clinical services within the laboratory.
3. Identify important aspects of care. To effectively use the institution’s resources in quality assurance, activities selected should be those with the greatest impact on patient care (the function occurs frequently or affects large numbers of patients, serious consequences could occur if services are not provided correctly or within set time frames, and the issue has tended to cause problems for staff and/or patients in the past).
4. Identify indicators. Indicators are well-defined, objective variables that are used to monitor the quality and appropriateness of any selected aspect of patient care. Within the laboratory, indicators could include clinical situations in which it may be inappropriate to use a particular test, situations in which inappropriate tests are often used, correct sequencing of tests, and clinical outcomes that may indicate inappropriate test use for a given situation.
5. Establish thresholds for evaluation. The thresholds for evaluation must relate specifically to the indicator and establish a value below which one does not continue to monitor and above which one continues to monitor and work on improvement and reaching the threshold or moving below.
Note Some monitoring of an indicator usually occurs before a reasonable threshold can be identified. Once the threshold has been determined, monitoring and educational efforts continue, with the goal being to reach or go below the threshold. Once the threshold has been reached, consideration may be given to lowering it even more, thus leading to additional improvements in the indicator being monitored.
6. Collect and organize data. The following must be determined for each indicator: data sources, data collection method(s), sampling system, time frame for data collection, and process for comparing level of performance with set thresholds.
7. Evaluate care. If the data indicate that the acceptable threshold of performance has not been reached, extensive review occurs to identify problems or opportunities for improvement. An analysis of patterns or trends (specific shifts, units, personnel, skills) can help identify specific areas for improvement and changes. If the threshold of acceptance has been reached, it should be reevaluated in terms of keeping it where it is or possibly lowering it further to strive for additional improvements. If the decision is made to leave the threshold where it is, monitoring may be performed on a less frequent basis (every 6 months and then every year), just to verify that the data do not indicate that performance has declined.
8. Take actions to solve identified problems. The laboratory develops a plan of action that specifies who or what is expected to change, what action is appropriate, and when the changes should be complete. Three of the most common causes of problems are insufficient knowledge or poor communication, defects in the process, and poor compliance with process expectations. Frequently, educational presentations by various means (one on one, verbal presentations, written information, newsletters) can be used to help resolve the problems.
9. Assess the actions and document improvement. After sufficient time is allowed for improvements to occur, follow-up assessments are very important in documenting what progress has been made. This process must focus on the problem or opportunity for improvement, not on the action taken. If improvement is found, less frequent monitoring may be necessary; if the problem remains, new action should be taken with subsequent assessment for evidence of improvements.
10. Communicate relevant information to the organization-wide quality assurance program. It is critical that the findings not only be reviewed within the area being examined but also be conveyed and discussed at all levels of management. In addition to these discussions, documentation of such discussions is mandatory; one method often used is meeting minutes.
Continuous quality improvement (CQI) (or total quality management) is a continuous quality improvement process that evaluates processes from a customer satisfaction point of view. The aim is continuous process improvement. This approach is a natural extension and expansion of the quality assurance programs that laboratories have been using for the past few years. CQI uses familiar tools such as check sheets, run charts, and flowcharts in new ways. Issues for review in a quality improvement program include some of the issues involved in a quality assurance program, such as timeliness of response to requests, turnaround time, and effective communication. The problem-solving process in a CQI laboratory is done by broad-based teams with members from all affected groups inside and outside the laboratory. Team members are trained in and use group process methods for identifying problems and generating solutions. Rather than management remaining “top down and autocratic,” it becomes “bottom up and independent.”
CQI laboratories focus on improving customer satisfaction; however, “customers” may be defined differently from the traditional use of the word. A CQI customer can be anyone who uses the products of the production process—a ward clerk responsible for charting results, a patient needing blood drawn for preadmission tests, or a physician waiting for a STAT result. Anyone who is an “end user” of the laboratory process is a customer and should be satisfied with the laboratory’s product.
The Joint Commission uses the term “continuous quality improvement.” The concept of “quality assurance” has been changed to “quality assessment and improvement” and includes the major trends leading to quality improvement. The formal surveillance process is deemphasized in lieu of promoting activities that better reflect the principles of CQI. However, this does not suggest that the Joint Commission will abandon the 10-step process. The use of CQI requires a shift in the organization’s definition of quality from “good enough if it meets standards” to “we must work continuously to improve quality.” This whole process is similar to any recommendation for problem solving; however, there are specific differences to consider.
1. Empowerment of employees to become involved in analyzing, operating, recommending change, and implementing solutions is necessary for CQI to be adopted.
2. CQI focuses on continuous monitoring of processes, not just limited issues.
3. The problems identified almost always cross over multiple departments or units.
4. The key issue always focuses on customer satisfaction and how we define it, measure it, monitor it for success, fix it when things go wrong, etc.
5. Groups who work on these identified problems include members from all areas relevant to the final service product (from initial ordering or product to final delivery).
6. The identification of areas for improvement originates from all levels within the institution.
7. A simplified version of the above is as follows.
A. Identify and choose a process to fix.
B. Analyze all aspects of the issue.
C. Select a possible solution.
D. Correct the process.
E. Monitor the results.
F. If results are satisfactory, solidify the change and move on to other issues.
G. Who does it? A group composed of representatives of all aspects of the process under review.
Another way to look at organizing performance improvement activities can be seen in Table 11.10. This approach merges the 10-step and FOCUS-PDCA approaches; similarities are certainly more numerous than differences.
