Ensuring Quality Beyond Accreditation – What Hospitals Need to Do to Stay One Step Ahead?

Ensuring Quality Beyond Accreditation – What Hospitals Need to Do to Stay One Step Ahead?

Reynaldo O. Joson, MD, MHPEd, MSc Surg

August 8, 2014

 

The scenario:

A hospital has recently been given a formal recognition of its quality management system in the form of either an award, certification or accreditation, such as ISO QMS 2001:2008; Joint Commission International (JCI); Accreditation Canada International (ACI); or a national quality award like the Philippine Quality Award (PQA); Singapore Quality Award, Thailand Quality Award, Taiwan National Quality Award, Malaysia Prime Minister’s Quality Award, Japan Quality Award, etc.

What are the commonly observed courses taken by such a hospital with regards to the quality management system program?

What should this hospital do to stay one step ahead to ensure quality beyond accreditation?

What are the commonly observed courses taken by such a hospital with regards to the quality management system program?

From my personal experience, I have observed two (2) general courses.

One course is for the hospital to just use the award, certification or accreditation for marketing purpose as long as it can until its client-attraction force wanes.  The hospital either does not go for re-certification or re-accreditation or if it does, it just tries to fulfill the minimum requirements.  This is the usual course of hospitals which just look at award, certification, and accreditation as a marketing tool.

The second course is for the hospital to elevate the bar of quality or excellence either by aiming for another quality and excellence award, certification or accreditation or for a higher or highest level, such as the diamond level in Accreditation Canada International or the national quality award.  This is the usual course of hospitals which put quality improvement and performance excellence as their primary reason for getting an award, certification or accreditation.

What should this hospital do to stay one step ahead to ensure quality beyond accreditation?

Between the two courses, no doubt the commendable and recommended would be the second one – to elevate bar to ensure quality and performance excellence beyond accreditation.  Thus, the broad answer to the question “What Hospitals Need to Do to Stay One Step Ahead in Ensuring Quality Beyond Accreditation?” is to take the second course – to elevate bar to ensure quality and performance excellence beyond accreditation.

Let me go deeper into the reasons why hospitals should take the second course – to elevate bar to ensure quality and performance excellence beyond accreditation – before I give my recommendations on how to do it.

Getting an award, certification or accreditation does not always mean that the hospital has achieved the highest level of excellence.  Most of the time, it is the minimum or lower level.

Getting an award, certification or accreditation does not mean that the hospital has reached the end of the line in the continuum of excellence.

There is absolutely no “period” at the end of the journey for excellence, always just a “comma.”  Quality is not just an end result but a continuing process or journey.

Thus, for hospitals that put more emphasis on quality improvement and performance excellence rather than on marketing for financial gain, they should go for the second course – to elevate bar to ensure quality and performance excellence beyond accreditation.

There are two other reasons why hospitals should go for the second course. One is stakeholder expectation and the other is vigilance.

Stakeholders’ expectation is higher when a hospital has achieved an award, certification or accreditation.  There is usually a higher risk and frequency of criticism and negative feedback from stakeholders particularly in hospitals being granted certification for the first time and at the lowest level of recognition at that.  The stakeholders’ threshold of tolerance for glitches and hitches in quality is now lower than before.  The following general remark is often heard: “You hospital is already ISO, PQA, JCI, ACI-certified, and yet the quality of service is still poor…..”    With a hospital getting a higher level of recognition for quality and performance excellence in the next round of assessment, though negative feedback cannot totally eliminated, the risk and frequency of criticism and negative feedback will be less. It goes without saying that a hospital being granted the highest level of recognition for quality and performance excellence will encounter least frequent negative feedback.  For these reasons, hospitals should always elevate the bar of quality and performance excellence after being granted an award, certification or accreditation.

Another reason why hospitals should go for the second course is the need for vigilance in maintenance and improvement of quality and performance excellence.  Quality now is never quality tomorrow, next week, next month, next year, and more so, forever.  Likewise, performance excellence now is never performance excellence tomorrow, next week, next month, next year, and more so, forever.

Good quality today can become poor quality tomorrow.  Performance excellence today can become poor performance tomorrow.

What contributes greatly to this lability is the unavoidable constant change of staff in the hospitals, both in quantity and quality.  The commonly seen challenge in hospitals in this regard is the fast turnover of hospital staff, particularly, the nurses, who usually constitute the majority of the workforce.  Leaders in the governance team also constantly change. Thus, leaders and followers with different levels of commitment and competency on quality and performance excellence come and go in hospitals.  This contributes to the lability, therefore, the need for vigilance in maintenance and improvement of quality and performance excellence.  The second course, that is, to elevate the bar of quality and performance excellence, is a good strategy to stay one step ahead to ensure quality beyond accreditation.

What specifically is or are my recommendations for hospitals to stay one step ahead to ensure quality beyond accreditation?

There are various courses of action, both long-term and short-term, that a hospital can take to stay one step ahead to ensure quality beyond accreditation and in particular, to elevate the bar of quality and performance excellence.  As I mentioned earlier, a hospital can either go for another quality and excellence award, certification or accreditation or for a higher or highest level, such as the diamond level in Accreditation Canada International or the national quality award.

I like to add another course of action which I consider to be the grandest in the sense that it will subsume the two courses of action that I mentioned earlier and it can produce steadfast results in terms of ensuring quality beyond accreditation.

My specific recommendation is for the hospital to establish a program that aims for the development of an organizational culture of quality and performance excellence.

What is an organizational culture of quality and performance excellence? It is the consistent observable demonstration of patterns of behavior (norms) of all hospital staff, inclusive of leaders and followers, on quality and performance excellence. This concept of culture is reflected in the simple aphorism of Aristotle: “We are what we repeatedly do.”  Thus, a hospital having developed a culture of quality and performance excellence will surely be able to steadfastly ensure quality beyond accreditation.

The key performance indicators for the program that aims for the development of an organizational culture of quality and performance excellence will be the documented presence of proven “best practices” in the hospital. At the minimum, the number of proven “best practices” will be in the following areas:

At least one “Best Practice” under each category of the Baldrige Criteria for Performance Excellence:

  • Leadership
  • Strategic Planning
  • Customer Focus
  • Measurement, Analysis, Knowledge Management
  • Workforce Focus
  • Operations Focus

At least one “Best Practice” under each category of hospital health care standards:

  • Patient Safety
  • Access to Care and Continuity of Care
  • Patient and Family Rights
  • Assessment of Patients
  • Care of Patients
  • Anesthesia and Surgical Care
  • Medication Management
  • Patient and Family Education
  • Hospital Infection Control

Just as Aristotle’s “We are what we repeatedly do” concretizes the concept of culture, the presence of “best practices” also concretizes a culture of quality and performance excellence in a hospital.

“Best Practice” is a formally documented method or technique that has been institutionalized in the hospital and that has consistently shown performance excellence results at least if not yet proven superior to those achieved with other means and which can be or is being used as a benchmark by other hospitals.

What are the recommended procedures and processes in developing a Program on Best Practice (PBP)?

  • Decide on a list of management systems that will be developed into “Best Practices.”
  • Formulate a design and development plan or blueprint that will include a systematic approach in the planning of a management system; deployment and implementation; evaluation, review, and continual improvement; management review and independent audit. In the blueprint, adopt / adapt with innovations best practices from other institutions if there are. In the planning also, use a systems approach, meaning taking into account the whole hospital system as well as components of the system for purposes of synthesis (i.e., look at and managing the hospital as a whole); alignment (i.e., promoting consistency of all plans, processes, evaluations, actions of the component systems to support the whole hospital’s goals); and integration (i.e, making all components function as an interconnected unit).  In the evaluation, always include timelines and measurements with key performance indicators. (Note the incorporation of Baldrige’s criteria for evaluating processes in the development of the blueprint: Approach; Deployment; Learning; Integration)
  • Track the implementation of the design and development plan.
  • Evaluate the results of the implementation for at least 3 years in terms of level (i.e., current level of performance based on formulated key performance index); trends (i.e., rates of performance improvements and the sustainability of good performance); and comparison (i.e., performance relative to appropriate comparisons such as other similar hospitals and benchmarks or hospital industry leaders). [Note the incorporation of Baldrige’s criteria for assessing results in the development of the evaluation blueprint: Level; Trend; Comparison.]

If a management system plan has been implemented for at least 3 years and has consistently shown performance excellence results even if not yet proven superior to those achieved with other means, then it can be considered as a “Best Practice” for the hospital.  Once publicized, it can be used as a benchmark by other hospitals.

What top management and senior leaders should do to effectively develop a Program on Best Practice (PBP)?

  • Leadership Strategy
    • Commitment
    • Motivation
    • Support
    • Role model
  • Management Strategy
    • Technical competence in the processes of developing “Best Practice”
  • Communication Strategy
    • Complete, clear and close-loop communication to align, integrate, and engage all staff to the Program on Best Practices
  • Education Strategy
    • Education, coaching, mentoring on developing “Best Practices” to all hospital staff

Establishing and developing an organizational culture of quality and performance excellence through the Program on Best Practices to ensure quality beyond accreditation is not easy as one can deduce from the concept and definition, procedures, and strategies that I just presented.

If you agree with me that it is course of action that will produce steadfast results in terms of ensuring quality beyond accreditation and if you put importance on quality and performance excellence for your hospitals, I suggest you start now. Ten years from now or even three years from now, depending on how fast and effective you are with your Program on Best Practice, I am optimistic you will say it was worth the journey and most important of all, it is efficient.

ROJ@14aug8

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4 Responses to Ensuring Quality Beyond Accreditation – What Hospitals Need to Do to Stay One Step Ahead?

  1. Dear Dr. Rey,

    I fully agree with your thesis that the best way to ensure quality beyond accreditation is to establish an organizational culture of quality and performance excellence through a program on best practices. This is a great article.

    Thank you.

    Dr. Manny Villegas

  2. gregoria arabe says:

    good day doc,  i have been following your articles, thank you very much for the enlightenment.

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