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

"When you feel like you're not making those incremental leaps, or it feels cumbersome or broken, or you do not have the right people talking, it may be time for change," she offers.

"You should ask yourself if you can find the root cause of a problem quickly; if you can, your structure is probably OK," Lau adds.

"But if things are not getting reported, or you're not able to find answers, maybe your structure isn't where it needs to be." That structure doesn't have to look the same in every hospital, she says.

"There's probably no one right answer, but you have to look at accountability in making sure quality happens. Depending on how your culture works and how people interact, you may have a different way of doing it, but your key question should always be, 'How do we assure accountability in quality?'"

Performance improvement, Lau reminds, is a process, not a program.

"Ideally, you want to have all the aspects related to performance communicating very well," she explains.

"For example, information services [IS] always has a ton of data, but I can tell you that I've gone into hospitals where you'd be amazed how few people know that data exist, and how much reinventing of the wheel gets done. IS decision support, benchmarking, risk management, your national effort--all have to be a part of the process," Lau says.

Should all this responsibility come under one report? "I don't know," she continues. "But there are so much data, so many requirements to prove you are keeping track of things--that data intensity that has probably brought this to a head.

"You have to know where the data are and work on it together. Also, you have to make sure everyone is educated in how to do quality the right way at the right time," Lau adds.

Key Points

* Periodically review the structure that governs your QI efforts.

* The search for maximum efficiency and benefit is one of the leading causes for re-examination.

* Make sure the right people are made accountable for key quality decisions.

Need More Information?

For more information, contact:

* Susan W. Adams, RN, CPHQ, Director of Quality Resources/Risk Manager, Primary Children's Medical Center, Salt Lake City, UT. Phone: (801) 588-2281. FAX: (801) 588-2288. E-mail: susan.w.adams@ihc.com.

* Sharon Lau, Medical Management Planning, Inc. (MMP), 2049 Balmer Drive, Los Angeles, CA 90039. Phone: (323) 644-0056. FAX: (323) 644-0057. E-mail: sharon@mmpcorp.com.

* Gayle Bielanski, RN, CPHQ, Director Quality and Patient Safety, Phoenix Children's Hospital, Phoenix, AZ. Phone: (602) 546-0706.