short communication
Application of Quality Improvement to Improve Patient Outcomes: Obesity Prevention
Dr. Lori J.
Alexander*
School
of Nursing, Western Kentucky University, Bowling Green, KY, USA
*Corresponding
author: Lori J. Alexander, Associate Professor, School of Nursing, Western
Kentucky University, 1906 College Heights Blvd. Bowling Green, KY 42101, USA. Tel: +12707454078; Email: lori.alexander@wku.edu
Received Date: 05 September, 2018; Accepted Date: 21 September, 2018; Published Date: 27 September, 2018
Citation: Alexander LJ (2018) Application of Quality Improvement to Improve Patient Outcomes: Obesity Prevention Int J Nurs Res Health Care: IJNHR-143. DOI: 10.29011/ IJNHR-143. 100043
1. Introduction
Healthcare facilities are faced with challenges to
incorporate holistic quality care across the continuum. It is important to
understand the meaning of systems and systems thinking in order for healthcare
facilities to function properly. A system is several independent actions or
processes interacting with each other to make a whole [1].
A systems approach in healthcare can be of value in analyzing and understanding
the independent prevention and intervention programs related to the obesity
epidemic and can provide a better understanding of how working together as an
interdisciplinary team to accomplish a goal is more effective than an
individual analysis of behavior. “Systems thinking” is applied in healthcare
facilities and it is important for the multidisciplinary team to understand
their interdependency when providing care to patients. Systems- thinking is a
framework for understanding the inter-relationships between individual parts
and comprehend that they are dependent on each other [1].
By applying this framework, coordination of care with other members of the
health care team is organized to improve patient safety and outcomes.
Until
recently, systems-thinking has not been applied to the obesity epidemic. Obesity
prevention efforts, to date, have not been comprehensive or well integrated;
understanding that obesity is a consequence of multifaceted interactions
between many variables is an important milestone for obesity research [2]. The obesity epidemic poses a challenge because it
is a complex problem with numerous inter-connected variables. Experts suggest
that improving the complicated structure of interdependent segments of the
obesity epidemic will require a holistic, integrated response from various
sectors [3]
in the healthcare team. Healthcare organizational leaders must understand and
learn elements within and between systems therefore, healthcare models can
assist them in discovery of these associations [1].
Within a system, there are three basic elements which include inputs,
conversion process, and outputs [1]. These
elements can be applied to obesity prevention through patients as inputs. The
conversion processes for obesity prevention patients would include educational
modules as an interventional treatment. Finally, the output for obesity
prevention is patients having an increase in health, a decrease in BMI, and a
decrease in co-morbid conditions such as: diabetes, hypertension, and
cardiovascular disease.
2. Application
of System’s Model to Obesity Prevention: Three Core Process Model
The
three core process model is incorporated as horizontal arrows as
interpretations to represent methods within the organization [1]. There are a total of four arrows with three core
categories that are aligned with the organizations’ desired results. There are
two administrative decision-making processes as arrows, one
clinical/medical/technical processes and one operational/patient & client
flow processes arrow. The clinical/medical/technical processes and
operational/patient & client flow processes are located between the two
administrative decision-making processes arrow to show how the organizational
leaders and their processes impact the organization in its entirety. These core
processes in this model demonstrate how the organization can evaluate each
grouping to review the interdependence between each process and make
adjustments or necessary improvements throughout the organization [1].
As
an example of application of this model, a pediatric clinic’s leaders implement
a new program to train the providers of care to improve recognition and
management of pediatric obesity. In the clinical/medical/technical process, the
providers would be trained on the epidemiology of pediatric overweight and best
practices for diagnosis, treatment, and management of overweight patients [4]. As patients would be assessed by more
knowledgeable providers, more accurate screenings would be conducted and best
practices would be implemented for management of overweight, therefore
improving patient outcomes. By utilizing the three core process model, leaders
and staff identify relationships between processes for this population to
receive overall better care, definitive diagnosis, treatment and management of
care [1].
3. Role of
Mission, Vision and Context to Organizational Results
An
organization’s mission is vital to having a vision and means to achieve
performance results. If a facility or community organization’s mission includes
meeting the physical and psycho-social needs of the population it serves,
developing an obesity prevention plan could assist in meeting that goal. By
providing education and resources, an organization is not only meeting the
physical and psychosocial needs of the community, but also improving the
overall health of the population.
The
healthcare system is dynamic with continual changes and within each
organization these changes take place at various rates [1].
There are also other variables of change that affect the organization as a
whole: the patient, the organizational contexts (employee transition,
technological advances, and research), and communities and political
environments [1]. Employees continually change
positions in healthcare facilities both within and outside of the
organizational structure. Evidence based research is continually conducted and
should be incorporated into policies and procedures of daily care. Technological
advances, or systems, to assist in organization of health care providers exist
to provide quality care. Also, the community where the facility is located will
be influenced to change with economic cycles, political ideologies, and
election cycles [1].
4. Purpose,
Desired Results, Measures of Results, Interventions, and Improvement Goals
Through
meeting an organization’s mission, an increase in maturity across the quality
continuum in performance measurement can be seen. A healthcare organization’s
measurement of performance management provides understanding into their
advancement along the quality continuum [1]. The
quality continuum in performance measurement analyzes healthcare organization’s
maturity of efforts and results. More mature organizations collect data that
includes demonstration of performance from main processes, monitor progress on
action plans, and reveal key business requirements. Additionally, maturity
determines if the healthcare organization is meeting the needs of clients and
stakeholders as well as the mission and goals of the organization or community
organization [1].
5. Goal
Statements
In
organizations, managers can set goals for improvements, guide incentives or
rewards, and to determine how well employees fulfill their job responsibilities
[1]. Organizational leaders must possess the
skills to effectively and strategically set goals at all levels to improve the
performance of the facility and patient outcomes. There are different types of
goal statements that are purposeful in a given situation to enable success;
therefore, it is imperative for leaders to examine the situation and desired
results in order to select an appropriate goal statement to achieve positive
outcomes [1]. There are multiple types of goal
statements that encompass features of various types of goals [1]. Improvement goals will accomplish preferred
results by ensuring that all components of the goals are obtained to meet the
needs of the system. The goal statement should be SMART: specific, measureable,
achievable, relevant, and time-framed. Once goals have been set, organizational
actions are influenced by adhering to the guidelines to achieve the desired
improvement result [1].
Managerial
behaviors, decisions, and effectiveness are all influenced by mental models. Organizational
leaders, within a system, need to be aware of mental models that could
influence the organizational culture. Mental models can be utilized as guides
to control behavior such as clinical guidelines for evidence based practice [5]. Once the organizational leaders understand how to
utilize mental models, these are implemented to achieve optimal outcomes. In
relation to obesity prevention, mental models regarding obesity can facilitate
success in weight management [6]. The desired
results of behavior change are to reduce the health risks associated with
obesity. Organizational leaders are responsible for creating a patient focused
environment. They also have an understanding of systemic structure that assists
them with: policies and procedures, staff development, and personnel
performance to sustain a patient focused environment [1].
By strategically incorporating quality care into management tools, leaders
serve as a role model for employees with exemplar service quality [1].
6. Patient and
Stakeholder Expectations
Within
obesity prevention, national research is conducted to incorporate the best
evidence based practice and provide education for health promotion and a
healthy lifestyle. Obesity is recognized as a major public health issue and is
a multi-disciplinary problem with both genetic and environmental causes [2]. Being obese has an adverse impact on health and
is associated with other co-morbid conditions. Additionally, there are negative
social and psychological implications associated with being obese or
overweight. This issue is very important to the consumers and community
stakeholders. Stakeholders of health services organizations can be made up of a
diverse population [1]. Organizational leaders
are responsible for recognizing stakeholders other than patients; accreditation
bodies and national quality forum are also examples of stakeholders. The Joint
Commission is an accrediting body that developed and implemented the National
Patient Safety Goals (NPSGs) program and incorporates a continuous quality
improvement approach applied through an annual review process [1]. By implementing the NPSGs, nurse managers can
prioritize improvement needs based on the organizational vision and mission and
the stakeholders’ perceptions.
The
Consumer Assessment of Health Providers and Systems (CAHPS) was initially implemented
on a voluntary basis to assess patients’ perceptions of care [1]. CAHPS was required by the Centers for Medicare
& Medicaid services (CMS) in 2008 as part of Reporting Hospital Quality
Data for Annual Payment Update (RHQDAPU) program and hospitals adopted the
Hospital CAHPS (HCAHPS) [1]. There are three
broad goals that are identified in the survey: identify patient’s perspectives
of care to compare to other facilities, public reporting in an effort to create
an incentive for organizations to improve quality of care, and provide
transparency of the quality of hospital care [1].
The results of the HCAHPS survey is reported on the CMS Hospital Compare
website and updated quarterly [1]. Managers’
understanding of the organizational structure, as they review HCAHPS data, will
guide leadership in quality improvement. Healthcare organizations are aware
that leadership is the key “to truly transform patient perceptions and clinical
quality” [1].
7. Role of
Quality Oversight Organizations
Types
of quality oversight organizations are seen through multiple agencies and range
from: state licensing bodies [7]. Another
quality oversight initiative is through licensure, accreditation, and
certification [1]. Licensure is through
governmental agencies whereas accreditation and certification are
non-governmental and represent competence or higher education. One
non-governmental accreditation organization is The Joint Commission and is a
quality review for several types of health care delivery systems. This
organization functions to assess quality standards, organizational compliance,
and recognition of compliance [1].
8. Public and
Private Policy Promoting Systems Change
The
quality oversight organizations are vital stakeholders of organizations in
healthcare. Based on their structure of standards, conditions of participation,
and regulations, they are increasingly being used to drive system change [1]. Quality improvement is a core function of CMS and implementation of a quality
improvement plan will strategically guide agencies and stakeholders in a
collaborative process to improve the health care delivery system. Transparency
is an effective strategy to promote accountability and reduce risk in health
care. Value is key factor in health care quality policy at the federal level
and initiatives are being taken to advance CMS toward value-based purchasing [1].
To
solve problems systematically or correct performance gaps, healthcare
organizational leaders must use a scientific evidence-based process [1]. There are a variety of improvement approaches
that leaders can utilize systematically to help make decisions and changes. These
models can assist with improved critical thinking, planning, developing process
change, implementation and evaluation within a complex healthcare system. These tools can be
helpful for all processes and programs including obesity prevention. By
utilizing these tools, obesity prevention and health promotion programs can be
evaluated and improved to meet patient needs and produce positive outcomes [1].
9. Sources of
Comparative Data and Obesity Prevention
Comparative
data allows leaders to better understand their performance against other
healthcare organizations [1]. In comparison of
data with other organizations, leaders can review systemic structures and
recognize best practices. Mandatory reporting has increased availability of
access to comparative data in healthcare over the last several years. So,
leaders can benchmark the data from their organization against other similar
sized healthcare facilities in order to determine what areas the organization
is doing well in and what improvements are to be implemented in order to
provide high quality care [1].
Data
sources evaluate and benchmark data regarding patient satisfaction, health
plans, population data, clinical data, and comparative practices [1]. A variety of sources provide comparative data [1]. For obesity prevention strategies, an example
would be the Centers for Disease Control and Prevention: Data and Statistics
site that allows the community to review the statistics of nutrition, physical
activity and obesity for Kentucky and other states across the nation [8]. Another example would be Hospital Compare that
allows the community to review hospital results of patient satisfaction and
disease-specific clinical indicators. Within this website, people can compare
and review the data between hospitals within the community to assist in making
decisions in where to receive their healthcare services.
10. Use of
Process Improvement Tools
The
quality oversight organizations are vital stakeholders of organizations in
healthcare. Based on their structure of standards, conditions of participation,
and regulations, they are increasingly being used to drive system change [1]. Quality improvement is a core function of CMS and
implementation of a quality improvement plan will strategically guide agencies
and stakeholders in a collaborative process to improve the health care delivery
system. Transparency is an effective strategy to promote accountability and
reduce risk in health care. Value is key factor in health care quality policy
at the federal level and initiatives are being taken to advance CMS toward
value-based purchasing [1].
To
solve problems systematically or correct performance gaps, healthcare
organizational leaders must use a scientific evidence-based process [1]. There are a variety of improvement approaches
that leaders can utilize systematically to help make decisions and changes. These
models can assist with improved critical thinking, planning, developing process
change, implementation and evaluation within a complex healthcare system. These
tools can be helpful for all processes and programs including obesity
prevention. By utilizing these tools, obesity prevention and health promotion
programs can be evaluated and improved to meet patient needs and produce
positive outcomes [1].
11. Continuous
Improvement Cycle
The
Shewhart cycle or Deming Wheel consists of four steps to improve quality [1]. This cycle assists leaders in Planning, Doing,
Checking or Studying and Acting (PDCA). This continuous and systematic approach
is cyclical in nature. In planning, health care leaders identify an opportunity
and plan for change. Doing is to implement the change on a small scale. Checking
or studying is using data outcomes from the small scale or trial change. The
data is evaluated to determine if a positive change has occurred. Lastly, it is
to act by implementing the change on a bigger scale or organizational wide if
it was successful. If the trial was unsuccessful, health care leaders can then
start the cycle with new planning again [1].
An
example of the PDCA cycle as applied to obesity prevention is to implement a
new program. Leaders may identify the need to implement an obesity prevention
plan in public health agency. A trial for new protocol or program to be
implemented with new mothers with a BMI over 30.1 would be planned. The trial
would take place for 30 days and then evaluation data would need to be
analyzed. The staff in the agency would be surveyed for their opinion of the
program and its effectiveness for these patients. When leaders are meeting with
stakeholders, they could question patients regarding satisfaction with their
care related to the new obesity prevention program. In addition, the agency’s
customer service scores should be reviewed for improvement from previous scores
prior to the implementation of the program. The program would be deemed successful
and plans would be made to implement the program to the public health
departments within the region.
12. Six Sigma
DMAIC
The
Six Sigma DMAIC methodology is an ongoing process or cycle that includes the
following steps: define measure, analyze, improve and control [1]. The leader starts the process by defining a
problem or improvement opportunity followed by measurement of the process
performance. Within measurement, data of the current process is collected. Next,
organizational leaders analyze the process to evaluate the root causes of
decreased performance to determine if the process has the ability to be
improved or if it should be redesigned [1]. This
structured format can assist leaders in brainstorming the potential or actual
causes to the problem [1]. Once the root causes
are identified, leaders improve the process by “Attacking” the causes of the
problem [1]. Finally, leaders must control the
improved process to hold the gains. The Six Sigma DMAIC process is similar to
the PDCA cycle; however, it primarily focuses on evaluating root causes and
ensures continuous evaluation and control [1]. Techniques
and activities are utilized by healthcare organizations to meet quality
standards [1]. Some may be more traditional
while others may advance to a higher level of maturity; however, organizations
have a common goal to strive to improve quality for internal and external
customers, as well as stakeholders. By moving to a higher maturity,
organizations promote better processes, quality and outcomes [1].
13. Process and
Deployment Flowchart
Process
flowcharts can help health care leaders and teams better understand the
organization [1]. Leaders must fully understand
a process in order to make decisions regarding making changes or improvements. A
process flowchart is a picture of the events in sequence for a process, which
is one of the process improvement tools utilized by organizations to make
quality improvements. Evidence based tools are available, integrated, and can
assist health care leaders to better understand processes to determine where
changes should be made. Through understanding processes, leaders can plan,
develop, implement, evaluate, and control the needed change within the
healthcare delivery system.
14. Conclusion
Leaders
must utilize system models to assist with making improvements to ensure quality
care. In understanding processes, leaders can plan, develop, implement,
evaluate, and control the needed change within the healthcare delivery system. Incorporating
a systems thinking approach to obesity prevention will have the potential to
address processes and facilitate ongoing communication, access to resources,
and high quality care. The application of the system models to prevention and
treatment of obesity shows great promise in effective coordination of care in
the healthcare arena. If healthcare organizations work in a systems thinking
framework, continual quality improvement can ensure high quality care [1].
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