Is it time to re-examine structure of your quality department? It may be an appropriate reaction to shifting market realities

HealthCare Benchmarks and Quality Improvement, Sept, 2004

Doesn't it make sense that a commitment to continuously improving performance should include a periodic review of the organizational structure that governs your QI efforts?

Several quality professionals contacted by Healthcare Benchmarks and Quality Improvement recognize that, in fact, conducting such reviews from time to time is essential to efficient QI operations.

In some cases, they observe, the structure just becomes tired or too large and cumbersome to operate efficiently. At other times, significant shifts in industry trends call for a new approach to structure design, they add.

"We have a very active discussion board.0569 and recently had a posting asking, 'How do you structure the quality function, what is your committee made up of--who's on it?'" reports Sharon Lau, a consultant with Medical Management Planning, in Los Angeles, referring to her BENCHmarking Effort for Networking Children's Hospitals.

"A number of replies indicated that the quality departments or committees were in the middle of a major revision," Lau notes.

What reasons were given for these revisions? "It sounds like people are really looking at how the quality function can be structured for maximum efficiency and benefit," she says.

"Which got us to thinking: It used to be that quality wasn't really a department but something that everyone was expected to do--a value, if you will," Lau points out.

"At that time, there was a person in charge of JCAHO issues, a corporate compliance officer, then a quality department. So you had all these different pieces being fragmented under different silos," she adds. Subsequently, Lau says, people began recognizing that all these different functions, including the medical staff, touched on quality.

Susan W. Adams, RN, CPHQ, director of quality resources/risk manager at Primary Children's Medical Center in Salt Lake City, has a similar viewpoint.

"In the late 1980s, the changes people tended to make were in response to regulatory issues and were more specific than they are now," she observes.

"We have more latitude to be creative and innovative than we did then. Then it was discipline-specific; you had medical staff functions and did quality specific to the disciplines. Nurses did their things--doctors did theirs--and so on," Adams says.

Streamlining the structure

With the scope of the quality function having become so broad, it is easy for the structure to become bloated, observers say. This, then, has become one of the predominant reasons for restructuring.

"I started at this position several weeks ago, and they hadn't had a quality director in quite a while," says Gayle Bielanski, RN, CPHQ, director of quality and patient safety at Phoenix Children's Hospital. "We are now thinking about restructuring."

The current quality council has a medical staff committee, composed of the vice chairs of several medical staff committees, nursing directors, representatives of clinical areas such as radiology and lab, and a patient care and quality enhancement committee--a board committee--that includes board members, an individual in charge of the quality council, and one or two directors, she explains.

"What happened was, they seemed to duplicate each other's work; it was not supposed to be that way, but it got that way," Bielanski says. "Our thinking was to combine the two."

The new structure she has in mind would consist of two nurse directors, two or three clinical directors, some physicians, and two or three board members. "This way, they could bring back to the board whatever they found," she explains.

In hospitals where Bielanski had previously worked, she says, the quality council was a hospital committee.0569 with an administrative function.

"It was not truly a medical staff committee, although there was medical staff in it," she says.

For additional input, she entered a posting on the aforementioned discussion board. What did her peers say?

"So far, all of them say they are a medical staff committee, and only one hospital said they had two separate committees," Bielanski adds.

"My guess is that it preserves the confidentiality of anything that comes out of it and protects it from discoverability." That means, she notes, that neither attorneys nor the media can get a hold of the information.

"For example, if it was reported that you had a certain number of errors, or a patient sued over receiving the wrong information, that could be used against your hospital," Bielanski notes.

Another issue she had been curious about was how often each of the departments reported, and when. "None of our departments had been reporting their quality information; it had been very lax," she says.

The respondents to the posting said reporting took place either quarterly or yearly. "We're leaning toward having all clinical departments report on a quarterly basis and the others every six months or every year," Bielanski explains.

Freeing up staff for systems PI

At Primary Children's, Adams is now contemplating the latest in a number of changes that have been implemented in the quality function during her 24 years there. What has occasioned this change?