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Fostering a Commitment to Quality: Best Practices in Safety-net Hospitals
Abstract
In 2007, the Martin Luther King, Jr.–Harbor Hospital (MLK-Harbor), which served a large safety-net population in South Los Angeles, closed due to quality challenges. Shortly thereafter, an agreement was made to establish a new hospital, Martin Luther King, Jr. Community Hospital (MLKCH), to serve the unmet needs of the community. To assist the newly appointed MLKCH Board of Directors in building a culture of quality, we conducted a series of interviews with five high-performing hospital systems. In this report, we describe our findings. The hospitals we interviewed achieved a culture of quality by: 1) developing guiding principles that foster quality; 2) hiring and retaining personnel who are stewards of quality; 3) promoting efficient resource utilization; 4) developing a well-organized quality improvement infrastructure; and 5) cultivating integrated, patient-centric care. The institutions highlighted in this report provide important lessons for MLKCH and other safety-net institutions.
... Supporting to this view also as emphasized by Hochman et al., (2016) said that commitment to quality can only be achieved if there are principles developed that foster quality, personnel who are also stewards of quality, and developed well-organized quality improvement process. One informant shared: ...
Using the sequential exploratory research design adopted from Creswell, this research included the collection and analysis of the qualitative data and themes were used to drive the development of a research instrument to further explore and validate the research questions and their responses. Further, three stages of analyses were conducted: (1) after the primary qualitative phase which used interview as its form of data collection, (2) after the secondary quantitative phase which instrument was developed, and (3) at the integration phase that connected the two strands of data and extended the initial qualitative exploratory findings and the development of conclusions and implications relevant to the essence of this study.
In this research, CI projects were grounded to DepEd goals anchored on quality, access, and governance which adhered to certain processes and strategies, implemented in a year and supported by the Division Office. Although there were certain driving and restraining forces on the implementation, still, it spawned an idea of ‘improved process’, resulting to significant impact to the welfare of teachers, improved commitment, satisfaction, and the whole organizational management.
Quantitatively speaking, instrument development was presented as it owned distinct phase. Since this research made use of sequential exploratory design, this phase presented the mixing of the qualitative and the quantitative phases. However, the two phases were not mixed, but analyzed differently since the qualitative phase served as the foundation for the quantitative analysis.
The framework developed in this research study was relevant to support the sustainability of Continuous Improvement. Support is seriously needed to sustain the implementation. The top management should value the process of CI since it is gearing towards the culture of excellence in the organizational process and performance.
Sustainable quality CI Projects would also be an important step from this research. Although the process is quite challenging, the need to understand it fully would benefit in solving problems where a mixed method approach is employed to further expand the study and analysis. However, this wouldn’t be realized if there would be no support from the top management, so, the need to develop support with accurate budget and resources would help in the implementation. The sustainability program should always include the training among teachers. Aspiring principals should also be knowledgeable on the projects implemented by the Division to allow a culture of knowing and understanding of Continuous Improvement Projects implemented. Since projects and plans of the Division Offices are now CI, it would be best to assess and analyze situations like how it would benefit in the School Improvement Plan and School Report Card.
... In this study, participants were clear that the intervention of an LSS education and training programme had contributed to what is termed a 'culture of quality' [126] in their organisation. This is congruent with the argument that LSS deployment is not just about the quality improvement itself [127] but about creating a supportive institutional culture [9,72,128]. It is also synergistic with the cultural aspect of person centredness that promotes and incorporates care [106]. ...
A lack of fidelity to Lean Six Sigma’s (LSS) philosophical roots can create division between person-centred approaches to transforming care experiences and services, and system wide quality improvement methods focused solely on efficiency and clinical outcomes. There is little research into, and a poor understanding of, the mechanisms and processes through which LSS education influences healthcare staffs’ person-centred practice. This realist inquiry asks ‘whether, to what extent and in what ways, LSS in healthcare contributes to person-centred care and cultures’. Realist review identified three potential Context, Mechanism, Outcome configurations (CMOcs) explaining how LSS influenced practice, relating to staff, patients, and organisational influences. Realist evaluation was used to explore the CMOc relating to staff, showing how they interacted with a LSS education Programme (the intervention) with CMOc adjudication by the research team and study participants to determine whether, to what extent, and in what ways it influenced person-centred cultures. Three more focused CMOcs emerged from the adjudication of the CMOc relating to staff, and these were aligned to previously identified synergies and divergences between participants’ LSS practice and person-centred cultures. This enabled us to understand the contribution of LSS to person-centred care and cultures that contribute to the evidence base on the study of quality improvement beyond intervention effectiveness alone.
Background:
There is limited understanding about whether and how improvement interventions are effective in supporting failing healthcare organisations and improving the quality of care in high-performing organisations. The aim of this review was to examine the underlying concepts guiding the design of interventions aimed at low and high performing healthcare organisations, processes of implementation, unintended consequences, and their impact on costs and quality of care. The review includes articles in the healthcare sector and other sectors such as education and local government.
Methods:
We carried out a phased rapid systematic review of the literature. Phase one was used to develop a theoretical framework of organisational failure and turnaround, and the types of interventions implemented to improve quality. The framework was used to inform phase 2, which was targeted and focused on organisational failure and turnaround in healthcare, education and local government settings. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to guide the reporting of the methods and findings and the Mixed Methods Appraisal Tool (MMAT) as a quality assessment tool. The review protocol was registered with PROSPERO (CRD: 42019131024).
Results:
Failure is frequently defined as the inability of organisations to meet pre-established performance standards and turnaround as a linear process. Improvement interventions are designed accordingly and are focused on the organisation, with limited system-level thinking. Successful interventions included restructuring senior leadership teams, inspections, and organisational restructuring by external organisations. Limited attention was paid to the potential negative consequences of the interventions and their costs.
Conclusion:
Dominant definitions of success/failure and turnaround have led to the reduced scope of improvement interventions, the linear perception of turnaround, and lack of consideration of organisations within the wider system in which they operate. Future areas of research include an analysis of the costs of delivering these interventions in relation to their impact on quality of care.
Background: Healthcare organisations in England rated as inadequate for leadership and one other domain enter Special Measures for Quality (SMQ) to receive support and oversight. A ‘watch list’ of challenged providers (CPs) at risk of entering SMQ also receive support. Knowledge is limited about whether the support interventions drive improvements in quality, their costs, and whether they strike the right balance between support and scrutiny.
Objective: Analyse trust responses to the implementation of a) interventions for SMQ trusts and b) interventions for CP trusts to determine their impact on these organisations' capacity to achieve and sustain quality improvements.
Design: Rapid research comprising five inter-related workstreams:
1. Literature review using systematic methods.
2. Analysis of policy documents and interviews at national level. 3. Eight multi-site, mixed method trust case studies.
4. Analysis of national performance and workforce indicators. 5. Economic analysis.
Results: SMQ/CP were intended to be “support” programmes. SMQ/CP had an emotional impact on staff. Perceptions of NHSI interventions were mixed overall. Senior leadership teams were a key driver of change, with strong clinical input vital. Local systems have a role in improvement. Trusts focus efforts to improve across multiple domains. Internal and external factors contribute to positive performance trajectories.
Nationally, only 15.8% of SMQ trusts exited within 24 months. Relative to national trends, entry into SMQ/CP corresponded to positive changes in 4-hour waits in Emergency Departments, mortality and delayed transfers of care. Trends in staff sickness and absence improved after trusts left SMQ/CP. There was some evidence that staff survey results improve. No association was found between SMQ/CP and referral to treatment times or cancer waiting times.
The largest components of NHSI spending in case studies were interventions directed at 'training on cultural change' (33.6%), 'workforce quality and safety' (21.7%) and 'governance and assurance' (18.4%). Impact of SMQ on financial stability was equivocal; most trusts exiting SMQ experienced the same financial stability before and after exiting.
Limitations: The rapid research design and one-year timeframe precludes longitudinal observations of trusts and local systems. The small number of indicators limited the quantitative analysis of impact. Measuring workforce effects was limited by data availability.
Conclusions: Empirical evidence of positive impacts from SMQ/CP were identified, however, perceptions were mixed. Key lessons:
• Time is needed to implement and embed changes.
• Ways to mitigate emotional costs and stigma are needed.
• Support strategies should be more trust specific.
• Poor organisational performance needs to be addressed within local systems.
• Senior leadership teams with stability, strong clinical input and previous SMQ experience
helped enact change.
• Organisation-wide quality improvement strategies and capabilities are needed.
• Staff engagement and an open listening culture promote continuous learning and a quality
improvement ‘mindset’, critical for sustainable improvement.
• Need to consider level of sustainable funds required to improve patients’ outcomes.
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