessed. The important components of QMP were discussed with the scope of implementation suggested.
The successful QMP includes an effective quality control system. Quality of the services provided is based on the organizational and personal culture. An appropriate organizational quality policy and training program can resolve many quality-related issues in the clinic. Currently, Marshfield clinic does not have an effective quality control system. However, the clinic has developed adequate organizational culture. It is important to provide effective quality control on the ongoing basis.
Appendices
Appendix 1 Quality Management Plan
Appendix 2 Components of Quality Management Program
References
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