Process improvement: Scarce resources make prioritizing a must

Existing or potential problems, outside agencies key determinants

It would be nice if all quality issues could be solved at once, but the truth is that improvement is an evolutionary process. Since you simply can’t fix everything at the same time, this places a premium on the ability to set priorities, quality experts say.

"There are limited resources, so an organization has to prioritize; the quality professional will help facilitate that prioritization," notes Patrice L. Spath, RHIT, health care quality consultant with Brown Spath & Associates in Forest Grove, OR. "The limitation applies to both human resources and financial resources, but the biggest cost of conducting QI projects is the human resource cost," she says.

"There are limited resources in hospitals, and you have to use them wisely, particularly the budget," adds Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Consulting in Canton, MI. "Accordingly, you clearly need to think about the cost benefit when it comes down to corrective action," she explains.

"We simply don’t want to waste resources and effort," notes Dorinne L. Peery, MT (ASCP), RN, patient safety program manager, quality management, at Lovelace Health Center in Albuquerque, NM.

Besides, "everybody needs a goal; you need to determine what those goals should be," observes Marie Pears, RHIA, CPHQ, quality coordinator at Meadville (PA) Medical Center.

Knowing priorities must be set is the easy part; determining what they should be is not quite so simple. Quality professionals note that several different variables can affect the selection process.

"We look at both internal and external data, and at literature like Sentinel Event Alerts. In addition, we look to our own policies and procedures. We also have internal data from patient safety suggestions left on our hotline," Peery says.

"No. 1, you want to make sure you address those issues that are going to have the largest impact on patient safety," Homa-Lowry says. "Of course, you need to have a good source of data and information, then what you look at are the obviously required elements of regulatory agencies; but instead of just taking them at face value, try to put some data behind them."

Some of those agency requirements can be a bit abstract, she says. "For example, if you’re looking at operative and invasive procedures, you may want to look not only at high-volume, high-risk procedures, but perhaps at outliers as well. I say, try to apply trim points to outliers; this will allow you to examine the larger population and what improvements you can make in that population. Your other systems — risk management, case management, and so on — may already be taking a look at the same things, so you will not have to duplicate that process," Homa-Lowry adds.

"You can use the old QI standard of high volume, high risk or low volume, high risk," Pears says. "Or an outside agency can set the priority; right now, that would be patient safety. Perhaps an incident that occurs in your facility could set a priority, such as surgery on the wrong side or a medication error."

"The ideal would be that the priority flows from your strategic planning process for the organization," Spath says. "The organization sets strategic performance improvement goals; most organizations have set some sort of goal, such as improving the safety of patient care. Generally, that comes with objectives, like reducing medication errors, falls, or the chances of wrong-site surgery. Or the goal may be complying with the Joint Commission [on Accreditation of Healthcare Organizations’s] national patient safety goals. It could, however, be other topics of interest, such as what the community says it wants, what competitors are doing, and so on."

Spath agrees with Homa-Lowry, however, that goals set by outside agencies can be very abstract. "The Joint Commission has for a number of years asked organization leaders to set strategic quality goals. But it may just say, improve the quality of patient care.’ The people in the organization then need to operationalize that goal and make their own objectives. What should have occurred at the top may need to occur at the departmental level. A nurse, for example, may identify the areas where there are specific safety improvement opportunities," she adds.

Spath’s comments bring up the key point that quite often the prioritization process is dictated by who makes the decisions. In some cases, that can be less than ideal. "Your board could set priorities, but they’re looking at things from the outside," Pears notes. "But here they are set by individual department managers, committees, or by the board."

Priorities should be set according to the policies of the institution, she continues. "Here, we say if you find a need, you can put it on your priority list and work it from there." As QI areas are identified by departments, the manager creates a priority matrix, where different quality areas are assigned a point range. (See example.) When the matrix is completed, the points are added up and the total tells the staff whether the problem should be looked at immediately, or whether it’s time to move on to something else.

"Physician involvement is critically important," Spath notes. "And you’re much less likely to get that involvement without commitment from senior leadership of the medical staff. For example, if you’re going to look at illegible handwriting [without such a commitment], it won’t get fixed."

At Lovelace, "we have a patient safety steering committee that is chaired by our chief quality officer — an MD," Peery says. The committee meets once a month and discusses, among other issues, quality improvement priorities.

How the process plays out

With such a wide range of potential subjects and a diversity of decision-making mechanisms, is that variety reflected in the subjects on which different facilities choose to focus?

Well, not exactly. Healthcare Benchmarks and Quality Improvement inquired about different facilities’ initial failure mode and effects analysis (FMEA) projects, and there was some similarity in the responses.

"I would say probably half of the people choose some component of the medication administration process," Spath says. "It could be ordering, selling, dispensing — any step. Basically, it’s because of media attention and because it’s a known area."

Some facilities, she continues, focus on processes that relate to national safety goals. "We’ve seen a lot on wrong-site surgery — failure mode and effects analysis on the process of identifying patients and surgery sites. Others have done them on equipment alarms. The national patient safety goals are based on known problematic areas, so it still comes back to the same process."

"The first FMEA we did, and the only one we’ve done so far, was on epidural pumps," Pears says. "We had a near miss that could have been harmful to the patient."

The next one will go a totally different way, she says. "We’ve put together the total of all the incidents that have been reported through risk management, and took it through our patient safety committee. The committee said we should look at some piece of the medication administration process, such as the validating process," Pears adds.

"Our very first one was done in June 2001 on the inpatient medication dispensing system," Peery reports. "We had joined an IHI [Institute for Healthcare Improvement] collaborative, and that was prescribed as part of it. Our second was on suicide precautions; basically, the source was the Sentinel Event Alert. At that time, the Joint Commission said it was going to do surveys based on the recommendations in the alert."

After the project was completed, she notes, the Joint Commission decided it would not base its surveys on the alerts.

Sometimes, it pays to devote some creative thinking to the prioritization process. For example, Spath suggests, you might want to look at issues such as redundancy, or processes that cross organizations.

"The [recent tragedy at] Duke [University Medical Center in Durham, NC] brings up processes that cross organizations," she asserts.

"Basically, the prioritization process allows us to determine where we hope to get the biggest bang for the buck; that might come from looking at processes that cross organizational boundaries — for example, the transfer of critical patients from one organization to the next," Spath says.

"What I typically see in organizations is a lack of checks and balances," Homa-Lowry adds. "That might apply, for example, to checking patient care equipment. A lot of times, people might assume biomedical has done that and done it correctly, but you can sometimes walk around and see equipment that has not been checked. The nurse manager may not have been made aware of performance checks. You could also check for expired meds or check the crash carts."

This movement into more sophisticated areas can be a gradual process, Homa-Lowry concedes. "I think that since it’s a learning curve, my experience is to have [early FMEAs] centered around issues that are a little safer,’ to get comfortable. For the people who will be responsible for conducting future projects, the process is time well spent, because you develop a train-the-trainer’ mentality. When you are more comfortable with the process, you move into more significant issues. I’ve seen one institution revise the process for infant abduction, for example."

Another possibility, Spath suggests, is to do an FMEA on something that could be a problem, vs. one that already is a problem. "However, since you’re going to need medical staff and employee involvement, if you can answer the so what?’ question, you are more apt to keep their interest and involvement.

"You can do that either by showing data on near misses within your own organization, by posing questions to employees about unsafe situations, or by going to the literature. The ideal would be to use your own data to prove you’ve had near misses,"she points out.

"Many organizations have near misses, so that may not be enough of a burden," Homa-Lowry counters. "You may find yourself splitting hairs between root-cause analysis and FMEA. This month, one facility looked at the fact that it was having problems with its education process. The consensus was it may be time to go back and do a failure mode," she adds.

"It’s not at all difficult to motivate the staff [to address potential problems]," Pears says. "If we have a situation that’s potentially harmful, we always do a root-cause analysis, and that can lead into the FMEA."

Peery contends that organizational culture is the key. "We’ve focused on changing the culture for several years now, and while we have accountability, we have a nonpunitive culture, so people are very happy to get involved in process-improvement activities — whatever the topic. That’s my belief; if you change the culture, it’s not a problem."

Need More Information?

For more information, contact:

• Marie Pears, RHIA, CPHQ, Quality Coordinator, Meadville Medical Center, 751 Liberty St., Meadville, PA 16335. Telephone: (814) 333-5583. E-mail:

• Dorinne L. Peery, MT(ASCP), RN, Patient Safety Program Manager, Quality Management, Lovelace Health Center, 5403 Gibson Blvd. S.E., Albuquerque, NM 87108. Telephone: (505) 232-1938. Fax: (505) 232-1943. E-mail:

• Patrice L. Spath, ART, Health Care Quality Consultant, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116. Telephone: (503) 357-9185. E-mail:

• Judy Homa-Lowry, RN, MS, CPHQ, President, Homa-Lowry Consulting, 7245 Provincial Court, Canton, MI 48187-2121. Telephone: (810) 245-1535. E-mail: