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Quality Hospitals

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The Institute of Medicine’s “To Err Is Human” report of 2000 estimated that nearly 100,000 deaths each year in the United States are caused by medical errors. Many hospitals are working to change that by employing certified quality engineers (CQEs) to apply quality tools and techniques to a wide variety of issues. This case describes one of those hospitals. In 2007, this hospital saw 350,000 patients, many of whom visited multiple times, for an overall total of 1.8 million patient encounters. Though this hospital has an excellent reputation for patient care, leadership has identified a need to make improvements. The certified quality engineers study a variety of areas including the physical layout of the hospital, its treatment rooms, and operating rooms. They assess operational efficiency and effectiveness. They study patient throughput and infection rates. A recent area of study is the surgery center. Whenever a patient is scheduled for a surgical procedure, pretests are scheduled. These may include a physical, blood testing, x-rays, cat scans, or other lab tests. This paperwork and test results goes into the patient’s file (a paper file, not an electronic file). Nationwide, hospitals and doctor’s offices do not usually use electronic files, despite significant evidence that efficiencies could be obtained by using them. This is because of a concern for patient privacy, information sharing between government and insurance companies, and other issues. All this paperwork needs to be at the surgery center at least 48 hours in advance of the surgery. This provides the time needed for the anesthesiologist and other key participants in the surgery to review the file and make sure that the right information is available. Without this information, the surgery may place the patient at risk. When the information is not available, the surgery is usually canceled.
The CQEs studied the number of canceled surgeries. They determined that incorrect, incomplete, or late paperwork accounted for 45 percent of the reasons why surgeries were canceled. Canceling surgeries is very expensive. Surgeons are paid for four hours of their time, anesthesiologists and surgical technicians bill their time, charges are incurred for sterilized equipment that did not get used, tests are rescheduled and redone, an appointment coordinator must reschedule the surgery, and so on. Don’t forget, there is also the patient who prepared mentally and physically for the surgery and now must go through the entire process again. The costs can run into the thousands of dollars for each cancellation.
Consider the situation and answer the following questions related to the quality philosophies discussed in this chapter.
1. Using Dr. Feigenbaum’s definition of quality, refer to the information provided and describe each of the major participant’s (doctor, patient, nurse, etc.) definition of quality.
2. Describe how you would recognize Dr. Shewhart’s common cause variation in the process of preparing a patient’s file for surgery.
3. Describe how you would recognize Dr. Shewhart’s assignable cause variation in the process of preparing a patient’s file for surgery.
4. You are the senior team leader in charge of making improvements to the process of preparing a patient’s file for surgery. You have recently attended a seminar focused on Dr. Deming’s teachings. Clearly state one of Dr. Deming’s 14 points that you will keep in mind as you focus on this situation. How will this point guide your actions and behavior as you tackle making improvements?
5. Describe two clues that suggest that the hospital is practicing Juran’s little q versus big Q. If they were to practice big Q, describe one way in which their focus would need to change.
6. During a meeting, someone has cornered you concerning the improvements and changes your team would like to make at the hospital. They accuse you of wanting to create a luxurious environment at the hospital. They said that a patient’s judgment of quality of the hospital is intangible and not measurable. They also said that there is an economics of quality. You recognize these statements as three of Mr. Crosby’s five erroneous assumptions about quality. Using what you know about Mr. Crosby’s approach to quality, pick one and argue against what this person has said.

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