Is It Time to Abandon Hospital Accreditation?

Hospitals contracting with the Centers for Medicare & Medicaid Services (CMS) must comply with Conditions of Participation (CoP), enforced by 4 certified independent accrediting organizations (AOs) or individual state survey. Recent work documents that the system fails to achieve consistent clinical outcomes, allowing several-fold variation in mortality and patient safety. Other publicly reported evidence shows weaker clinical performance by state-surveyed hospitals, inexplicable variation in individual state surveys, and recurring disagreement between initial and audit surveyors. Although the leading AOs and CMS are committed to continuous improvement, a proven management system that is extensively documented in hospitals, accreditation has not achieved it. Requiring an auditable public annual report by each hospital, including improvement targets and analogous to the 10K reports required of publicly listed corporations, might create a more effective system. Updating the CoP and refocusing the on-site inspection also would help.

An Organizational Model for Excellence in Healthcare Delivery: Evidence From Winners of the Baldrige Quality Award.

EXECUTIVE SUMMARY: Winners of the Baldrige National Quality Award in healthcare have documented top quartile clinical outcomes and patient satisfaction across a variety of American communities and a full spectrum of care. Their results also show high levels of satisfaction among physicians, nurses, and other workers, as well as effective financial performance. The managerial methods they use-collectively, the Baldrige model-are consistent with organizational theory literature and are found across all winners. The winners have sustained excellence after winning and expanded it by acquisition of other healthcare organizations.The model differs substantially from traditional management approaches in healthcare delivery. It is a comprehensive program that emphasizes a shared focus on excellence, systematically responsive management, evidence-based medicine, multidimensional measures and negotiated goals, improvement of work processes, thorough training, and extensive rewards. The model could be expanded on a much larger scale. Doing so successfully would substantially improve the quality and cost of healthcare, as well as the satisfaction and commitment of care providers and other staff. The opportunity deserves further study and trial by large healthcare delivery systems, insurers, and consulting companies.

Understanding High-Reliability Organizations: Are Baldrige Recipients Models?

Chassin and Loeb argue persuasively that healthcare organizations (HCOs) can and should be "high-reliability organizations" (HROs) seeking zero defects in outcomes quality. They suggest that the Baldrige model is a sound platform for achieving high reliability. This article analyzes the similarity of the HRO concept to the Baldrige model using a recent Malcolm Baldrige National Quality Award recipient's application. The analysis suggests that neither high reliability nor Baldrige criteria are easily achieved, but the two have strong similarities. The principal difference is in Baldrige's emphasis on strategic independence versus the HRO commitment to "zero patient harm" and quality as "the organization's highest-priority strategic goal." Based on this analysis, the article reviews data on the actual performance of Baldrige recipients as recorded at WhyNotTheBest.org. The data show that the Baldrige approach is an effective method of generating above-average performance. Award recipients have made substantial strides in safety, reductions of infections, immunizations, and patient satisfaction, but receipt of the award has not translated as effectively to reduced readmissions, mortality, and costs. The pattern of results suggests that Baldrige recipients have exploited the right to establish their own strategic goals and are likely to respond to strengthened financial rewards for quality. The Baldrige model has documented successes in quality improvement and should be the standard of excellence in managing all HCOs.

A positive deviance perspective on hospital knowledge management: analysis of Baldrige Award recipients 2002-2008.

Knowledge management (KM) is emerging as an important aspect of achieving excellent organizational performance, but its use has not been widely explored for hospitals. Taking a positive deviance perspective, we analyzed the applications of nine healthcare organizations (HCOs) that received the Malcolm Baldrige National Quality Award from 2002 to 2008. Baldrige Award applications constitute a uniquely comprehensive, standardized, and audited record of HCOs achieving near-benchmark performance. Applications are organized around leadership, strategy, customers, information, workforce, and operations. We find that KM is frequently referenced in all sections, and about two thirds of each application addresses KM-related issues. Many specific KM activities, such as strategic and action plans, communications, and processes to capture internal and external knowledge, are addressed by all nine applications. We present examples illustrating these frequently appearing KM concepts. Baldrige Award-recipient HCOs apply continuous improvement to KM processes, as they do to their organizations as a whole. We conclude that these HCOs have developed sophisticated, comprehensive KM processes to align both culture and specific procedures throughout the organization. KM in these organizations is a deliberate effort to keep all relevant knowledge at the fingertips of every worker, characterized by frequent communication, careful maintenance of content accuracy, and redundant distribution. We also conclude that the extent and rigor of their KM practice distinguish them from other U.S. hospitals.

Transforming the dominant logic of hospitals.

Substantial and sustained change is inevitable for U.S. hospitals, driven by the Medicare and Medicaid cost inflation curve and embodied in regulatory initiatives and reforms. This study explores the conception that evidence-based management is necessary but not sufficient for 21st century success in health care organizations. Success will require challenging and changing the organization's dominant logic, substituting a more transformational style of problem analysis and decision making. In order for evidence-based management decisions to transform organizations, the organizational culture must be ready to adopt transformation changes. The outcomes of this shift in management style are dramatic changes in worker engagement and retention and a reinforcing cycle of performance improvement efforts. We use a series of examples to illustrate changes in the dominant logic and to identify how the combination of evidence-based management and a new dominant logic results in a fundamental and highly productive shift in how problems are framed and solved. We conclude with recommendations for changing the dominant logic--such as visioning, sensemaking, process questioning, getting the right people together, rewarding innovation, and overcoming risk aversion--all necessary for transforming the dominant logic, allowing evidence-based management techniques to flourish.

Finding the frontier of hospital management.

The frontier of demonstrated high-performance community hospital management is a valuable guide to the potential of this important healthcare sector. The best documented frontier cases are recipients of the Malcolm Baldrige National Quality Award, a varied set of 34 U.S. community hospitals in nine states. As validated by trained independent examiners, recipient data suggest that performance at or near the best decile of current distributions can be sustained simultaneously across several critical dimensions. However, these hospitals operate substantially differently from tradition, emphasizing a broadly communicated mission, a supportive learning culture, universal measurement and benchmarking, and systematic process improvement.

Development of an interprofessional competency model for healthcare leadership.

During the past decade, there has been a growing interest in competency-based performance systems for enhancing both individual and organizational performance in health professions education and the varied healthcare industry sectors. In 2003, the Institute of Medicine's report Health Professions Education: A Bridge to Quality called for a core set of competencies across the professions to ultimately improve the quality of healthcare in the United States. This article reviews the processes and outcomes associated with the development of the Health Leadership Competency Model (HLCM), an evidence-based and behaviorally focused approach for evaluating leadership skills across the professions, including health management, medicine, and nursing, and across career stages. The HLCM was developed from extensive academic research and widespread application outside healthcare. Early development included behavioral event interviewing, psychometric analysis, and cross-industry sector benchmarking. Application to healthcare was supported by additional literature review, practice analysis, expert panel inputs, and pilot-testing surveys. The model addresses three overarching domains subsuming 26 behavioral and technical competencies. Each competency is composed of prescriptive behavioral indicators, or levels, for development and assessment as individuals progress through their careers from entry-level to mid-level and advanced stages of lifelong development. The model supports identification of opportunities for leadership improvement in both academic and practice settings.

Improving preparation for senior management in healthcare.

Noting the historical and practical relationship of management education in healthcare to business generally, this paper reviews and analyzes four recent criticisms of management education by Pfeffer and Fong, Ghoshal, Mintzberg, and Bennis. It concludes from that analysis that increased effort on assessing and improving healthcare education efforts is essential, and proposes a model for a national program of continuous improvement of educational practice. It reviews existing competency assessment tools in the light of needs, and suggests next steps for educators and practitioners.

Is anybody managing the store? National trends in hospital performance.

Nine standardized measures compiled from Medicare data show trends in the safety, quality, financial management, and efficiency for more than 2,500 community hospitals over five years ending in 2003. Although much public attention has been given to hospital performance, along with exhortations to improve, few measures show substantial positive trends, either in variance reduction or overall improvement. The authors conclude that environmental forces are not stimulating improvement and that the overall picture is one of randomness rather than management.

The revolution in hospital management.

Five healthcare systems that have either won the Malcolm Baldrige National Quality Award in Health Care or been documented in extensive case studies share a common model of management: they all emphasize a broadly accepted mission; measured performance; continuous quality improvement; and responsiveness to the needs of patients, physicians, employees, and community stakeholders. This approach produces results that are substantially and uniformly better than average, across a wide variety of acute care settings. As customers, courts, and accrediting and payment agencies recognize this management approach, we argue that it will become the standard for all hospitals to achieve. This article examines documented cases of excellent hospitals, using the reports of three winners of the Baldrige National Quality Award in Health Care and published studies of other institutions with exceptional records.

The impact of evidence on teaching healthcare management.

As healthcare management becomes more responsive to market demands, healthcare management education must prepare a more sophisticated and effective product. The author reviews the barriers to change in education and suggests that education will evolve to a new business model emphasizing "small bites" that are directly related to work needs and often learnable at the worksite, as well as integrative materialbest learned in a university environment. The ultimate model will have the following characteristics: 1. Managers' learning will be continuous, and will be recorded in individual certified "life transcripts" of mastery. 2. Learning will be performance driven, where performance is measured as contribution to the employer's goals and the patients' needs. 3. Learning will be flexible as to site, medium, and timing. 4. Managers' learning programs will emphasize recurring evaluation, celebration, and goal-setting.

A framework for evaluating and continuously improving the NCHL transformational leadership initiative. National Center for Healthcare Leadership.

The National Center for Healthcare Leadership transformational leadership project is a broad and ambitious initiative that seeks to bring to the table top leaders from industry and academe. Their charge is to accomplish nothing short of resetting the course for health management education and practice in the coming decades. Four councils were recruited to launch the four major interventions: (1) recruitment and diversity, (2) core competencies, (3) the advanced learning institute, and (4) accreditation and certification. After describing intervention goals, we provide examples of baseline measures for tracking educational and performance outcomes longitudinally. We believe this transformation is only beginning, and it will take many years or decades. The transformation will be most successful if it is guided by data and systematic evaluation.