Is it time to re-examine structure of your quality department?

It may be an appropriate reaction to shifting market realities

Doesn’t it make sense that a commitment to continuously improving performance should include a periodic review of the organizational structure that governs your QI efforts?

Several quality professionals contacted by Healthcare Benchmarks and Quality Improvement recognize that, in fact, conducting such reviews from time to time is essential to efficient QI operations.

In some cases, they observe, the structure just becomes tired or too large and cumbersome to operate efficiently. At other times, significant shifts in industry trends call for a new approach to structure design, they add.

"We have a very active discussion board.0569 and recently had a posting asking, How do you structure the quality function, what is your committee made up of — who’s on it?’" reports Sharon Lau, a consultant with Medical Management Planning, in Los Angeles, referring to her BENCHmarking Effort for Networking Children’s Hospitals.

"A number of replies indicated that the quality departments or committees were in the middle of a major revision," Lau notes.

What reasons were given for these revisions? "It sounds like people are really looking at how the quality function can be structured for maximum efficiency and benefit," she says.

"Which got us to thinking: It used to be that quality wasnt really a department but something that everyone was expected to do — a value, if you will," Lau points out.

"At that time, there was a person in charge of JCAHO issues, a corporate compliance officer, then a quality department. So you had all these different pieces being fragmented under different silos," she adds. Subsequently, Lau says, people began recognizing that all these different functions, including the medical staff, touched on quality.

Susan W. Adams, RN, CPHQ, director of quality resources/risk manager at Primary Children’s Medical Center in Salt Lake City, has a similar viewpoint.

"In the late 1980s, the changes people tended to make were in response to regulatory issues and were more specific than they are now," she observes.

"We have more latitude to be creative and innovative than we did then. Then it was discipline-specific; you had medical staff functions and did quality specific to the disciplines. Nurses did their things — doctors did theirs — and so on," Adams says.

Streamlining the structure

With the scope of the quality function having become so broad, it is easy for the structure to become bloated, observers say. This, then, has become one of the predominant reasons for restructuring.

"I started at this position several weeks ago, and they hadn’t had a quality director in quite a while," says Gayle Bielanski, RN, CPHQ, director of quality and patient safety at Phoenix Children’s Hospital. "We are now thinking about restructuring."

The current quality council has a medical staff committee, composed of the vice chairs of several medical staff committees, nursing directors, representatives of clinical areas such as radiology and lab, and a patient care and quality enhancement committee — a board committee — that includes board members, an individual in charge of the quality council, and one or two directors, she explains.

"What happened was, they seemed to duplicate each other’s work; it was not supposed to be that way, but it got that way," Bielanski says. "Our thinking was to combine the two."

The new structure she has in mind would consist of two nurse directors, two or three clinical directors, some physicians, and two or three board members. "This way, they could bring back to the board whatever they found," she explains.

In hospitals where Bielanski had previously worked, she says, the quality council was a hospital committee.0569 with an administrative function.

"It was not truly a medical staff committee, although there was medical staff in it," she says.

For additional input, she entered a posting on the aforementioned discussion board. What did her peers say?

"So far, all of them say they are a medical staff committee, and only one hospital said they had two separate committees," Bielanski adds.

"My guess is that it preserves the confidentiality of anything that comes out of it and protects it from discoverability." That means, she notes, that neither attorneys nor the media can get a hold of the information.

"For example, if it was reported that you had a certain number of errors, or a patient sued over receiving the wrong information, that could be used against your hospital," Bielanski notes.

Another issue she had been curious about was how often each of the departments reported, and when. "None of our departments had been reporting their quality information; it had been very lax," she says.

The respondents to the posting said reporting took place either quarterly or yearly. "We’re leaning toward having all clinical departments report on a quarterly basis and the others every six months or every year," Bielanski explains.

Freeing up staff for systems PI

At Primary Children’s, Adams is now contemplating the latest in a number of changes that have been implemented in the quality function during her 24 years there. What has occasioned this change?

"We’ve been using the interdisciplinary model since 1991," Bielanski explains.

"At this time, the enterprise is so heavy with so many people trying to represent things that we need to free up resources to have more time to devote to solving and monitoring and evaluating the solutions we come up with. We want to make [the structure] leaner and meaner to free people to do systems process improvement," she adds.

The current quality function is "a cast of hundreds," Adams observes. "We have unit-based geographic functions, hospitalwide functions, leadership functions. There is also a group or body outside the quality council that oversees the hospitalwide and the unit-based functions."

There is another issue driving the redesign, she continues. "We were trained to hold people accountable who were technically filling volunteer positions, so we are really trying to engage our senior leaders and look at accountability kinds of issues," Adams notes.

"We think that maybe some improvements weren’t happening because we were asking the wrong people to be held accountable, rather than connecting the dots with leadership," she says.

To come up with a new plan, Adams created a strategic team of six individuals — the medical director, Chief Operating Officer, patient care services administrator/Chief Nursing Officer, patient safety manager, process improvement director, and herself.

"Our corporate strategic planning folks conducted some focus groups with all the participants, all the nursing medical directors, senior leadership, and then people on the existing committees and processes and functions," she reports.

In addition, the quality department did an intense analysis of accountability of committees, resources, strengths, weaknesses, regulatory requirements, and other key areas.

"We just completed a two-day retreat, and I think we were blown away with the complexity of the process," Adams says. "Some people thought we could spend a day coming up with a model, but we really want to streamline the structure; and I think we’ve come up with some innovative ideas we need to flesh out."

While a true model has not yet been finalized, one of the key recognitions of the group is that "you can’t get a committee of gigantic proportions to do real work productively," Adams points out. "So we’re adopting a model of three — it’s a SWAT team approach to real process improvement, and I think we’ve done the right process."

A change in the structure will require a change in board bylaws, Bielanski says, "But we haven’t had a problem yet. We have gone to most of the medical executive committee meetings and will go to the quality council tomorrow and the board next week. I don’t think we will have an issue, because all the docs realize there’s a problem they need to fix."

Bielanski says she is hopeful the bylaws can be changed within 30 days or so.

Know when change is needed

To make such improvements in the quality structure, you need to be able to recognize when change is needed, Adams notes.

"When you feel like you’re not making those incremental leaps, or it feels cumbersome or broken, or you do not have the right people talking, it may be time for change," she offers.

"You should ask yourself if you can find the root cause of a problem quickly; if you can, your structure is probably OK," Lau adds.

"But if things are not getting reported, or you’re not able to find answers, maybe your structure isn’t where it needs to be." That structure doesn’t have to look the same in every hospital, she says.

"There’s probably no one right answer, but you have to look at accountability in making sure quality happens. Depending on how your culture works and how people interact, you may have a different way of doing it, but your key question should always be, How do we assure accountability in quality?’"

Performance improvement, Lau reminds, is a process, not a program.

"Ideally, you want to have all the aspects related to performance communicating very well," she explains.

"For example, information services [IS] always has a ton of data, but I can tell you that I’ve gone into hospitals where you’d be amazed how few people know that data exist, and how much reinventing of the wheel gets done. IS decision support, benchmarking, risk management, your national effort — all have to be a part of the process," Lau says.

Should all this responsibility come under one report? "I don’t know," she continues. "But there are so much data, so many requirements to prove you are keeping track of things — that data intensity that has probably brought this to a head.

"You have to know where the data are and work on it together. Also, you have to make sure everyone is educated in how to do quality the right way at the right time," Lau adds.

Need More Information?

For more information, contact:

• Susan W. Adams, RN, CPHQ, Director of Quality Resources/Risk Manager, Primary Children’s Medical Center, Salt Lake City, UT. Phone: (801) 588-2281. FAX: (801) 588-2288. E-mail:

• Sharon Lau, Medical Management Planning, Inc. (MMP), 2049 Balmer Drive, Los Angeles, CA 90039. Phone: (323) 644-0056. FAX: (323) 644-0057. E-mail:

• Gayle Bielanski, RN, CPHQ, Director Quality and Patient Safety, Phoenix Children’s Hospital, Phoenix, AZ. Phone: (602) 546-0706.