Performance Improvement: A Topic Whose Time Has Come—Again

Abstract

In the last “Accreditation News & Views” column, I wrote about the priorities of elements of performance (EPs) that were unique to medical equipment management. In this column, I’m writing about a small group of standards that are in common to all functions in a hospital—performance improvement (PI). The Joint Commission (JC) added PI standards to their accreditation manuals quite a few years ago. When they initially did this, PI became a major theme. Over the years, there have been relatively minor changes to the wording and the placement of the PI requirements, but their essence has remained the same: collect and analyze data, plan and take action, evaluate, and report results. Then do it again, in a perpetual, performance improvement cycle. When PI standards were added to JC accreditation manuals, they made a big splash. The hospital staff who oversaw JC standards compliance put major effort into training and motivating departmental leadership into doing PI projects. How many of you remember “story boards?” In those days, a JC survey looked like show and tell day in elementary school. In the years since, however, there have been other, newer “initiatives” from the JC, and PI standards have become second tier. Perhaps this is because hospitals do a good job with PI and it no longer requires special attention. Perhaps it’s because the JC realizes that they, and hospitals, can only concentrate on a limited number of high priority standards at a time, and other issues have become more important (analogous to the way that National Patient Safety Goals come and go). For whatever reason, I believe that clinical engineering departments never put the emphasis on PI that the rest of the hospital did—even when PI was in its heyday. Now that it is not emphasized in the hospital as a whole, it appears to me that most CE departments barely even pay PI lip service anymore. Putting PI on the back burner may not be hazardous to your standards compliance health, but it definitely leads to a missed opportunity. A couple of well-chosen PI projects can pay huge dividends to your relationships with your staff, your boss, and your customers. PI projects deserve to be a favorite tool in your management tool box.