The Quality Floor

When I first started working in quality, I found myself surprised by how many staff did not follow quality measures. "But they know what they are supposed to do," I would say. In response, I would be told that I needed to lower my expectations for people.

Quality Floor
At the very bottom of quality care is what I refer to as the quality floor. This is the very minimum staff need to do to achieve quality goals. They fill out the audit forms, complete the history and physical, check the box, and do what they think they are supposed to do. In this case, the quality bar is set so low that it is easy for any staff member to step over it. No outcomes are measured, no follow-through occurs, no patient followup occurs, no analysis of results occurs.

Mediocrity
There are other quality departments and organizations that set their quality goals at what "passing" is for a quality indicator.  The passing point maybe 50% patient satisfaction, 60% of audits completed, reaching 70% on core measures. Passing is set at whatever minimum score the organization has pre-determined is acceptable. It's much like getting a "D" in school. If a student knows 60% of the material in school, then the student passes the class. However, does knowing or achieving 60% really make this student knowledgeable? Passing is not succeeding. Rather, passing promotes a "lowest common denominator" mentality. That is, what is the lowest common denominator, or least someone can do, to achieve this goal.

Photo courtesy of Pixabay.com

Good Enough is Good Enough
Other organizations may set standards above the level of mediocrity, such as wanting all measures to be at 80%. Then, the standard is set higher than passing, or higher than average, but it is still not set at a stretch goal. In this scenario, the idea is that when a certain quality target is reached, the work is done. This is the "Good Enough is Good Enough" mentality. Staff achieves quality goals to reach a potential benchmark, and then they quit trying to improve. This might be likened to students who have contracts for B's or C's in school. The students know they only have to put forward a certain amount of effort to get the B or the C. As a result, they don't try harder to get the A. They are already guaranteed the B or C without the extra effort. There is no incentive to reach the A or higher goal because, for some students, rewards are given at the B and C level, which may or may not be the same type of rewards for the A work.

Achieving High Expectations
In order to reach the loftiest goals, as really established by to Err is Human, Crossing the Quality Chasm, -- these reports were, in fact, a call to action --  and in standards promoted by AHRQ (Agency for Healthcare Research and Quality) and the Institute for Healthcare Improvement (IHI), high expectations for quality must be set. For example, establishing a standard for the Core Measure of providing post-partum women with contraceptive care should be set so high that the goal is to be consistently over 90% on the outcome measure. This means that the outcome is a stretch goal, a goal that requires work and forethought to implement, and dedication to track and maintain. Systems may need to be changed in order to ensure the measure is met. Nonetheless, the "least" that is accepted is 90%. Thus, the level of mediocrity for this measure has been raised from merely passing. A high base requirement has been established, and that base then sets the stage for increasing and achieving positive outcomes. By setting high expectations with regard to quality, the organization develops expectations of a quality culture.

Sources
Understanding Quality Measurement. Content last reviewed November 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/understand/index.html
Quality Measures. Content last reviewed June 2018. Centers for Medicare and Medicaid Services, Baltimore, MD. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html
Quality Payment Program. Content retrieved June 2018. Centers for Medicare and Medicaid Services, Baltimore, MD. https://qpp.cms.gov/mips/overview
2018 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set). Content Retrieved June 2018. Medicaid.gov, Centers for Medicare and Medicaid Serves, Baltimore, MD. https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2018-adult-core-set.pdf