Abstract
This paper describes an evaluation study that will examine a quality program of a 500-bed government hospital. The study is motivated by the need to evaluate the achievements of the quality program since its implementation five years ago. A trigger event often prompts the development of a quality program. Proper implementation of a quality process requires structural and clinical changes, formation of the quality council and unit, and management commitment to facilitate program activities. The paper describes the key components of the hospital’s quality program and quality-related activities that will be the focus of an evaluation study. It also outlines the evaluation criteria and data collection tools and methods that will be used in the study. The sample size, data sources, data collection procedure, timeline, and presentation are also described.
Background
QI programs aim to improve hospital care over time. However, attaining and sustaining quality improvement is often a challenge. In this view, an evaluation of a hospital’s QI program since its implementation (baseline) is essential in determining whether improvement is occurring. Program evaluation encompasses an analysis of its infrastructure and activities as well as an assessment of the implementation aspects of the program. The paper describes a proposed study evaluating the QI program of a 500-bed government hospital. The discussion will occur in the context of the hospital’s quality improvement objectives after conducting an inquiry about the goals of its current QI program.
Infrastructure Aspects of the Program
A hospital’s quality infrastructure facilitates the implementation of its QI program. Quality infrastructure entails the organizational elements that affect the degree of QI implementation in a hospital. The evaluation study will describe all aspects of the hospital’s infrastructure, including the management, the quality council/committee and QI unit, the quality coordinator, and the non-human resources.
The Management
Management commitment is a crucial ingredient in the successful implementation of QI programs. A hospital’s top management makes the major decisions that the staff at the lower levels implements. Management commitment to a quality program entails active participation or involvement in the planning and execution phase of the intervention. It also involves providing financial support to actualize the QI program, coordinating resources to ensure the program is successful, endorsing the initiative, and displaying the willingness to find out more about the intervention (Ransom, Joshi, Nash & Ransom, 2008). The study will evaluate the actions and sentiments of the individuals occupying the top management positions at the hospital, including the CEO, chief medical officer, nurse/physician leader, and board members.
A strong commitment from the executive administrators ensures that quality improvement is embedded in the hospital’s work processes and protocols. The study will describe the management’s role in establishing quality committees and QI protocols to improve hospital care at the facility. Other indicators of commitment will include collaboration with clinical departments to ensure the staff meets expected performance and allocating resources to recruit or train staff and purchase equipment required to improve quality. Hospital administrators committed to QI improvement establish a central quality unit consisting of health care practitioners and led by a quality manager (Ransom et al., 2008).
Other indicators that the study will examine include quality training to enhance awareness about quality among physicians and nurses, the establishment of a resource library archiving QI reference materials, facilitation of regular seminars, and dissemination of information about health care quality to the public. The management also plays the role of enforcing policies and procedures, monitoring compliance with quality standards, initiating QI projects, and motivating staff to achieve quality improvement (Ransom et al., 2008). Through their actions, the management of a health care organization can gradually instill quality into hospital processes. Thus, quality only becomes an organizational priority if there is a strong management commitment.
The Quality Council
A quality council or committee is a formal group that spearheads the quality improvement at a hospital. They are responsible for overseeing the implementation of the QI process, including protocol development. Thus, the quality council is an important aspect of a QI program infrastructure. Ransom et al. (2008) describe a quality council as a committee created by the top management that coordinates professionals drawn from various “disciplines, departments, and units” to formulate QI guidelines (p. 23). A hospital’s CEO in consultation with the quality coordinator constitutes the quality council. Its membership often consists of high-ranking professionals and front-line staff drawn from the facility’s different specialties and departments.
Once constituted, the council formulates its charter document that defines the roles of each member (Ransom et al., 2008). The proposed study will examine the level of training on QI concepts that council members go through to prepare them for their roles. Quality councils develop new approaches for “problem-solving and protocol development” (Kroch, Duan, Silow-Carroll, and Meyer, 2007, p. 54). One of the key aspects of the quality council that the study will describe is performance-related data archival. Baseline data will help in comparing the hospital’s past and present performances. The study will also describe the quality benchmarks established by the council for evaluating the performance of each unit in the identified problem areas.
Strengthening the role of the quality council is essential in addressing problem areas. The study will describe the mechanisms the hospital uses to strengthen the council’s role as an important ingredient in QI efforts. It will also involve a description of the council’s membership. Ideally, quality council membership should come from the “advisory board, administration, medical staff, and nursing staff” (Ransom et al., 2008, p. 25). This multidisciplinary committee has the skills to identify problems, implement an intervention, and monitor the results. The problem areas are determined using data on measures such as patient satisfaction or falls. The council either develops new QI strategies or modifies current programs to address the problems identified.
Some hospitals involve all employees in their QI efforts. Multidisciplinary teams often consist of the clinical and support staff, QI coordinator, leaders, and housekeepers, among others. The teams hold occasional meetings that focus on ways of enhancing hospital care by involving all employees in QI efforts (Kroch et al., 2007). The development of quality goals at the departmental level involves input from the staff. The QI coordinator identifies problem areas that should be addressed. The teams collaborate in assessing the problem through root cause analysis and suggest appropriate action plans. They also play a central role in the implementation of the solution or policy.
The Quality Unit
The quality unit tracks quality indicators in all the departments of an organization with the aim of ensuring sustained QI efforts. It benefits from the support and input of each unit (Ransom et al., 2008). The quality unit receives financial support from the top leadership. Its mandate is to monitor the performance of individual units within the facility. The study will describe the hospital’s quality unit in terms of its organizational structure, functions, visibility in the facility, and relationships with the other units. Since it plays a central role in a hospital’s QI efforts, the quality unit should be linked to the information technology department (HRSA, 2014). This will allow it to access data on performance indicators.
Quality units involve various organizational structures. The study will document the organizational structure of the unit in terms of reporting lines and functions placed under the unit. As Ransom et al. (2008) write, typically, the quality unit falls under the clinical staff unit; however, in other models, the CEO oversees its operations. On the other hand, most hospitals require clinical and administrative departments to report to the quality control unit. Other functions that fall under the quality unit include “control, utilization, case management, risk management, and credentialing” (Ransom et al., 2008, p. 27). The study will describe the problem-solving methods that the unit employs to eliminate deficiencies in hospital processes. Another area of focus will be the techniques used to report adverse events externally.
The study will also examine efforts made to restructure the quality unit to strengthen its role. The data analytic tools of the quality unit will also be described. The study will examine the resources allocated to this unit to improve its capacity to monitor QI efforts in all departments.
The Quality Coordinator
The role of a quality coordinator is critical to a successful QI program. An experienced physician or nurse leader should occupy this authoritative position. Having both clinical is necessary as the role entails liaising with multidisciplinary teams on QI protocols and processes. In addition, a quality coordinator should be an individual conversant with quality techniques used in hospitals. The position also requires leadership that displays “credibility and authority” (Kroch et al., 2007). This implies that the individual must have direct links with the top management of the health care organization.
Non-human Resources
The non-human resources include the facilities and equipment required by the program. The study will describe the medical technologies used in prescribing, monitoring, administration, and clinical care processes across all units. It will also document all the facilities and items available in the units.
The Specific Activities/Components of the Program
The QI activities are the initiatives implemented to improve performance in “high-risk aspects of clinical care and membership service” (Kroch et al., 2007, p. 55). The study will examine the essential program activities under quality and patient safety management. It will also examine program components such as data collection and measure selection, data analysis and validation, and sustaining quality improvement.
Program Activities
Management of Quality Methods and Processes
The management of patient safety and care quality is central to the success of a quality improvement program. The study will evaluate the management of quality improvement and patient safety across the hospital. In particular, it will focus on the implementation of the quality and patient safety program at the hospital, including the methods and processes utilized.
Standards
With respect to quality management, the JCI standard for patient safety and quality management will be used. In particular, the study will judge the implementation success based on the quality of council staff. A person spearheading the implementation of the program will be expected to be an expert in quality improvement processes and methods (Ransom et al., 2008).
Methodology
The collection and analysis of survey data will indicate the quality of patient safety management. The survey will involve the recipients and the providers of health care services providing the services (Ransom et al., 2008). The survey questionnaires will be administered to the recipients and staff to measure their views on the management’s role in staff empowerment and safety initiatives.
Oversight of Patient Safety Responsibilities
Besides implementation, another key management activity of the QI program the study will examine is the oversight of patient safety responsibilities at the hospital. The oversight role requires qualified staff to drive the improvement process. In this regard, the study will analyze in detail the management skills of the individuals carrying out the oversight role to support staff discharging care quality responsibilities.
Standards
The person charged with the oversight role should support staff to optimize productivity throughout the hospital. This standard also requires the program to support and coordinate measures and prioritize improvement activities in the entire hospital.
Methodology
To evaluate the oversight role of the quality council or unit, interviews involving staff as the respondents will be conducted. The aim is to generate data on the oversight activities and goals of the quality unit and council. The interviews will explore the quality goals developed by the quality unit, how they are implemented, and how process improvements are measured.
Support and Coordination
Another essential activity of a QI program is support and coordination in the identification of priorities for improvement in a hospital (Jha, Li, Orav, & Epstein, 2005). Prioritization helps identify opportunities for optimizing QI resources to improve clinical service at a hospital. Priority is also given to diagnoses that have adverse effects on the outcomes of patients. The study will investigate how the program supports coordination and prioritization of care delivery processes, based on similar measures, to improve performance in all departments.
Standards
The coordination of activities of the quality coordinator must involve epidemiological and demographic data analysis to identify aspects of care that have the largest effect on health care quality.
Methodology
This will entail a direct observation of the program structures and processes (Ransom et al., 2008). The researcher will observe the role of the quality coordinator in implementing the activities of the program. This will involve direct observation of how he/she coordinates clinical and administrative activities in line with the program’s goals.
Staff Training
A quality program also supports a staff-training program. Staff training geared towards improving skills and efficiency is another essential program activity that the study will describe. It will examine the focus areas of the training program for the medical staff in all the units. It will focus on how the programs have empowered the medical staff to use the new protocols and methodologies developed by the QI council. Additionally, the relevance of the training programs to the staff’s roles in patient safety and quality care will be evaluated. A quality program facilitates regular communication of quality issues within the hospital. In this regard, the study will evaluate how quality issues and messages are passed to staff in all hospital units.
Standards
The program should contain staff-training programs tailored according to the roles of the staff. Additionally, the program should facilitate the dissemination of quality issues across the hospital.
Methodology
This will involve a survey of physicians or nurses providing care at the hospital (Ransom et al., 2008). The staff survey questionnaires will measure their views on the management’s commitment to staff empowerment through training.
Quality Program Components
Measure Selection and Data Collection
A QI program staff plays a significant role in the coordination and integration of quality measurement activities across the hospital. One essential activity of a QI program is to support the selection of measures at both hospital and department/service levels. The study will document how the hospital’s program fosters coordination of measurement activities such as safety culture and event reporting measures, among others, to promote integrated improvements throughout the hospital. Another key measurement activity of the program that the study will examine is the utilization of measurement data to track the progress of the identified priorities (Ransom et al., 2008).
The QI committee or council develops methodologies and protocols for improving the priorities set. Measures are identified to track the implementation progress using data. Thus, the integration and coordination of data and quality measures is an essential QI activity. The study will evaluate the extent to which the program facilitates the integration and utilization of quality measures and data to monitor progress.
Another key component of a quality program is the utilization of current scientific findings and evidence to improve patient care. As Ransom et al. (2008) write current information helps health care practitioners discharge their roles effectively. The information may come from clinical practice guidelines, relevant literature, and research evidence available in print and online sources. Practice guidelines are evidence-based guidelines that help measure performance in key improvement areas. The development of these guidelines involves multidisciplinary teams and committees, including the QI and therapeutics committee (Ransom et al., 2008). The study will describe how the program facilitates the timely utilization of information to support patient care, clinical education, research, and management.
Standards for Measure Selection and Data Collection
The evaluation of data collection and measure selection processes at the hospital will be based on two standards. First, an ideal program is one that supports the identification of appropriate measures and facilitates the coordination and integration of activities both at the hospital and department levels. It should also provide mechanisms for event reporting and measures for promoting a safety culture within the hospital. In this way, it facilitates the adoption of solutions geared towards improving care quality. An ideal program contains a mechanism for monitoring the progress of the improvement initiatives using data.
The second standard is the utilization of up-to-date information to support care delivery, clinical research, learning, and management (Ransom et al., 2008). The aim of this standard is to promote evidence-based practice in health care settings (Bradley et al., 2005). Health care practitioners at the hospital will be expected to use research findings and guidelines in their daily practice. The key program elements covered by this standard include patient care, clinical education, research, and management. Timely use of scientific information meets patient expectations, which improves health outcomes.
Data Aggregation and Analysis
Data aggregation and analysis is a core component of the quality program of a hospital. The analysis of data collected helps promote patient care and hospital management role. The key aspects of data aggregation and analysis that the study will describe include the process used in data aggregation and its role in facilitating patient care and management functions. It will also examine how to aggregate data and information is shared with external agencies and regulatory bodies in the health care sector. The study will also examine how the process facilitates external sharing and links with relevant databases for comparison purposes. Another aspect of the process that the study will describe includes the approach used to maintain the security and confidentiality of data when sharing or accessing external databases.
The data analysis process requires staff with the right skills and experience in hospital data management. In this respect, the evaluation will also cover the skill-job match of the data analysis team. The determination of the cost-effectiveness of the quality improvements is a key function of data analysis. Cost-benefit analysis is done at least once a year using hospital data. Another data analysis activity of the program is data validation. The study will describe the internal process and measurements that the hospital uses to validate its data. Data validation is necessary when new measures are adopted or when the protocols have been changed. A quality program also defines an approach for managing sentinel events when they occur. The study will examine how the hospital’s definition and reporting structures for sentinel and ‘near-miss’ events are in line with regulatory guidelines.
Standards for Data Analysis and Validation
Seven standards will be used to judge the hospital’s data analysis and validation elements of the program. The first one is the use of data aggregation and analysis in patient care and in the management of the hospital, programs, and external databases (Ransom et al., 2008). The study will evaluate the program and its implementation based on the availability of a data aggregation process, the use of data to promote patient care, manage the facility, and review professional practice. Other criteria in this standard will include how well the hospital shares data with external agencies as part of regulatory requirements and the use of external databases to compare its services with those offered by other organizations. Information exchange via databases should be secure and confidential.
The second standard relates to the expertise of the team involved in data aggregation and analysis. The personnel should have the requisite knowledge and skills to analyze and interpret hospital data into meaningful information. Additionally, the data analysis team should possess clinical and managerial experience and understand relevant statistical tools and methods. Besides the staff, data analysis approaches should be appropriate for the variable under study and the findings should be forwarded to the management for action (Ransom et al., 2008). The data analysis process should also support internal and external comparisons.
Cost and efficiency determination is another hallmark of a quality program. The cost-benefit analysis should be done annually based on data collected in the previous year. Program efficiency means that the quality staff collaborates with professionals from other departments, including the human resources and IT, in data analysis and interpretation. The fourth standard is the presence of an internal methodology for data validation to ensure that valid data are used to measure new changes or processes. Ideally, data validation is done for specific reasons and is often sanctioned by the management. A standard program also has a clear methodology for reporting sentinel events, such as death or physical injury. The study will evaluate the hospital’s definition of sentinel events and compare it with that of the regulator.
Another standard practice is the use of data analysis to determine the best way forward following the occurrence of undesirable events, such as medication errors or drug reactions. Ideally, these events should be analyzed and measures are taken to avoid recurrence. The program should also define near-miss events and how they should be handled. In addition, it should describe the measures for reducing near-miss events at the hospital.
Sustaining Quality Improvement
QI programs describe the approaches for attaining and sustaining care quality and safety improvement. The approaches may involve policy changes, patient safety and care planning, and utilization of data. Risk management is another essential component of the QI program. Its aim is to reduce risks associated with care delivery that lower the health outcomes of the patients. This activity entails the identification of possible risks and the development of interventions to mitigate them. The study will describe the hospital’s risk identification, prioritization, reporting, and management strategies, which will indicate its level of clinical preparedness.
Standards for Sustaining Improvement
The study will evaluate the measures used to attain and sustain quality improvement. The criteria for measuring how the hospital attains and sustains quality improvement will involve the availability of data, the present policy changes/plans, and the documentation of improvements. The study will also use continuous risk management standards to evaluate the program. In particular, it will examine strategies used in risk identification, reporting, prioritization, and management. Ideally, risk management exercises should be done annually to reduce risks and redesign processes.
Data Collection Methods
The evaluation study will aim to describe the dynamics of the hospital’s quality program. It will involve an analysis of qualitative and quantitative data on its performance over the past five years. The potential sources of data for the study include administering survey questionnaires, interviews, observation, and reviewing documents.
Survey Questionnaires
The study will involve the collection and analysis of survey data. This will involve the recipients of health care services, e.g., the patients, or those providing the services, e.g., physicians or nurses (Ransom et al., 2008). The survey questionnaires administered to the recipients or staff will measure their views on the structure of the program and the management’s role in staff empowerment. In this respect, the surveys will measure the infrastructure element of management. Respondents will give their expectations and views on the role of the management in resource allocation, investment in clinical equipment, and staff recruitment and training under the hospital’s QI program.
A patient satisfaction questionnaire will be administered to admitted patients to collect data on how the management, the quality council, and staff collaborate in the delivery of health care services at the hospital. The second questionnaire will survey the views of the nurses, physicians, and pharmacists working in the hospital on the work breakdown structure, including staff duties, work schedules at the unit level, staff involvement, and empowerment, and the supervisory role of the management, as defined by the QI program.
Interviews
This will involve structured and semi-structured questions with the leadership, and staff as the respondents. The objective is to obtain qualitative data on the activities and goals of the quality council and the QI unit. The in-depth interviews will explore the activities of the quality unit in the hospital’s QI efforts. It will also explore the quality goals developed under the hospital’s QI program, how they were rolled out, and the change processes and performance measures involved.
The leadership will be interviewed on the quality unit and council’s work domains, functions, and goals in the hospital’s QI efforts. It will involve finding out information about the person in charge of the quality unit and council and his/her relations with administrative and clinical staff. Additionally, issues related to the development of the QI goals and strategies, communication of the initiatives, and monitoring of progress will be explored.
The staff interviews will focus on the reporting structures and feedback systems between each clinical unit and the quality council in implementing quality initiatives. The interviews will also focus on the quality council’s involvement in protocol changes, evidence-based practice, and training and engagement of staff in line with the QI program. The respondents will also answer questions related to the role of the quality unit and council in streamlining work practices and flow in the hospital.
Observation
This will involve researcher observation of the hospital’s structures and processes (Ransom et al., 2008). In this view, the researcher will observe the role of the quality coordinator in implementing the activities of the program. This will involve direct observation of how he/she liaises with the individual departments and the administration to implement new protocols and processes at the units. The researcher will also observe and document the hospital’s non-human resources, including medical technologies, available at the units.
Direct observation is crucial in program evaluation. As Corbetta (2003) puts it, observation is appropriate for documenting program “activities, processes, and activities” (p. 44). In the study, researcher observation will be used to collect direct information about the operations of the quality coordinator and the clinical resources of the hospital. This will involve paying random visits to the departments and wards.
The researcher will use direct observation to evaluate ongoing processes, such as observing the way physician/nurse training programs are conducted. According to Corbetta (2003), observation focuses on six program components, namely, characteristics of the participants, interactions, nonverbal behavior, program leaders, program surroundings, and outcomes. The researcher will observe the characteristics, such as gender, age, skills, and values, of doctors, nurses, and pharmacists in the hospital.
Reviewing of Documents
This will involve a review of written documents such as reports, minutes of QI meetings, medical records, and policy statements (Ransom et al., 2008). Other informative documents include research journals on the topic. In the study, the analysis of documents will generate qualitative and quantitative data on the activities and roles of the management, quality council/unit, and quality coordinator as defined in the QI program. The review will also reveal the hospital’s processes, program structures, and non-human resources. According to Corbetta (2003), reviewing documents or reports supplements data collected through interviews, surveys, and observation. Furthermore, the process is unobtrusive and therefore, convenient for enriching knowledge about the participants or setting.
The descriptions contained in the QI policy documents will be related to budget allocations. Review of documents involves a process known as content analysis, which is an approach for interpreting “artifacts of a social group” (Corbetta, 2003, p. 21). The study will use content analysis to describe communication materials discussing the various infrastructural elements of the QI program, including the management, the QI council/unit, and the quality coordinator. Furthermore, a quantitative description of the non-human resources of the program will be provided.
Data Sources, Sample Size, and Data Collectors
The study will use qualitative and quantitative data sources addressing quality trends at the hospital over the last five years. The study will combine primary and secondary data sources. Primary data sources will include interviewing, participant observation, and surveys. In-depth interviews involving the clinical staff, the leaders, and patients will give qualitative data about the significant improvements the hospital has made in terms of quality indicators, such as reduced errors, re-infection rate, and mortality rate, since the QI program was implemented. Participant observation will generate data on the key attributes of patients and clinical staff, nonverbal behavior, program leaders’ actions, hospital environment, and program outcomes. On the other hand, survey questionnaires will generate data on patient satisfaction and staff satisfaction.
Secondary data sources will include organizational reports, minutes, medical records, policy statements, brochures, journal articles, and other documents. They will provide derived information about clinical processes such as diagnostic tests and laboratory results. The study will also review electronic records of services offered by the hospital pharmacy and laboratory. The secondary data sources will provide quantitative data to complement the data collected through qualitative methods.
Since the study will involve a case study approach, a representative sample of hospital staff and patients will participate in the interviews. According to Corbetta (2003), appropriate sample size is one that allows the researcher to make broad generalizations about the results. A convenient sample of 50 individuals drawn from the executive administrators, nurses, physicians, pharmacists, and patients will be interviewed. The interviews will also include representatives from the quality council and the quality units, as these are the individuals implementing the QI initiatives at the hospital. The surveys will also involve a convenience sample of patients, medical staff, administrators, and quality council representatives. Each survey will involve 20 individuals drawn from each of the four groups.
The survey data collection will involve trained interviewers who will administer the questionnaires. The team will be trained on how to collect qualitative data from the respondents. An advance letter will be mailed to the participants (staff, administrators, and physicians) requesting their participation in the survey. The letter will also inform the participants of the purpose of the survey. After receiving informed consent, the interviewers will administer the patient and staff questionnaires to consenting respondents within the hospital. The team of interviewers will guide the respondents, especially the patients, in answering the questions to achieve a higher response rate. The researcher will conduct the face-to-face interviews over a period of one week. The researcher will also collect secondary data from the hospital documents and clinical reports. Data collection through participant observation will also involve the researcher.
Data Collection Tools
The main data collection tools will be the questionnaire instrument, observation checklist, interview protocol, and focus group. Data collected using these tools will be used to evaluate the current QI efforts at the hospital. They will measure core outcome areas of the program.
The Survey Questionnaire
The questionnaire will seek the respondent’s views on the role of the management in the implementation of the QI program. In particular, the survey questions will focus on resource allocation, purchase of state-of-the-art clinical equipment, and staff empowerment as the key management functions. The aim is to evaluate how the management allocates human and non-human resources to the program to improve quality care.
Observation Checklist
An observation checklist will assist the researcher to examine firsthand how the quality coordinator prioritizes issues and activities related to the QI program. The researcher will observe how the coordinator facilitates seamless cooperation between the clinical departments and the administration. The observation checklist will be used to record the coordinator’s role in QI council meetings and discussions. This will indicate how the quality council and the management value the QI program and initiatives. The checklist will also indicate the non-human resources that are essential to the QI program.
Interview Protocol
The interview protocol will contain structured and semi-structured questions. It will serve as a guideline to interviewers when surveying the respondents’ (staff) views on the activities and goals of the quality council and the QI unit. The interview will focus on four core areas, namely, the goals of the QI program, the implementation plan of the program, the key change processes/areas, and the performance measures involved. It will cover questions about the sort of trigger events that prompted the development of the QI program and the type of QI initiatives implemented thus far.
Focus Group
The focus group approach will be used to understand the perspectives of the quality unit/council and the management regarding the program. It will entail discussions involving a sample of participants from the quality council. The aim is to help the researcher understand how the individuals involved in the implementation of the QI program regard the initiative. According to Corbetta (2003), focus groups give more detailed information than other qualitative data collection tools because they involve “interactions among members of a group”. Therefore, focus group interviews will generate richer information about the implementation experiences of the QI units and clinical teams.
Time Plan for Data Collection
Data collection will span a period of six months. The quantitative and qualitative data will be used to evaluate the success of the QI program of the hospital-based on a wide range of quality indicators, including reductions in inpatient falls, re-infections, and medical errors and increase in bed occupancy, response time, and patient/staff satisfaction.
Data Presentation Format
The analyzed data will be presented in tables as shown below.
A summary of the quality improvement goals and activities at the hospital (2010-2015)
Summary of the program structures and processes
References
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