After completing this week’s reading, you have learned that teamwork is an essential part of continuous quality improvement (CQI) and health care delivery. Health care professional roles include physicians, nurses, diagnostics (laboratory) and radiology staff, hospital administrators, patient registration, pharmacists, triage staff, and so forth. Each role has its own contribution to ensuring the delivery of quality care.  

In your opinion,

·  Discuss two of the roles listed above and their role in the delivery of quality care.

·  Identify two professional responsibilities of the chosen roles, and link them to the quality improvement process of improving patient wait times in the emergency room.

·  Include communication techniques this role would utilize to assist in improving patient wait times to the CQI team or staff.

Your initial post should be 250 to 300 words and utilize at least one scholarly source from the Ashford University Library to justify your statements

223

What is Special Education?

1

iStockphoto/Thinkstock

Pre-Test

1. You can use the terms disability and handicap interchangeably. T/F
2. The history of special education began in Europe. T/F
3. The first American legislation that protected students with disabilities was passed in the 1950s. T/F
4. All students with disabilities should be educated in special education classrooms. T/F
5. Special education law is constantly reinterpreted. T/F

Answers can be found at the end of the chapter.

8Real-World Aspects
of Quality Improvement

iStock/Thinkstock

Learning Objectives
After reading this chapter, you should be able to do the following:

• Summarize the impacts—economic, sociological, safety, and ethical—that a quality improvement
project can have on an organization.

• Relate the importance of communication and teamwork to a quality improvement project.

• Examine the ways that organizations can help their employees adapt to change and why this is
critical in quality improvement.

• Contrast how continuous PDSA is used in quality improvement with other methods described in
the book.

• Evaluate the principles of continuous quality improvement (CQI) and its importance in healthcare.

• Describe the role that social media can play in quality improvement.

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Section 8.1 Decision-Making Considerations

Introduction
Quality improvement is a science that involves close examination of practical concepts that
can be widely applied. Much like building a house, quality improvement requires pre- and
post-project stages. Every quality improvement project, regardless of scope, will require some
investment of time and resources. Just as a contractor would do, a quality improvement team
must consider whether available resources are sufficient to complete the proposed project
scope and timeline. If the scope is too expansive or the timeline is insufficient, the project
may be doomed to fail before it starts. It is also important to consider the sociologic impacts
and safety issues ahead of time, much like a contractor would do. Thus, a great deal of pre-
planning must occur to ensure quality improvement project success.

In the post-project stage, quality improvement efforts must be ongoing to ensure long-term
sustainability of gains achieved. This is part of an organization’s continuous quality improve-
ment program. When building a house, a contractor cannot walk away as soon the home is
constructed. There are tests and several rounds of walk-throughs with code inspectors to
ensure everything is in working order and up to city standards. The same principle can be
applied to quality improvement. There should be continuous monitoring of progress and fine-
tuning of quality even after desired improvements are put in place.

Lastly, even after a home is sold and occupied it is possible that additional issues (i.e., plumb-
ing, electrical) may arise over the long term, prompting the need for additional attention.
These types of issues are bound to occur over the lifetime of any home and a contractor would
need to revisit the situation and help resolve it. The same is true of quality improvement
efforts in healthcare organizations. The task of quality improvement never really ends and
remains a continuous process over the lifetime of the organization as its members strive for
effective, efficient, safe, patient-centered care. This chapter will review some of the pre- and
post-planning efforts that must be part of every quality improvement effort.

8.1 Decision-Making Considerations
Quality improvement efforts are intended to lead to change and significantly impact the day-
to-day operations and interactions in a healthcare setting. This includes the obvious and
intended effects of improving a current process or service, but it is also important to con-
sider the spillover effects, which are less obvious and possibly unintended impacts from a
sociologic, economic, or safety viewpoint. Prior to embarking on a new quality improvement
initiative, it is important for the team to closely consider the risks and benefits of proposed
changes, which are unique to each project.

There are a number of decision-making models that healthcare organizations can use. One is
a 10-step process that includes the following steps (Hammond, Keeney, & Raifa, 1999):

1. Identify problems. Collect and analyze facts of what, where, when, how, who, and
why (i.e., 6Ws). Describe the impact of a do-nothing approach. Quantify priority and
impact of the problem using decision support information.

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Section 8.1 Decision-Making Considerations

Stockbyte/Thinkstock

Cost effective means demonstrating that a
substantial improvement can be achieved relative
to the associated cost or with little costs, such as
using trained nurses, instead of pharmacists, who
will call to remind patients about the importance of
medication compliance.

2. Define objectives. Prioritize potential for improvement in qualitative and quantitative
terms. Determine 6Ws. Make them realistic, understandable, measurable, behav-
ioral, and achievable (RUMBA).

3. Identify alternatives. Be creative and exhaustive. Define the 6Ws and the contribu-
tions to the objectives. Consider benchmarking or comparison to another business
entity. Consider economic and legal implications. Define costs and feasibility of each
alternative, using decision support information.

4. Understand consequences. Clearly understand the pros and cons of each alterna-
tive identified. Decision support systems may help with micro simulation and mock
scenario outcomes. Establish potential implementation and problem solving time
frames.

5. Assess tradeoffs. Determine the give and take of decision making. Identify the win-
ners and losers in a decision process.

6. Clarify uncertainty. Identify the possibilities of changes in the basis of which a deci-
sion was made. Decision support systems to identify “what if ” scenarios may help.

7. Identify risk tolerance. Determine the amount of, or willingness to take, risks. Avoid
common pitfalls of decision making. Try to share risk or seek risk-reducing decision
support information.

8. Consider linked decisions. Consider how one decision may affect other decisions or
require other decisions to be made. Look at the problem history or healthcare trends
that may affect the process.

9. Evaluate and choose an alternative. Based on steps 2 through 8, it must remedy the
problem and remain consistent with mission statements, philosophy, and organiza-
tional policies.

10. Implement the decision. Follow up on the results and degree of goal achievement.
Reorganize, reverse, replace, or revise any lack of problem solution. Hold your gains.

Economic Impacts
Economic impacts of quality improve-
ment projects are important to appre-
ciate in current times. Rising medical
costs remain a national concern and
many healthcare organizations are
struggling to decrease medical costs
of care (Porter & Lee, 2013). Thus, the
quest to improve quality in healthcare
must go hand-in-hand with consider-
ation of all associated costs.

For feasibility and sustainability over
the long term, a quality improvement
project must either be cost saving
or cost effective. Cost saving means
demonstrating that money can be
saved over the long term. Cost effec-
tive means demonstrating that a sub-
stantial improvement can be achieved
relative to the associated cost or with

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Section 8.1 Decision-Making Considerations

little costs. For example, one way to determine whether a quality improvement initiative is
cost effective is to weigh the expected gain against the associated cost. For example, one way
for a nursing home to help prevent resident falls is to install a new lighting system for all
bathrooms that automatically turns on when the door is opened. Purchasing the lighting sys-
tem will cost money, but will make the facility safer for residents. On the other hand, hiring
a round-the-clock monitor for each patient at risk for falls is expensive and not sustainable
over the long-term. Consider an example in an outpatient medical clinic where the goal is
to improve blood pressure control among patients with high blood pressure or hyperten-
sion. It’s estimated that 67 million Americans have high blood pressure and only half of them
have their condition under control (CDC, 2014a). Yet high blood pressure contributes to over
360,000 deaths each year in the United States. The National Committee for Quality Assurance
(NCQA) developed Healthcare Effectiveness Data and Information Set (HEDIS) to measure the
performance in care and service of health insurance plans and included a measure to deter-
mine whether blood pressure is controlled in patients ages 18 to 65 with a diagnosis of hyper-
tension. According to a February 2014 report, only 64% of adult patients with diagnosed high
blood pressure who are enrolled in HEDIS-reporting health plans had documentation that
their blood pressure was controlled (CDC, 2014b). It is no wonder that healthcare organiza-
tions are working to improve. An outpatient medical clinic’s quality improvement team may
consider a variety of initiatives but may not have the resources to implement more than one
initiative per year. Choosing the measure that would have the most impact on patient health
and at the same time be the most cost effective initiative would be one way to decide among
the list of possible interventions.

One intervention that has shown promise is involving nurses or pharmacists to follow up
with patients on their treatment plans. For example, pharmacists at the medical clinic may
call patients to remind them of the importance of taking their high blood pressure medica-
tion. This may prompt more patients to take their medication as prescribed, but it comes with
added costs of hiring and maintaining pharmacists in the clinic. Pharmacists typically com-
mand high salaries. Therefore, the clinic may consider less costly options: training individu-
als with a different medical degree and with enough medical background to review medica-
tions, such as nurses, or automating the process by using recorded messages or sending text
messages.

Nurses, for example, could make the same type of reminder phone call, but at a lower wage
than pharmacists, which would be more cost effective. Therefore, if both options were thought
to improve blood pressure control and medication compliance to a similar degree, it would be
most logical to choose the more cost-effective method.

In summary, some key questions regarding economic issues include:

• What is the cost of proposed change(s)?
• Does the cost change over time?
• Is there a way to lower cost while achieving the same outcome?
• Is this change cost effective or cost saving while achieving the same outcome?

In order to answer these questions, it is important to have a budget and detailed overview of
project finances as a team is making decisions. Examples of items that must be included in a
budget are costs for salaries, training, IT/computer systems, and supplies/materials needed

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Section 8.1 Decision-Making Considerations

to support proposed quality improvement changes. As noted in Chapter 7, many quality
improvement teams in large healthcare organizations include financial analysts to help with
these types of decisions.

Sociologic Impacts
In addition to economic impacts, it is also important to consider the sociologic impact of qual-
ity improvement initiatives. Examples of sociologic effects include how proposed changes
might affect the culture of the organization, the well-being and satisfaction of staff, and the
interaction among staff members. A particular solution, although improving a process or ser-
vice, can have a negative impact on staff satisfaction or well-being.

Consider an example in an outpatient medical clinic where the goal is to improve patient wait
times. A proposed change could include increasing the work hours of the clinic physicians
by adding mandatory weekend shifts. Clinic staff may prefer the traditional Monday through
Friday hours and resent being forced to work on weekends, leading to unanticipated negative
impacts, such as poor morale. This may result in increased conflict in the work setting (i.e.,
if there is disagreement on coverage of holiday shifts) or increased staff turnover. Ironically,
this could also negatively impact patient wait times if the clinic were to become short-staffed
because of turnover. Thus, it is important to consider the social impact of proposed changes
over the short and long term.

Another example of sociologic impact may involve the need to eliminate employee jobs while
making a process more efficient. If a process is automated, then the number of employees
required to complete the work may be reduced. This reduction may lead to cost savings and
increased efficiency but can significantly impact the social system, or group of employees,
within the organization. Will other employees fear for their jobs? Will they resent managers
for laying off their colleagues? Will they feel the hospital administration cares only about
money and not its workers?

Safety and Ethical Issues
In addition to economic and sociologic impacts, it is critical that quality improvement teams
closely consider safety and ethical issues prior to initiating proposed changes. This is particu-
larly true in healthcare systems where patients’ lives are at risk. Consider the previous exam-
ple in which physician work hours are increased to reduce patient wait times. If physician
work hours are increased so much that they become more fatigued and work continuously
without intermittent days off, the likelihood of medical errors may increase. Thus, it would be
important to consider how physician hours can be increased within reason, or alternatively, if
new physicians can be hired to cover the additional after-hours or weekend shifts.

Additional examples of safety issues could include:

• Safe deployment of new systems: a new automated medication order entry system
would need additional checks in place before it can go live through a health system.

• Data security issues: ensuring patient privacy is of utmost concern and will have
legal implications if data is not properly stored and transmitted.

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Section 8.1 Decision-Making Considerations

The consideration of ethical issues is also important to keep in mind when conducting quality
improvement work. Ethical issues focus on moral behavior and concepts of right and wrong.
For example, ethical concerns can arise when quality improvement efforts result in any of the
following: 1) harm to patients, staff, or resources; 2) unfair or inequitable care (i.e., a certain
group or type of patients receiving benefit over others); or 3) an increase in the self-interest
of the healthcare provider or organization (as opposed to the interest of the patients) (Nelson
& Gardent, 2008). Most large healthcare organizations have an institutional review board
(IRB) or an ethics committee that can resolve any potential ethical issues or concerns that
may arise (Nelson & Gardent, 2008).

Quality improvement does not occur in a vacuum. It is important that both anticipated and
unanticipated ramifications of proposed changes are considered. The risks versus the ben-
efits of each potential initiative must be weighed carefully so that quality improvement teams
can identify the most appropriate initiative.

The Patient Voice
An emphasis on patient-centered care, or care that is focused on the needs of the patient,
and a decision-making process that involves patients and families, is also important (Barry &
Edgman-Levitan, 2012).

In almost all instances, having the patient voice included in the decision-making process
helps ensure that proposed initiatives are appropriate. Patients bring a unique and critical
perspective to the decision-making process because they ultimately have the most at stake
when healthcare organizations consider change. In many hospitals, patient advisory boards
are used to guide quality improvement work. Patient volunteers can also be part of a quality
improvement project team.

Consider, for example, a pediatric unit that provides care to very ill children. There is a great
deal of anxiety that parents feel when their child is admitted to a hospital. Physicians and
nurses are aware of this, but parents who have had ill children have lived through the experi-
ence and may be in the best position to suggest areas for needed improvement. The input of
parents can guide hospital staff as they think through issues such as facilitating the admis-
sion process and decreasing the anxiety parents experience. The overall goal of ensuring
higher quality care is one of the main areas of emphasis in patient-centered care.

Patient-centered healthcare organizations are adopting various practices to respond to the
needs and preferences expressed by patients and their families. The idea of a patient-centered
culture is to try to satisfy what patients are looking for in their healthcare experience.

One component is the environment of care itself. Patients often enter the doors of a healthcare
facility with heightened feelings of stress, anxiety, and vulnerability. What they find inside can
help allay or exacerbate those emotions. Is there a desk manned by a friendly person who can
direct them to the laboratory or mammography center? Is the facility clean and safe? Does the
physical arrangement help guard patient privacy?

Take, for instance, the fact that many patient-centered hospitals have rid themselves of clut-
tered corridors. They’ve created solutions (storage areas at the end of hallways or little used
closets) to remove clutter and improve patient safety. It’s not only aesthetics at work here.

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Section 8.2 The Importance of Communication and Teamwork

One of the most frequently cited standards in Joint Commission surveys is a life safety code
standard that requires hospitals to maintain the integrity of the means of exit. The fear is that
medical equipment will block corridors in a fire or emergency, making it difficult to evacuate
patients in beds and wheelchairs and putting lives in danger.

Questions to Consider

1. You are leading a quality improvement initiative to decrease emergency room wait
times. A detailed analysis of the current state and extensive discussion with the emer-
gency room staff has led to two proposed initiatives, but hospital leadership has asked
you to choose the best option. What are some things to consider in making this type of
decision?

2. The team ultimately decides one of the key solutions to reducing wait times in the emer-
gency department is to accelerate the receipt of laboratory results. If physicians don’t
have to wait as long for lab results, they can diagnose patients and either send them
home or admit them into the hospital. This will free up beds for other patients waiting
to be seen in the emergency department. What are some of the economic, sociologic,
and safety issues surrounding the decision to ensure staff members receive lab results
in a more timely manner?

8.2 The Importance of Communication and Teamwork
The overwhelming majority of quality improvement work is conducted by groups of people
who come together to work on a specific project. These are often referred to as interdisci-
plinary teams. Multiple healthcare professionals, administrative personnel, and people inter-
ested in an issue who volunteer are often represented on these teams. Anytime collaboration
occurs, there are two elements that can significantly impact the success of the group project.
These elements involve how information is exchanged among group members (communica-
tion) and the cohesiveness of the group as a whole (teamwork).

When teams come together, they typically go through a number of stages, which are some-
times referred to as form, storm, norm, and perform. In the initial stage, forming happens
when people first come together. This is the typical “honeymoon” period, where people are
initially polite, finding out about one another and the work they will focus on. It’s important
to introduce people to each other and ensure people who are naturally quiet are included.
The next phase, storm, can occur as the initial politeness wears off, people get more into the
work of the team, and start to argue. There may be more than one person who wants to lead
the group and asserts dominance. It’s important to resolve differences that can splinter the
team. A third phase is the group norm. Roles and personal conflicts are sorted out and people
focus on the task at hand. Feeling they are a team, people help one another more. The last
phase is perform, in which the team reaches an optimal level of performance.

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Section 8.2 The Importance of Communication and Teamwork

Communication
Communication is the way in which individuals exchange information. Communicating effec-
tively with patients and families is critical in providing quality healthcare. It’s considered a
cornerstone of the patient-centered care discussed earlier. Patients need to understand their
health problems and treatment options, know what medications they are being prescribed,
and understand any follow-up instructions. Patients should feel free to ask questions about
their care and feel that they have a firm grasp of what’s going on with their health.

In medicine, ineffective or inaccu-
rate information exchange about a
patient’s medical case may result in
serious injury or even death. During
an average four-day hospital stay, a
patient may see as many as 50 differ-
ent healthcare staff members, includ-
ing physicians, nurses, and technicians
(O’Daniel & Rosenstein, 2008). It is
important for staff to communicate
information to patients about their
condition, lab results, and tests.

It is important to appreciate that com-
munication extends beyond words or
verbal exchanges. People can use a
combination of words, sounds, signs,
or nonverbal behaviors to communi-
cate with others. In fact, the majority of

information exchange depends heavily on nonverbal cues, tone, and body language (O’Daniel
& Rosenstein, 2008). This is true between staff and patients. Does a physician give a patient
her full attention or is she distracted? Does a nurse make eye contact and seem receptive to
questions from a patient?

Communication is also a key to effective multidisciplinary quality improvement teams. Team
members must be able to agree on goals and tackle the tasks at hand. After developing initial
trust, team members must be comfortable expressing their differing opinions and challeng-
ing others when they don’t agree. It’s important, however, that team members aren’t unpleas-
ant and unprofessional. Team members must be able to resolve their differences and allow
everyone on the team to participate in the decision-making process. It’s important everyone
feels they can express their opinions and views.

Teamwork
Teamwork is also a critical component of both medical care and quality improvement activi-
ties. All improvement methodologies require that a group of individuals come together to
work on a quality improvement project. For example, if an organization uses the Six Sigma
method (described in Chapter 7), the team may consist of one or more Six Sigma Black Belts

iStock/Thinkstock

It is critical that effective communication take place
between the patient and all of the health providers
she interacts with.

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Section 8.2 The Importance of Communication and Teamwork

or experts and one or more Six Sigma Green Belts working closely with a group of provid-
ers at the front line (i.e., physicians, nurses, technicians, etc.). Applying lean methodology
(described in Chapter 7), the team may consist of a group of front line providers who have
come together for a Kaizen event, where the team will collaborate on an improvement project.

Or a healthcare organization may not use one of these particular methodologies. It may
decide that it wants to pull together a quality improvement team to address a specific prob-
lem and includes a variety of people who can help come up with solutions. Members of the
team depend on the issue at hand.

For instance, a hospital decides it wants to integrate traditional social work functions with
the case management department so it can improve discharge planning for patients ready to
leave the hospital. As with most changes, initiating such a merger comes with challenges. The
hospital forms a broad-based committee that includes supervisors, as well as case managers,
who are typically registered nurses, and social workers. It also includes “transitions of care”
staff who help patients plan for discharge from the hospital and representatives from outside
agencies from the community who collaborate with the hospital to ensure patients have the
services they need when they get home. It includes the medical director and hospital leaders,
including the chief medical officer.

In each of these quality improvement scenarios, communication and teamwork are key pre-
dictors of ultimate success.

If group members do not communicate effectively about data regarding the current situation,
it could lead to an inability to identify the true problem(s), the associated root causes, and
the ultimate solution. For example, in the case of combining social work and case manage-
ment into one department, the team should look at the facility’s average daily patient census,
payer mix, demographics, and emergency department use. What is the right mix in terms of
the number of social workers and case managers that are needed in the facility? A hospital
with a high number of low-income patients may need more social workers. A facility with
many elderly patients on Medicare may need an equal number of case managers to deal with
medically complex cases and social workers to provide frail elderly patients with community
resources when they are discharged from the hospital.

Additionally, if the group members are unable to work cohesively, as a team, toward a com-
mon solution for the problem at hand, it is unlikely that the project will be completed success-
fully (O’Daniel & Rosenstein, 2008). For instance, the last thing a hospital trying to merge two
departments wants to do is create a battleground between its social workers and case manag-
ers. It’s important to bring all parties together to fairly determine the new roles of both social
workers and case managers. Ultimately, many staff members will see their responsibilities
change, and they must integrate new team members and allow them to take on new duties.
The importance of teamwork is heavily emphasized in quality improvement methodologies
for these reasons.

A list of components of successful teamwork for quality improvement activities include
(O’Daniel & Rosenstein, 2008):

• Open and effective communication;
• Non-punitive environment/avoidance of the blame game;

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Section 8.2 The Importance of Communication and Teamwork

• Clear and known roles and tasks for group members;
• Appropriate balance of member participation for the task at hand;
• Respectful atmosphere;
• A common goal or direction;
• Acknowledgment and processing of conflict;
• Clear and known decision-making procedures; and
• Regular and routine communication and information sharing.

Different quality improvement projects will require various team members and range from
smaller groups of 1–2 individuals to very large groups of 10 or more members. It’s worth-
while to mention that larger teams may not always lead to speedier project completion. This
is highlighted by the Mythical Man Month analogy, which states that certain tasks can’t be
divided (i.e., they must occur sequentially) so bringing on additional team members does not
always add speed (Kim, 2013). In fact, team dynamics may be more complicated as the size
and personalities of team members increase.

In this and prior chapters, the importance of communication has been emphasized in great
detail. In Chapter 7, the importance of a non-punitive organizational culture and avoidance
of the traditional “blame-game,” or tendency to identify and punish one individual for a par-
ticular error, was also discussed. Clear roles/tasks and balanced participation are also high-
lighted by Six Sigma (e.g., Black Belt levels) and lean (e.g., identification of team leaders and
clear assignment of medical staff to a Kaizen event for one week as opposed to routine clini-
cal duties). A respectful atmosphere and unifying goal are also key components of quality
improvement activities, and explicitly discussed as part of lean methodology in Chapter 7.

The acknowledgment and attempted resolution of any conflict, clear procedures for making
decisions, and routine communication are also just as critical to the success of any quality
improvement project. Effective group meetings should include all three of these additional
components of teamwork. In order to have an effective quality improvement team meeting,
it is important to set an agenda for the session; designate member roles, such as who will
take minutes; agree on how decisions will be reached; document action items or to-dos; and
assure that all members are heard and can play a role in overall project progress (Langley et
al., 2009). In other words, effective meetings are those in which decision making follows a
delineated process and includes several previously agreed upon steps, providing an avenue
for identification and resolution of conflict.

Communication and teamwork are critical to any and all quality improvement projects. As
such, quality improvement methods emphasize the importance of both as integral to the suc-
cess of all quality improvement efforts.

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Section 8.3 Adapting to Change

8.3 Adapting to Change
Innate to the study and improvement of processes is the need to make change. Understanding
and appreciating the human side of change is critical in quality improvement. According to
experts, the human side of change helps us understand the motivations of people, how they
interact with one another, and how they will react to a specific change in order to gain com-
mitment (Langley et al., 2009). Change usually elicits some kind of reaction, ranging from total
agreement to animosity (Langley et al., 2009). In many situations, change can feel uncomfort-
able and may be unwelcomed despite the promise that it will lead to improvements in quality.

Consider the case of a hospital pharmacy responsible for processing all inpatient medication
orders. A quality improvement project focused on increasing the efficiency by which pre-
scriptions are filled may lead to changes in the day-to-day pharmacy operations, such as the
order and nature of tasks handled by the pharmacists. Steps the pharmacists routinely fol-
lowed may be removed or a series of new steps may be added. The new flow in pharmacy
operations will feel foreign to the pharmacy staff and possibly even uncomfortable. Although
the pharmacists might appreciate the need to improve efficiency, they are also bound to have
a range of reactions to the changes taking place. Thus, preparing the pharmacists for upcom-
ing change will be critical to the success of this quality improvement project.

The acceptance and commitment to change is critical to the ultimate success of any given
quality improvement project. If employees on the front lines do not embrace the proposed
change(s), the quality improvement initiative is unlikely to impact day-to-day operations and
lead to improvement.

Committing to Change
To help employees commit to change more readily, organizations should: 1) inform employees
why change is needed, 2) include them in the way change is created, and 3) notify them of the
progress being made after the change (Langley et al., 2009). The first concept involves letting
employees know why change is needed so they can understand why a quality improvement
project is going to take place. It is important to do this as soon as possible—even before the

Questions to Consider

1. In communicating with patients and their family members, it’s important to establish a
connection. Providers can fail to do that when they do not truly listen to a patient before
responding, don’t introduce themselves to a patient, or don’t acknowledge the patient
by name. Can you think of other ways that providers fail to establish communication?
Can you establish some guidelines to assist caregivers in establishing effective commu-
nication?

2. When a team collaborates on a quality improvement, it is conceivable that conflicts
may arise among group members. Consider a scenario where two team members have
identified two potential solutions for the problem at hand. What are some components
of effective teamwork in resolving this type of conflict in the context of ongoing quality
improvement activities?

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Section 8.3 Adapting to Change

quality improvement project team is fully assembled. This way, employees will appreciate why
a change is taking place and have as much time as possible to get used to the idea of change.

In the case of the hospital merging its social work and case management departments, staff
members should know why this change is critical to the organization. It may help to explain
that while many hospitals have traditionally separated the two functions, there is a strong
movement in the case management field toward a collaborative model that recognizes the
partnership of social work and nursing. The change will allow the hospital to use resources
more effectively and meet its goals and objectives, such as improving length of stay numbers,
reducing readmissions, and increasing patient flow by increasing patient capacity.

Including employees in the way change is created can range from asking for their input about
a particular step in a process to asking for their participation as a full member of the quality
improvement project team. The importance of engaging all employees within the organiza-
tion in quality improvement activities was discussed in the context of both Six Sigma and lean
methodologies.

Gathering input from those who will be most affected by change, such as the pharmacists
in the previous example, is critical for several reasons. First, the pharmacists have the best
understanding of the pharmacy workflow. Their input would therefore provide the most
relevant opportunities for making improvements and identifying what problems they expe-
rience with existing processes. A project team that does not have a solid understanding of
the existing pharmacy system may create a solution that is difficult to implement, possibly
leading to further inefficiencies in day-to-day operations. However, by getting input from the
pharmacists, or even including them on the project team, it is more likely that the proposed
solution(s) will be feasible on the front lines and lead to improvements in efficiency.

Once change is being tested and is in place, it is important to inform employees of the ongoing
progress. This serves several purposes. The first is a constant reminder of the common goal
that everyone is working together to achieve. This helps to decrease any continued resistance
and unify the front line staff affected by change. The second is the avoidance of reverting back
to the old way of doing things. If everyone is aware progress is being made, there is motivation
to continue with change. Lastly, updates on ongoing progress serve as a check that the team
is headed in the right direction. If the changes were not leading to the anticipated results, this
would be a signal to re-evaluate the new process and consider further adaptations until the
desired success is achieved.

For example, it is important that hospital leaders support the transition of social workers and
case managers into one department. It is well and good to plan for a change, but actual imple-
mentation may not go as anticipated. Leaders should expect the case management depart-
ment will run into obstacles when it actually starts doing the work with combined teams of
case management and social workers. It’s important to be flexible and to change processes
as needed if issues arise. Quality improvement teams should not be firmly committed to an
idea if it does not work. For example, the discharge planning process may work differently on
some hospital units. Social workers may provide more services on some units that affect their
caseload. So, the quality improvement team may not have foreseen every obstacle or may find
that what they expected to happen didn’t work in reality. It’s important that quality teams are
prepared to revise their process down the road.

fin81226_08_c08_223-246.indd 234 10/30/14 7:30 PM

Section 8.3 Adapting to Change

The cooperation of front line employees is essential to make effective change (Langley et al.,
2009). Front line employees will naturally be concerned about how the change will affect
their responsibilities, tasks, and roles within the organization. In our pharmacy example,
pharmacists may be asked to give up control of a step in the medication processing flow. It
is important for the team to recognize and deal with these concerns (Langley et al., 2009).
The quality improvement team should listen to these concerns and come up with solutions if
possible to ensure the pharmacists are not negatively impacted by the proposed changes. Per-
haps they can agree to modify pharmacy staff work hours and improve satisfaction. Or in the
case of merging social workers and case managers into one department, the hospital should
be prepared to help staff transition into their new roles.

In the 1960s, Everett Rogers, professor of communication studies, first described his Diffu-
sion of Innovation theory, which includes four main elements (Rogers, 2003):

• Innovation: the change or the new idea/practice/object
• Communication channels: how information about the innovation is spread
• Time: the rate of adoption or the speed with which adoption of an innovation occurs
• Social system: the group or related units that are involved in communication, adop-

tion, and diffusion

In this model, adoption refers to what happens at an individual level, such as when one
employee decides to accept a new process (Rogers, 2003). Diffusion, on the other hand, is
the spread of change across a group of people, or the collective decision among a group of
employees to adopt a change (Rogers, 2003).

Within a social system, there are different categories of adopters of change, which vary based
on their degree of innovativeness and speed of adoption. There are the first individuals to
adopt change, or innovators, followed by the second group of early adopters, followed by the
early majority, late majority, and finally the laggards (Rogers, 2003). The laggards are the
slowest to adopt change and need the most convincing. It is important that organizations
understand the varying degrees with which their employees may be committed to the idea of
change and willing to adopt new ideas or practices. In doing so, they can outline strategies to
help staff adopt change and spread its use more seamlessly across organizations.

It’s also important for organizations to be aware of people’s subconscious resistance to
change. The subconscious mind wants to keep a person safe and is very resistant to change.
So, even if the possibility of change consciously seems exciting and new, the subconscious
works against that, doing its utmost to keep people firmly rooted where they currently are
because it is safe and familiar. People feel the benefit of staying where they are now, even if
consciously they want to move forward and change.

Consequently, successful change agents or leaders must always create and communicate to
people what’s been referred to as WIIFMs (What’s In It For Me) in order to sustain behavioral
changes in employees. Employees who believe they will personally benefit from a change are
more likely to accept a new way of doing things.

fin81226_08_c08_223-246.indd 235 10/30/14 7:30 PM

Physiological Needs
Breathing, food, water, shelter, clothing, sleep

Safety and Security
Health, employment, property, family, and social stability

Love and Belonging
Friendship, family, intimacy, sense of connection

Self-Esteem
Confidence, achievement, respect of

others, the need to be a unique individual

Self-
Actualization

Morality, creativity,
spontaneity, acceptance,
experience, purpose,

meaning, and inner potential

Section 8.3 Adapting to Change

Motivating Behavior
When it comes to motivating behavior, including change, another well-established theory that
deserves mention is American psychologist Abraham Maslow’s hierarchy of needs (Maslow,
1943). Maslow (1943) describes a hierarchy of needs that begins with the most fundamental
needs, such as food and water, and moves up toward less tangible needs, such as esteem and
self-confidence. This hierarchy is shown in Figure 8.1.

What motivates behavior? According to Maslow, actions are motivated in order to achieve
certain needs. Fundamental needs must be met first before a person can transition to higher
level needs. This is another framework for consideration when creating and spreading change
within an organization. It is important to ensure that change does not hinder basic needs for
employees and can promote the attainment of these whenever possible. Changes that threaten
employees’ basic needs, such as work breaks and wages, or safety needs, such as job security,
seniority, or pensions, will be met with resistance.

Figure 8.1: Maslow’s hierarchy of needs

Higher order needs can only be achieved once the lower order needs have been met.

Source: Maslow, Abraham H., Frager, Robert D., & Fadiman, James. Motivation and Personality, 3rd Edition, © 1987. Printed and
electronically reproduced by permission of Pearson Education, Inc., Upper Saddle River, New Jersey.

Physiological Needs
Breathing, food, water, shelter, clothing, sleep
Safety and Security
Health, employment, property, family, and social stability
Love and Belonging
Friendship, family, intimacy, sense of connection
Self-Esteem
Confidence, achievement, respect of
others, the need to be a unique individual
Self-
Actualization
Morality, creativity,
spontaneity, acceptance,
experience, purpose,
meaning, and inner potential

fin81226_08_c08_223-246.indd 236 10/30/14 7:30 PM

Section 8.4 Continuous Use of PDSA

8.4 Continuous Use of PDSA
Plan-Do-Study-Act (PDSA) provides a framework and sequence with which quality improve-
ment can take place. The four PDSA steps were discussed in detail in Chapter 6. (Just as a
reminder, you may sometimes see this described as Plan-Do-Check-Act [PDCA]. However, as
this quality improvement model evolved it has been changed to PDSA to encourage organiza-
tions to study or analyze the information from its improvement project and determine the
success or failure of the interventions undertaken.)

With PDSA, it is unlikely that the desired improvement may be achieved in just one cycle
(Jain, 2005). It is generally the case that several back-to-back cycles of PDSA will occur before
a project is completed. In the rare instances where the desired changes are achieved in just
one cycle, it is possible that new goals or areas for further improvement will arise, requiring
additional cycles (Jain, 2005).

Social needs can include a sense of belonging in one’s relationships with others, and can be
met with participation in work groups, teamwork, and encouraging participation in the orga-
nization. Based on Maslow’s theory, once those needs are met, people can pursue the needs of
self-esteem. A worker appreciates recognition for a job well done and recognition will moti-
vate them to continue working hard for an organization. Organizations should recognize qual-
ity work in many ways, from praise in the presence of peers to promotions. Self-actualization
is the highest level in the hierarchy of needs. People are seeking personal growth and are
interested in fulfilling their potential. Organizations can do that by providing challenges and
encouraging creativity, including problem-solving and quality improvement activities.

While a change may be ultimately good for healthcare organizations and their patients, mak-
ing a change isn’t always easy for people. Healthcare organizations implementing quality
improvement projects need to make it clear why they are making changes and make efforts
to get everyone on board.

Questions to Consider

1. Consider a scenario in an outpatient clinic where an increase in patient dissatisfaction
has led to the initiation of a quality improvement project aimed at identifying the exist-
ing problems, associated root causes, and potential solutions. What are some key things
to consider when discussing the proposed project with the clinic staff ? What should be
emphasized to those most affected by the project?

2. In the example provided in Question 1, how would you a) inform the staff why change is
needed, b) include the clinic staff in the way change is created, and c) potentially notify
the clinic staff of progress being made after change?

fin81226_08_c08_223-246.indd 237 10/30/14 7:30 PM

Section 8.4 Continuous Use of PDSA

With each additional PDSA cycle, it is expected that knowledge about a particular process
will increase. Therefore, PDSA cycles are meant to occur in a repeating manner, which is also
referred to as iterative—that is, building on the knowledge gained from the previous cycle. In
fact, the “A” in PDSA, which usually stands for “Act,” is sometimes also referred to as “Adjust”
in order to illustrate the need for additional cycles. Questions to ask in the “A” step of PDSA
include:

• What have we learned from this test?
• Have we achieved the desired effect (ideal state)?
• Is there room for further improvement?
• What other changes could lead to further improvement?
• How can we spread the improvement to other areas?

Once a PDSA cycle is complete, it is important to assess what was learned and whether the
desired goals have been met. If the goals have not been met, which is usually the case after
one or two cycles, the project team will need to conduct further cycles. With each PDSA cycle,
the team should be planning and testing additional changes to move closer and closer to the
ideal desired state. When the desired goals are met, additional cycles may still be required to
spread the change. Spreading the change may entail more widespread implementation of the
initial test conducted.

Recall the pharmacy example from the previous section to help illustrate this further. Suppose
the project team plans an intervention to increase the time it takes to process medication
orders, replacing the traditional handwritten orders in the patient’s chart with a new com-
puter order entry system. Since computer programs are prone to glitches and pharmacists
need to learn how to use the new system, a small test incorporating simulated patients is an
ideal first step. If glitches in the computer order entry system are not caught and resolved
prior to widespread implementation across the entire hospital, the results could be disastrous.

If the desired effects are achieved with the small test, the next PDSA cycle could involve real
patients but only those in a small section of the hospital. An ideal choice for the test would be
a unit or floor with patients requiring less acute care. In that case, medication changes are not
likely to occur as frequently or be as urgent. Again, if the desired effects are achieved, then
testing can be expanded to an even larger section of the hospital until widespread implemen-
tation is achieved.

Once desired effects are achieved on a hospital-wide basis, additional PDSA cycles may also
be used to continually monitor progress in order to sustain quality improvement efforts. In
many instances, there is a lot of excitement, enthusiasm, and attention focused on a newly
initiated project that can eventually fade over time. In order to keep momentum and ensure
the implemented changes result in the desired effects over both the short and long term,
additional cycles are necessary.

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Section 8.5 Continuous Quality Improvement (CQI)

Questions to Consider

1. Suppose you are about to lead a quality improvement project and plan to use PDSA
cycles to improve emergency room wait times. How will you describe the PDSA process
to your team members? What should they expect when working on a PDSA project?

2. Suppose your project in Question 1 is completed after 12 PDSA cycles. Emergency room
wait times are now down to an all-time low of one hour per patient. Everyone in the
emergency room has been enthusiastic about the changes made. What will you tell your
team now? What should they expect would happen moving forward? What are some
ways to sustain the improvements implemented?

8.5 Continuous Quality Improvement (CQI)
Continuous quality improvement (CQI) is defined as a comprehensive management philoso-
phy that applies scientific methods to increase knowledge, reduce variation, and sustain con-
tinuous improvement (Tindill & Stewart, 1993). In other words, CQI philosophy states that
quality improvement never rests and should be ongoing. Thus, as soon as problems have been
identified and improved, a new cycle should begin. The new cycle incorporates the use of
analytical decision-making tools, such as Pareto charts or process control charts (described
in Chapter 7), to monitor the improved process.

CQI Steps
CQI involves several steps that can be
adapted to any of the process improve-
ment methods discussed in prior chap-
ters, including Six Sigma or lean the-
ory. As a general summary, the steps in
CQI can include the following (Kahan
& Goodstadt, 1999):

Step 1: Identify the problem.

Step 2: Define the current situ-
ation—identify major problem
areas in existing processes or day-
to-day operations.

Step 3: Analyze the problem—
identify the root causes of the
problem using charts and dia-
grams as needed.

Step 4: Develop an action plan—
outline ways to correct the root
causes of the problem and the next
specific actions needed to resolve
the problem.

Shironosov/Thinkstock

Step five of Continuous Quality Improvement (CQI)
is to examine the results—confirm that the problem
and its root causes have decreased, identify whether
the target has been met, and display results in
graphic format before and after the change.

fin81226_08_c08_223-246.indd 239 10/30/14 7:30 PM

Section 8.5 Continuous Quality Improvement (CQI)

Step 5: Examine the results—confirm the problem and its root causes have decreased,
identify whether the target has been met, and display results in graphic format before and
after the change.

Step 6: Start the cycle again—go back to the first step and use the same process to move
closer to the ideal state or address another problem.

A key feature of CQI is the detection of variation, which is the fluctuation in an existing pro-
cess or the tendency to revert back to the old system (see Chapter 7). If variation is detected,
then additional processes may be tested and put into place to sustain improvements over the
long term. Dr. Walter Shewart is credited with developing the concept of control in respect
to variation while he was working to improve quality in the Bell Telephone factories in the
1920s (Statit Software, 2007). Dr. W. Edwards Deming built on the work of Shewart and later
took these concepts to Japan, including PDSA, where he was also extremely influential (Statit
Software, 2007).

Guiding CQI Efforts
Several key questions can be continually asked to guide CQI activities. The first involves an
assessment of the current state: “How is this process/service doing?” By using analytic meth-
ods, it is possible to gather detailed information on how things are going. Once an assess-
ment of the current state is conducted, it is possible to ask several other follow-up questions,
including:

• Can this be more effective?
• Can this be faster?
• Can this be done with less cost?
• Can this be better?

Consider the pharmacy example discussed earlier, and assume that initial tests and subse-
quent larger trials were conducted, leading to hospital-wide implementation of the new com-
puterized medication order entry system. The first step in CQI would be continued monitor-
ing once the new system is in place. For example, it would be important to know the average
turnaround time for a medication order in the new system. By tracking the average time from
when a physician entered an order in the system to the delivery of the medication, the quality
improvement team would have a measure of process efficiency that could be used as a bench-
mark moving forward.

By charting the times in a statistical process control chart, the quality improvement team
would have a visual representation of this information and allow for rapid identification of
any variations in the process. Does the chart show times have decreased since the new system
was put in place? The turnaround time for all medications ordered could be averaged and
plotted on a daily basis. Significant trends in turnaround times would be easy to detect. The
team could also continually ask if there are additional ways to improve the process once the
desired state has been achieved.

fin81226_08_c08_223-246.indd 240 10/30/14 7:30 PM

1

LCL = 18.410

15

20

25

30

35

40

45

Average days, positive mammogram to definitive biopsy, control chart

Week
Avg Delay

1
34

2
30

3
35

4
32

5
28

6
26

7
29

8
28

9
35

10
26

11
34

12
31

13
28

14
40

15
26

16
32

17
31

18
30

19
33

20
35

21
26

22
19

23
21

24
23

25
25

26
17

27
21

28
22

29
21

30
17

31
23

32
22

33
24

34
19

35
20

36
21

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

UCL = 43.890

Benchmark

Mean = 31.190

LCL = 12.980

UCL = 29.650

Note the Improvements

Mean =
21.313

Section 8.5 Continuous Quality Improvement (CQI)

An example of a statistical process control chart, showing the turnaround from the time a
suspicious spot was found on a woman’s mammogram test to a follow-up biopsy to determine
whether she has breast cancer, is provided in Figure 8.2. Here, the quality improvement effort
was aimed at decreasing the average delay in time to biopsy after a mammogram showed a
concern for possible breast cancer. The average turnaround time was plotted in weekly incre-
ments for patients who received mammograms. Significant decreases in turnaround times
are detected after week 20, when the quality improvement initiative had begun. This bench-
mark is continually assessed to ensure the gains from the quality improvement initiative are
sustained.

It is important to note that CQI data analysis and feedback is meant to occur in real time.

As illustrated by the examples provided, it would not make much sense to implement a new
system and then wait one or two years before understanding whether this has led to improve-
ments. In the pharmacy example, it would be important for hospital leadership and front
line providers to know as soon as possible whether the new order entry system is improving
efficiency. If it is not working as anticipated, then further refinements must be made. Waiting
extended periods of time or retrospectively collecting data would delay the ability to achieve
the desired state within a reasonable time frame.

Figure 8.2: Sample statistical process control chart

Process control charts allow desired benchmarks (in this case, time from abnormal mammogram to
biopsy) to be continually assessed to ensure the gains from the quality improvement initiative are
sustained.

Source: From “Improving Healthcare with Control Charts” by Raymond G. Carey, PhD. Reprinted by permission

1
LCL = 18.410
15
20
25
30
35
40
45
Average days, positive mammogram to definitive biopsy, control chart
Week
Avg Delay
1
34
2
30
3
35
4
32
5
28
6
26
7
29
8
28
9
35
10
26
11
34
12
31
13
28
14
40
15
26
16
32
17
31
18
30
19
33
20
35
21
26
22
19
23
21
24
23
25
25
26
17
27
21
28
22
29
21
30
17
31
23
32
22
33
24
34
19
35
20
36
21
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
UCL = 43.890
Benchmark
Mean = 31.190
LCL = 12.980
UCL = 29.650
Note the Improvements
Mean =
21.313

fin81226_08_c08_223-246.indd 241 10/30/14 7:30 PM

Section 8.6 An Online Presence and Social Media

CQI can be adapted to a variety of quality improvement methodologies. In fact, the concepts
of continual improvement and use of analytic methods are embedded in PDSA, Six Sigma, and
lean methodologies. Thus, CQI is easily added and in many ways already incorporated in the
core concepts of existing quality improvement methodologies.

Questions to Consider

1. You recently led a quality improvement initiative to decrease wait times in the emer-
gency room. With the input of emergency room providers, your team tested and ulti-
mately implemented a new patient triage system that fast tracks urgent or emergent
cases (such as possible heart attacks or strokes) to physicians while common, everyday
conditions (such as flu-like symptoms or minor cuts/wounds) are seen by newly hired
physician assistants. What type of information should be collected to understand if the
new system is working?

2. What are some additional questions your team might want to consider in the first few
months after the new triage system is in place?

8.6 An Online Presence and Social Media
Online media allows the spread of information about healthcare organizations—both good
and bad. You’ve heard the expression “blow your own horn”; when it comes to their quality
improvement efforts, some healthcare organizations are doing just that. With people across
the globe increasingly using the Internet and social media websites, including blogs and social
networking sites such as Facebook, Twitter, and YouTube, for business and personal commu-
nications, more and more healthcare organizations are jumping on the bandwagon.

After all, if healthcare organizations are using quality improvement for steps such as reducing
resident falls, avoiding medication errors, or reducing surgical site infections, why hide the
good news under a barrel? Healthcare organizations are sharing their successes with patients
and potential future customers. Social media is a way for users to participate in communica-
tion forums that reach many people. In fact, hundreds of U.S. hospitals are now using social
networking tools, with numbers increasing dramatically. Hospitals have their own websites
and are finding social media is too difficult to ignore.

Healthcare organizations can use social media to reach out to patients with information about
their programs and also to educate patients about healthcare issues. Social media also pro-
vides a way for consumers to bring a great deal of attention to healthcare issues, both pro and
con. They may have good things to say about their care at a healthcare organization. On the
flip side, they can also bring attention to poor quality, which can adversely affect an organiza-
tion’s reputation.

fin81226_08_c08_223-246.indd 242 10/30/14 7:30 PM

Summary & Resources

One caveat for all healthcare organizations is that they must keep medical information of
patients confidential, which is a requirement of the Health Insurance Portability and Account-
ability Act (HIPAA) regulations. Healthcare organizations must ensure that patients’ health
information and pictures are not posted on the Internet without permission. They need to
caution staff members about the dangers of blogging about a patient they have cared for if
that information allows the patient to be identified.

But despite those concerns, healthcare organizations are using social media for marketing,
including connecting with patients about the quality improvement taking place within their
walls. The Mayo Clinic, which has been a leader in the use of social media, has established a
Center for Social Media, which helps other healthcare organizations adopt and explore social
media tools.

Questions to Consider

1. How might you use social media to spread the word about a quality improvement proj-
ect you have just led?

2. What type of information should you share on social media? Is there information you
should not publicize?

Summary & Resources

Chapter Summary
This chapter reviewed the pre- and post-project efforts that must be part of all quality
improvement activities. In the pre-project phase, it is important to consider the economic,
sociologic, and safety impacts a project may have. The risks versus benefits of each project
and associated solutions must be weighed carefully. The project scope and timeline must
align with available resources. Effective communication and teamwork are also necessary to
move the project forward smoothly. It is important to keep the lines of communication open
among the team members and between the team and the rest of the organization. Preparing
the organization for upcoming change is critical to help everyone adapt and move forward in
unison. Once a project achieves the desired state, continuous monitoring is needed to ensure
these gains can be sustained. Quality improvement never really ends and should be consid-
ered a continuous process. Social media is a new way for organizations to share the progress
made in improving patient care through their quality improvement efforts.

Mini Case Study
If it takes a village to raise a child, it takes more than physicians and nurses to make a hos-
pital. A hospital must ensure the quality and delivery of a range of services that include feed-
ing patients and employees; managing the facility; transporting patients; maintaining clini-
cal equipment; safeguarding the facility; and providing a clean, comfortable environment.

fin81226_08_c08_223-246.indd 243 10/30/14 7:30 PM

Summary & Resources

Consider the role that a hospital’s safety officer and facility management play in ensuring
patient satisfaction. Facility department staff undertake all kinds of jobs, from changing light
bulbs to unclogging toilets and cleaning rooms—all tasks needed to maintain a safe and
comfortable environment. But just what role does facility management play in improving
the quality of patient care?

When the hospital where he worked as the safety officer launched an initiative to improve
hand hygiene, Joe Thomas didn’t see how his department would be involved. However,
the facility department staff played a role. Caregivers need to wash their hands every time
before they touch a patient or they increase the risk for hospital-associated infections.
However, if the sink in the room is broken, caregivers might skip washing their hands or
instead go into the next room to wash their hands, which can increase the risk of cross-
contamination if germs from one patient are spread to another. Therefore, Joe and the main-
tenance staff committed to fixing sinks throughout the facility within 24 hours of receiving a
work order for a repair. The facility management department has tracked performance and
found that 97% of sinks are fixed within 24 hours of a report.

Discussion Questions

1. What are some ways non-clinical staff can contribute to improving patient care?
What are some of the most important contributions various departments make to
patient care? What role can those departments play in improving quality?

2. What other ways can the facility maintenance department help improve quality?

Key Terms

adoption Accepting change at an individual
level, such as when one employee decides to
adopt a new process.

communication channels How informa-
tion about the innovation is spread.

continuous PDSA Several back-to-back
PDSA cycles to move from the present situa-
tion to the ideal future situation.

cost effective Demonstrating that a sub-
stantial improvement can be achieved rela-
tive to the associated cost or with little cost.

cost saving Demonstrating that money can
be saved over the long term.

diffusion The spread of change across a
group of people, or the collective decision
among a group of employees to adopt a
change.

innovation The change; the new idea/
practice/object.

social system The group or related units
that are involved in communication, adop-
tion, and diffusion.

time The rate of adoption or the speed with
which adoption of an innovation occurs.

variation Fluctuation in an existing process
or the tendency to revert back to the old
system.

fin81226_08_c08_223-246.indd 244 10/30/14 7:30 PM

Summary & Resources

Critical Thinking Questions

1. You have been assigned to lead a quality improvement effort on the inpatient oncol-
ogy ward. One of the main goals is to improve the efficiency with which the medical
team evaluates and manages ongoing medical issues. Ideally, this effort should help
decrease patient length of hospital stay, which may also result in cost savings for the
hospital. What are some social and ethical considerations that might be relevant to
this case?

2. What are the benefits of conducting quality improvement activities in a continuous
fashion? What are the downsides, if any?

3. In what ways do the concepts discussed in this chapter, such as PDSA and CQI, over-
lap with methodologies, such as lean or Six Sigma, covered in a prior chapter? Are
there notable differences?

Suggested Websites

• U.S. Department of Health and Human Services (HHS):
https://www.childwelfare.gov/management/reform/soc/communicate/initiative
/soctoolkits/cqi.cfm#phase=pre-planning
This website provides a review of Continuous Quality Improvement.

• Agency for Healthcare Research and Quality (AHRQ):
http://www.ahrq.gov/
This website provides information on evidence to make healthcare safer, higher
quality, more accessible, equitable, and affordable.

• National Center for Biotechnology Information (NCBI):
http://www.ncbi.nlm.nih.gov/books/NBK2651/
This website includes a 51-chapter book on quality improvement in the healthcare
setting [Hughes, R. G. (Ed.). (2008, March). Patient safety and quality: An evidence-
based handbook for nurses (Prepared with support from the Robert Wood Johnson
Foundation; AHRQ Publication No. 08-0043). Rockville, MD: Agency for Healthcare
Research and Quality.].

• Robert Wood Johnson Foundation:
http://www.rwjf.org/en/research-publications/research-features/evaluating-CQI.html
This website describes the Robert Wood Johnson Foundation, which has worked to
improve the health and healthcare of all Americans, including information on the
Science of Continuous Quality Improvement.

• Communication Theory:

Shannon and Weaver Model of Communication

This website reviews the Shannon and Weaver Model of Communication.

• Business Communication Answers:
http://www.answers.com/Q/Shannon_weaver_model_of_communication
This website includes information on the Shannon and Weaver Model of
Communication.

fin81226_08_c08_223-246.indd 245 10/30/14 7:30 PM

https://www.childwelfare.gov/management/reform/soc/communicate/initiative/soctoolkits/cqi.cfm#phase=pre-planning

https://www.childwelfare.gov/management/reform/soc/communicate/initiative/soctoolkits/cqi.cfm#phase=pre-planning

http://www.ahrq.gov/

http://www.ncbi.nlm.nih.gov/books/NBK2651/

http://www.rwjf.org/en/research-publications/research-features/evaluating-CQI.html

Shannon and Weaver Model of Communication

http://www.answers.com/Q/Shannon_weaver_model_of_communication

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