Improving and Maintaining Quality Management Excellence

Implementation of new systems that are supported by tools, such as software products specifically designed to facilitate performance monitoring and improvement, requires a thorough review of the organizational barriers to this change. Of particular importance are the cultural beliefs of the medical staff membership toward more open review of group and individual performance. The organizational review should include a detailed examination of:

(1) the organizational structure

(2) the policies and procedures that are in place or are needed to establish a clear, uniform plan for the processing and management of performance data

(3) the resources, including both personnel and automation, required to support the established process

Insight Health Solutions suggests that you give serious consideration to adding the availability of an experienced Quality Management Consultant or Medical Management Consultant to assist you in the change. The consultant's initial role is to carry out an organizational assessment. This includes a review of the organization's structure and the current processes that are in place to support both the performance review and reporting of departments (administrative and clinical) and committees. Simultaneously, the existing policies and procedures that relate to the quality management processes are reviewed, and an inventory of existing and planned data sources and methods of data aggregation and dissemination is taken. Finally, the consultant completes an assessment of the products of the quality activities in terms of issues found, recommendations made, actions taken, and outcomes achieved. These findings, along with recommendations that are developed with the Quality Manager, are presented to the appropriate publics. During this phase, consultation needs to be frequent enough to give visibility to the fact that a change process is moving along.

The second stage of the consultation is to be available on a periodic basis to monitor progress toward approved recommendations, to assist in troubleshooting snags in implementation, to serve as an outside voice to introduce new topics, and to be a coach and/or cheerleader when needed. The frequency and duration of this phase is determined by the usefulness of the consultation to the continued progress of the Quality Management Program.