The Performance Improvement Cycle

The concept of “performance improvement" is at the heart of all JCAHO standards. Although it often seems buried under many layers of mandates to “do this" and “document that," the driving force is “do better."

We can probably agree that JCAHO standards are, at best, only imperfect attempts to implement the concept. However, it’s still a valid concept and one worth keeping in mind as we think about the JCAHO programs we’re responsible for.

We should ask ourselves two questions: First, “Are we doing OK?" And second, “Are we getting better?" If we can look at ourselves in the mirror and answer “Yes" to both questions then we can sleep peacefully at night. If not, we might have some “opportunities for improvement" to pursue.

When the answer to the first question is “No," or anything short of a confident “Yes," then we need to initiate some sort of corrective action as quickly as possible. The first order of business is to have all the basics in place. That’s the foundation we build on.

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My experience is that EC programs are generally in pretty good shape. The basics are in place and we can usually say that our programs are at least OK—and in many respects they’re much better than OK. But that alone doesn’t mean we can rest comfortably.

The second law of thermodynamics says that all physical systems move toward entropy unless energy is added. Organizational systems behave this way too. In any organization, the systems we put in place will deteriorate unless we put energy into them. “OK" can become “not-OK" before we know it.

And, let’s face it, we may be good but we’re not perfect. We can always do better. And, since our fundamental mission is to support high-quality patient care, we should always strive to do better. The challenge is to do better within the financial and organizational constraints that confront us. Meeting that challenge is the interesting part of our jobs.

So what does JCAHO have to say about all of this? First, we are required to write seven management plans. These are “executive summaries" of the programs we have in place to meet JCAHO Environment of Care standards regarding safety, security, hazardous materials and waste, emergency management, fire prevention (life safety), medical equipment, and utility systems.

Second, we are required to continuously monitor the performance of our EC programs as defined in our management plans. Continuous monitoring typically includes monthly calculation of performance statistics that are reported quarterly to the safety committee (or whatever group is charged with oversight of EC-related programs).

Third, we are required to annually evaluate the “objectives, scope, performance, and effectiveness" of each of our EC management plans. Management plans, continuous monitoring, and annual evaluation represent the “Are we doing OK?" part of the process. It gives us a working definition of what’s OK and tells us when we’re not.

Finally, we use the results of the annual evaluation to modify our management plans and the methods we will use to monitor them. The annual evaluation will also help us identify one or more performance improvement activities to implement (and monitor) during the new year. This is the “Are we getting better?" part of the process. If we keep moving steadily through the performance improvement cycle the answer will be, “Absolutely!"

Matthew Baretich, P.E., Ph.D., is President of Baretich Engineering Inc, a consulting firm based in Fort Collins, Colorado. His areas of practice include safety management, facilities management, and medical equipment management. Send your comments to Matt at [email protected].

Reprinted with permission from Joint Ventures: JCAHO and You ©2001 Baretich Engineering, Inc.