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The research is devoted to the discussion of the notion of the continuous quality improvement (CQI) in connection with the patient-centered care, based on the Chapter from the Disease Management in Patient-Centered Care by David Levy, and combined with the Internet resources on the topic. Outcomes Assessment and Quality Management Introduction Placing the Patient-Centered care into the broader societal context, there will be understood its meaning and current interest in it. The Patient-Centered Care (PCC) is now closely connected with the notion of the continuous quality improvement (CQI), one trend of it moving toward the aging part of population, the other coming closer to the increased prevalence of chronic diseases. The main idea is that PCC can be viewed as an outgrowth of philosophies in management, relating to total quality management (TQM), and CQI. According to Levy (1998), the future of the healthcare will be focused around the patient and its needs and concerns. The patient should play much greater role in the process of his curing.
Both patients and their families possess the increasing amount of medical information available (Levy, 1998). Present healthcare systems are mostly focused on different treatments and treatment sites, while they should be better focused on human needs and concerns. The main idea of the future healthcare system should be the one with patient being the central element of it together with illness being tangential. Levy (1998) notes, that there are the two main parallel movements in the evolution of health care at present time. One of the movements is characterized by the science and medical technology addition, the other one being a mix of the medical science, and organizational managerial learning with information technology.
It is essential, that the opportunities of the caregiver in relation to the patient can be modified by both movements. Due to the modern digital age any consultant can be brought directly to the patient without the need of visiting a physician. Simultaneously, there are two distinct approaches which are usually taken by researches in the area of PCC one of them defines the PCC and the other one applies a specific theoretical perspective in communication area with its possible enlightening the general notions of the PCC. Both of the described approaches have their problems. As Cegala (1997) writes, the biomedical perspective is still dominating, simultaneously, when the PCC is seen merely as a context for communication theories, the health conceptualizations tend to be impoverished. As it is seen through reading the discussed Chapter 17 of the book, the author provides the three different groups or rather, participants of the CQI process these are the patient, the care provider and the payer.
Simultaneously, he views the PCC process from the viewpoint of non-catastrophic chronic diseases and more severe cases, as oncology for example. These three groups of PCC process participants for sure need different patterns in controlling utilization and costs. The reason for this can be described in the following way: all three participants play three different roles in the management of PCC and CQI; the care provider should be in close interaction with the utilization nurse, but the physician itself should not be involved into the process of control, and spend more time with the patient and his family; the payer is usually blind to the general; course of treatment, as the report cards relating to the costs and utilization rarely clarify the content and the conduct of the care measures, thus the utilization control on the side of the payer might be addressed to the quality of measures designed as a part of the patients benefit plan; the control of utilization and costs on the side of the patient should acquire new meaning, as it is usually performed with the same idea: if all organ and physiologic systems were treated correctly, the utilization management verifies the correct course of treatment. (Levy, 1998) Despite the generally accepted opinion, that CQI is a very beneficial process especially in the area of healthcare delivery, there are several problems and constraints which prevent making the whole system real and working. These problems are practical, and not theoretical: PCC has not been easy to implement.
There is still an unfortunate tendency to devalue the patient-oriented work. Organizational inertia, resource constraints, professional dominance, conflicting interpretations, and resistance from providers have all been cited as barriers to change efforts. (Ceville, 2001) In other words, to fully implement the promising processes of the CQI and the PCC, the main stress should be made at changing the whole business psychology in the area of healthcare. Patient-centered care is often seen as a mere means of hospital redesign, without taking into account real needs of patients. The initiatives of PCC are often mixed with CQI and TQM in the wrong way, thus the central element of the newly designed system the patient is lost among a huge number of cost cutting, reengineering and downsizing instruments and approaches. There is still a question, whether a total healthcare system is headed toward mass customization. On the one hand, each of the situations in the healthcare delivery is unique and should be addressed separately; on the other hand, there are many conditions which presuppose the application of mass customization concepts.
I suppose that the system might probably move to the principles of mass customization in case of the wrong and illiterate application of CQI and PCC concepts. (Levy, 1998) Conclusion CQI and PCC both have promising future, and with the correct application might lead to the delivery of high quality services at reasonable costs. However, the principles of CQI should be implemented with the use of patient-centered care designed through the prism of communication and medicine principles. References (1) Cegala, Donald J. (1997). Provider-patient communication, patient-centered care and the mangle of practice. Health Communication, vol. 9, issue 1, 27 - 46 (2) Ceville, Mayne. (2001). Crossing the Quality Chasm: a New Health System for the 21 st Century.
National Academies Press, 28 - 37 (3) Levy, David, Thar, William and McLaughlin, Curtis. (1998) CQI and patient-centered care. (4) Murdock, Marianne. (1993). Continuous improvement (CI), customer satisfaction (CS) and systems engineering. Annual Quality Congress, Boston MA, vol. 47, 31 - 37 (5) Scheme, Paul. (1997). Standardizing quality evaluation.
Annual Quality Congress, Orlando FL, vol. 51, 246 - 248 (6) Vineyard, Michael. (1992). Quality in the health care industry. Business Perspectives, vol. 5, issue 4, 1 - 8 Abstract The main idea of the work is the discussion of the main principles of Total Quality Management (TQM) in relation to the healthcare, comparing it with the continuous quality improvement. The paper is based on the case study of Holston Valley Hospital and Medical Center, as it was one of the brightest examples of applying the basic methods of TQM. Outcomes Assessment and Quality Management Introduction The total quality management theory has been created in 1950 s and was usually applied to the technical enterprises, among which were Toyota Motor Company, Motorola and others. Only recently has the concept of TQM acquired the new meaning in relation to possible positive changes in the quality of healthcare delivery.
The core of the TQM is that this theory views any object as a combination of processes, thus making its main goal the improvement of these processes which will ultimately influence the quality of the product in a positive way. (Hashmi, 2002) The strategic reason to invest into the development of TQM in Holston valley Hospital was the reducing of medical care costs for Eastman Kodak, which is the major player in the local community and defines the whole policy and strategy of its living. By the time the need of implementing the TQM was realized, the HVHMC was experiencing serious troubles with the staff turnover, utilization costs, finances and continuous construction. While the implementation of CQI in the previous case was directly related to the patient-centered care and the processes taking place in the hospital, the implementation of the TQM in the HVHMC was set too far from its clinical processes, and the facilitators were put aside. To undertake the strategic impetus of the TQM program in HVHMC, there have been developed the following steps to achieve the main goal of the program: team building exercises; listening skills; managing customer expectations; developing process measures; statistical thinking. As the combination of the TQM and the CQI is necessary to achieve better results, there have been designed several classes for separate groups in continuous quality improvement. (McLaughlin, 1998) The main strength of the implemented TQM strategy was in its focus on the team work. According to the article, there have been created training programs for natural and process teams, and process and project teams were both responsible for multifunctional issues. (Martin, 1996) The system has allowed the hospital to move from the periodic appraisal system to the performance management.
However, it should be admitted, that the implemented system has displayed more weaknesses, which lied in the following: Not all groups received the necessary 80 hours of training, which especially concerned the process groups. Despite the high effectiveness of the program in increasing the quality of healthcare, the following questions of high importance were still unsolved: The organizational structure and the human infrastructure had to be changed to be adjusted to the principles of performance management; An emphasis on the quality management in relation to clinical decision making should have been increased; The psychology and vision of the staff had to be changed to make them see the necessity in the described changes. (McLaughlin, 1998) In achieving the strategic goal of cutting the costs of medical care, there have been measured the impact of the general TQM strategy on the HVHMC and its activity, and it has been found that admitting and processing times have been decreased to 5. 6 minutes, the preadmission lab testing went to 75 percent (being only 30 percent at the beginning of the program implementation) with the length of stay dropping to one day. In distinction, the CQI and the PCC were mainly concentrated on improving the role of the patient in the general process of medication, making his and his needs the central element, the TQM was mainly designed to improve the processes which in reality concern the patient only indirectly, but ultimately influence the effectiveness and efficiency of the whole hospital activity and thus the cost of the medical services. In achieving the strategic goal of the TQM program, there has been made an effort of implementing the TQM program for supporting several tactical goals, as it has been with the attempt to improve the radiology transport teams work, the linen management system and the training of facilitators, hired as additional staff. (Westphal & Gulati, 1997) The community took an active participation in the process of quality improvement implementation in the HVHMC, which also makes it different from the implementation of the CQI in the previous case. Kingsport became involved into the process of improving the community health, with the HVHMC being the central element of this idea. It should also be pointed out, that the community competition of the HVHMC and the Indian Path medical center in acquiring better results through the implementation of QUALITY FIRST programs was another side of the community's role in increasing the quality of healthcare delivery in HVHMC.
The case study presented certain data to be analyzed through the notions of Systemetrics data. Having made the analysis of the presented data, it became clear that despite the effectiveness of the TQM program, the LOS ratio, which usually shows the exceeding length of stay over the average and the expected one, was 1. 1 in average across all hospital departments, with the fewer portions of them showing the indices below 1. 0. This meant that the average exceed in length of stay was 10 % higher than expected. (McLaughlin, 1998) Simultaneously, the mortality ratio was much higher across the hospital, than it is usually accepted on the national level. These two indices have direct relation to financial and quality issues of the HVHMC and display the need of further focusing the future TQM strategy on the reduction of the stay length, which will ultimately lead to the cost reduction and efficiency increase. This is what should be done by Mr. Bishop in his future development of the quality improvement strategies for the HVHMC, as well as medical staff and hospital board should be involved into the planning process. (Avery & Zabel, 1996) Conclusion The main difference of the TQM and CQI strategies laid in the first being focused on processes, with the latter focused on humans (patients).
However, the implementation of the TQM was constrained by the administrative factor and the fact that the clinical aspect of the hospital activity was avoided in the process of quality improvement. References (1) Avery, Christine & Zabel, Diane. (1996). The quality management sourcebook. Routledge, 36 - 42 (2) Martin, Evelyn E St. (1996). Community health centers and quality of care; A goal to provide effective health care to the community. Journal of Community Health Nursing, vol. 13, 77 (3) McLaughlin, Curtis & Simpson, Kit N. (1998).
Holston Valley Hospital and Medical Center. (4) Rice, Gillian. (1998). Information systems technology and healthcare quality improvement. Review of Business, vol. 19, 67 - 68 (5) Westphal, James D. & Gulati, Ranjay. (1997). Customization or conformity? An institutional and network perspective on the content and consequences of TQM adoption. Administrative Science Quarterly, vol. 42, 10 - 12 (6) Hashmi, Khurram. (2002) Introduction and implementation of Total Quality Management (TQM).
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