Leadership, Quality-Driven Culture, and Organizational Performance

Leadership, Quality-Driven Culture, and Organizational Performance

Summary of Task Force Agenda

The newly established Quality Improvement Task Force has been charged with a crucial responsibility: To facilitate and execute sustainable improvements to patients’ care and safety as well as the healthcare organization’s performance in the Health System. As an organization, we have formulated a broad plan for approaching evidence-based practices and developing policies that help to enhance patient care, encourage ongoing staff development and training, and integrate our activities with leading national standards and programs.

One major activity will be a comprehensive evaluation of the current measures and procedures of quality assessment to determine what we do well and what aspects need improvement. In light of these analyses, specific quality improvement strategies will be formulated and implemented for each service line; this approach will minimize generalizations and deliver targeted strategies for issues that deserve attention. Ongoing systematic data collection and monitoring procedures will be implemented to oversee progress on the main quality indicators.

Recognizing that quality improvement is a collaborative endeavor, actively promoting interdisciplinary teamwork and engagement among all staff members is paramount. Their insights, expertise, and commitment will be invaluable in shaping and sustaining our quality initiatives. Compliance with regulatory requirements and accreditation standards will also be a central focus, ensuring our organization meets or exceeds industry benchmarks.

Role of Governing Boards in Quality Care and Hospital Governance

The governing board plays an indispensable role in overseeing and championing quality care within our healthcare organization. It is their responsibility to set the strategic vision for quality improvement, establish clear accountability measures, and allocate the necessary resources to support these efforts effectively (Australian Commission on Safety and Quality in Health Care, 2019; Diener, 2020). Furthermore, the board must remain actively engaged in reviewing quality performance data, identifying areas that require attention, and ensuring corrective actions are promptly implemented when needed.

Effective hospital governance hinges on a strong collaborative partnership between the governing board and the executive leadership team (Australian Commission on Safety and Quality in Health Care, 2019; Diener, 2020). Open communication channels and alignment on quality goals are paramount to achieving success. The board should also stay abreast of industry trends, best practices, and evolving regulatory developments that impact quality and patient safety standards.

Quality and Patient Safety Initiatives by Healthcare Organizations

Several national healthcare organizations have taken the lead in establishing quality and patient safety initiatives aimed at driving improvements across the industry (Mistri et al., 2023). The Centers for Medicare and Medicaid Services (CMS) has implemented programs such as the Hospital Value-Based Purchasing Program, Hospital Readmissions Reduction Program, and Hospital-Acquired Condition Reduction Program, tying reimbursement to performance on key quality metrics and penalizing facilities with poor outcomes.

The National Association for Healthcare Quality (NAHQ) plays a vital role in setting ethical guidelines, defining competency frameworks, and offering professional certifications for healthcare quality professionals. These resources serve as valuable tools for organizations striving to enhance their quality management practices.

Stakeholders and Drivers of Quality Care in Hospitals

Quality care in hospitals is driven by a diverse array of stakeholders, each with distinct perspectives and priorities (Williams & Finkelstein, 2023). Patients and their families rightfully expect safe, effective, and patient-centered care that respects their preferences and values. Healthcare professionals, deeply committed to their calling, strive to uphold best practices and deliver the highest quality of care possible.

Regulatory agencies enforce quality standards and increasingly tie reimbursement to performance on specific metrics, incentivizing hospitals to prioritize quality improvement (Williams & Finkelstein, 2023). Accrediting bodies establish benchmarks and conduct periodic evaluations, ensuring facilities meet rigorous criteria. Payers, including insurers and government programs, are implementing value-based reimbursement models that reward high-quality, cost-effective care. The broader community also plays a vital role in advocating for accessible, equitable, and culturally competent healthcare services that meet the diverse needs of the population served.

ACHE Leadership Safety Culture Domains

The American College of Healthcare Executives (ACHE) has identified six domains that contribute to a robust safety culture in healthcare organizations:

1. Leadership commitment to safety
2. Accountability and responsibility for safety (American College of Healthcare Executives, 2024)
3. Communication and collaboration around safety
4. Staff empowerment and respect for individual contributions
5. Continuous learning and improvement in safety
6. Integration of safety priorities into organizational goals and processes

Four Levels and Six Aims for Quality Improvement (NAM)

The National Academy of Medicine (NAM), formerly the Institute of Medicine (IOM), has outlined a framework for quality improvement in healthcare, encompassing four levels and six aims:

Four Levels

1. Experience of care
2. Population health management
3. Per capita cost
4. Engaging patients and communities

Six Aims

1. Safe: Minimizing the risk of harm to patients from care that is aimed at benefiting the patient in one way or another (Agency for Healthcare Research and Quality, 2022).
2. Effective: Supplying service on the basis of the precise scientific data to all those who could receive such services.
3. Patient-centered: To execute caring, patients’ delivery of healthcare that adheres to the individual patient’s preferences, needs, and values.
4. Timely: Elimination or reduction of time spent waiting and other forms of adverse downtime.
5. Efficient: Selecting the best mode—not wasting equipment, material, ideas, or energy (Agency for Healthcare Research and Quality, 2022).
6. Equitable: Offering an equal level of quality of health care regardless of the individual’s gender, race or origin, or social status in society.

Barriers to Quality Improvement

Even with good strategies and frameworks in place, some challenges will affect healthcare organizations and hamper their quality improvement initiatives. The first one relates to resistance to change, where some of the staff may refuse to embrace the change in the organization’s processes or practices because they prefer to maintain the status quo (Odhus et al., 2024). Lack of financial and human resources may also be a problem if there is inadequate funding, inadequate staffing, or no equipment or technology. These constraints can prove to be a hurdle in implementing new programs, recruiting qualified human resources, or procuring necessary tools and systems.

Lack of proper coordination of operations between departments or between different clinical zones makes it difficult to achieve a well-coordinated approach to the delivery of care. To implement quality improvement programs, the organization has to ensure that there is a proper and efficient workflow across the organization to enhance the sharing of information which may be a challenge in organizations with a strongly established silo structure.

Cultural or organizational factors like the absence of a focus on the quality enhancement program or the unwillingness to deliberate and educate from mistakes cause a considerable challenge (Alexander et al., 2021). It is my belief that leadership should foster a corporate culture that is based on openness, sharing of knowledge, and dedication to quality enhancement.

Regulatory pressures can also be learned as healthcare organizations are faced with legal and reporting demands from numerous agencies (Alexander et al., 2021). This can be time-consuming and may prove to be costly, which may draw focus from the need to improve the quality of patient service delivery. Finally, data limitations include inadequate data collection processes or the absence of sufficient analysis to use in decision-making and measuring progress. Reliable documentation and evaluation procedures are necessary for assessment, setting priorities, and targeting changes in the quality of treatment plans to be made.

Accreditation Organizations and Programs

Accreditation agencies are important in ascertaining that a healthcare facility has the best quality and has improved the safety of the patients (Hussein et al., 2021). Such organizations examine institutions and offer accreditation depending on the standards and recommended parameters set for an educational or other kind of institution.

The Joint Commission is one of the most commonly identified accreditation bodies. It accredits healthcare facilities, including hospitals, ambulatory care facilities, and many other types of organizations (The Joint Commission, 2022). A wholly objective accreditation process assesses the compliance of other organizations with a wide range of standards, including patient services, governance, environment, and improvement.

Another accrediting body is the Healthcare Facilities Accreditation Program (HFAP), which primarily accredits acute care hospitals, ambulatory care, clinics, and clinical laboratories. This has included patient safety, quality of care, and the ability to meet legal standards, which form the fundamentals of accreditation (Hussein et al., 2021).

Det Norske Veritas (DNV) Healthcare is a Global independent organization that offers a wide range of healthcare accreditation services to hospitals, ambulatory care centers, and other healthcare institutions. It enhances their focus on risk management, the improvement of operations procedures, and the integration of QM systems across the organization.

For specialized healthcare and medical facilities, special accreditation agencies like the Commission on Accreditation of Rehabilitation Facilities (CARF) and the College of American Pathologists (CAP) exist to accredit such facilities and programs. CARF certifies organizations and services that provide rehabilitation services, guaranteeing that these organizations provide rehabilitation services that are of high quality and easily accessible to consumers (Hussein et al., 2021). The CAP, on the other hand, centers on the accreditation of the laboratory services to gain accuracy in the testing.

Being accredited by these organizations is a showroom of dedication by a healthcare facility towards constant and sustainable improvement of standards and practices. It also helps as a sign to patients, payers, and regulatory agencies to show that the organization is committed to safe, effective, and quality care provision.

References

Agency for Healthcare Research and Quality. (2022). Six Domains of Health Care Quality. Agency for Healthcare Research and Quality. https://www.ahrq.gov/talkingquality/measures/six-domains.html

Alexander, C., Tschannen, D., Argetsinger, D., Hakim, H., & Milner, K. A. (2021). A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. Journal of Nursing Management, 30(3). https://doi.org/10.1111/jonm.13537

American College of Healthcare Executives. (2024). Blueprint | Leading for Safety. Www.ache.org. https://www.ache.org/about-ache/our-story/our-commitments/leading-for-safety/blueprint

Australian Commission on Safety and Quality in Health Care. (2019). National Safety and Quality Health Service Standards Roles and responsibilities of governing bodies. https://www.safetyandquality.gov.au/sites/default/files/2019-09/nsqhs_standards_roles_and_responsibilities_for_governing_bodies_sep_19.pdf

Diener, M. (2020). The Board’s Role in Quality Oversight and Patient Safety | AHA News. Www.aha.org. https://www.aha.org/news/blog/2023-11-08-boards-role-quality-oversight-and-patient-safety

Hussein, M., Pavlova, M., Ghalwash, M., & Groot, W. (2021). The impact of hospital accreditation on the quality of healthcare: A systematic literature review. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-07097-6

Mistri, I. U., Badge, A., Shahu, S., Mistri, I. U., Badge, A., & Shahu, S. (2023). Enhancing patient safety culture in hospitals. Cureus, 15(12). https://doi.org/10.7759/cureus.51159

Odhus, C. O., Ruth Razanajafy Kapanga, & Oele, E. (2024). Barriers to and enablers of quality improvement in primary health care in low- and middle-income countries: A systematic review. PubMed, 4(1), e0002756–e0002756. https://doi.org/10.1371/journal.pgph.0002756

The Joint Commission. (2022). Benefits of Joint Commission Accreditation | the Joint Commission. Www.jointcommission.org. https://www.jointcommission.org/resources/news-and-multimedia/fact-sheets/facts-about-benefits-of-joint-commission-accreditation/

Williams, V., & Finkelstein, J. B. (2023). Speaking and listening: The importance of stakeholder engagement in quality improvement in pediatric urology. Journal of Pediatric Urology, 19(6). https://doi.org/10.1016/j.jpurol.2023.08.017

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---

This Individual Project (IP) builds upon your work in Units 1 and 2.

In response to the board’s request for the initiation and execution of quality programs, you appointed a task force for quality improvement to address the board’s accountability concerns and to implement the Centers for Medicare and Medicaid Services (CMS) quality initiatives, and the National Association for Healthcare Quality (NAHQ) initiatives, and the six safety culture domains by the American College of Healthcare Executives (ACHE). You and the task force will create a quality improvement report for the board that includes the following:

1. Summary of the agenda for the hospital by the task force
2. Role of governing boards in quality care and hospital governance
3. Quality and patient safety initiatives promoted by healthcare organizations
4. Stakeholders and drivers of quality care in hospitals
5. ACHE Leadership Safety Culture Domains for Healthcare Organizations
6. Four levels and six aims for quality improvements in healthcare as advanced by the National Academy of Medicine (NAM), formerly the Institute of Medicine (IOM)
7. Barriers to quality improvement
8. Accreditation organizations and what programs they accredit

Deliverable Requirements: The quality improvement report should address the points above in at least 5 pages (title and reference pages are not counted in the page requirement) and cite 5 sources in APA format.

Submitting your assignment in APA format means, at a minimum, you will need the following:

• Title page: Remember the running head. The title should be in all capitals.
• Length: 5 pages minimum
• Body: This begins on the page following the title page and must be double-spaced (be careful not to triple- or quadruple-space between paragraphs). The typeface should be 12-pt. Times Roman or 12-pt. Courier in regular black type. Do not use color, bold type, or italics, except as required for APA-level headings and references. The deliverable length of the body of your paper for this assignment is 5 pages. In-body academic citations to support your decisions and analysis are required. A variety of academic sources is encouraged.
• Reference page: References that align with your in-body academic sources are listed on the final page of your paper. The references must be in APA format using appropriate spacing, hanging indent, italics, and uppercase and lowercase usage as appropriate for the type of resource used. Remember, the Reference page is not a bibliography but a further listing of the abbreviated in-body citations used in the paper. Every referenced item must have a corresponding in-body citation.