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INTRODUCTION

KEY QUESTIONS

  • Lean management is frequently used in process improvement. What are the seven wastes identified in lean theory?

  • In creating a strategy for quality improvement in a healthcare process, what is the role of front-line workers, such as registered nurses (RNs), technicians, surgeons, and other providers?

  • What are three primary sources of failure for a quality-improvement process?

A 27-year-old female presents to the Emergency Department (ED) complaining of nausea and belly pain for the past 12 hours. The general surgeon on call is consulted after examination by the ED physician's assistant (PA) confirms the presence of morbid obesity and active bowel sounds. The surgeon sees her and recommends discharge with use of over-the-counter laxatives. Six hours later, the patient returns with the same complaints. The ED PA finds nothing new, and the general surgeon elects not to see her again, recommending that she again be sent home, this time with codeine. She returns four hours later and precipitously delivers a baby in extremis, with Apgar scores 0 and 2. Asked later, the PA and consulting surgeon each admitted omitting a pelvic exam because pregnancy was of low probability and “it takes too long to get a pelvic tray up to the ED.”

Why would we care about process improvement in the medical center setting or any healthcare delivery system? In short, the reason is that healthcare delivery in the United States is too expensive, waste-filled, and dangerous. It is unsustainable. Donabedian (2003, pp. xxiii–xxiv), a doyen of quality improvement, once wrote:

Strictly speaking, one cannot assure or guarantee quality. One can only increase the probability that care will be “good” or “better” … no given level of quality can be fully satisfactory; one should always try to do even better, progressing to ever higher levels of goodness.

Too many patients and providers would agree that the current level of quality in healthcare is not “fully satisfactory.” It must become more efficient, cost-effective, and conducive to higher-quality outcomes. And it must provide better value to patients and payers.

Process improvement is a business strategy with a long and positive history of successful boosting of efficiency and quality, as measured by structure, process, and outcome measures. The question “What should be measured, and with what frequency?” generates many different answers, particularly as the metrics have now become the purview of external regulatory and accrediting agencies. Even some of those metrics have value, however. A key determinant of process-improvement efforts is the definition of quality. Yet definitions of quality may alter with time and changes in patient, provider, and accreditation expectations as well as the economic exigencies that are ever more significant in healthcare delivery. Although the definition of quality is most useful and valuable when chosen by the local team engaged in its improvement, this short one has been effective for me: Quality care is ready access to effective healthcare.

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