Building a Quality Management System

Building a Quality Management System

Because CMS and other credentialing bodies require quality management, it’s often seen as expensive, excessive, and even bureaucratic in the healthcare industry. Even a bare-bones quality assurance program requires dedicated resources, and if you’re like many healthcare administrators, your staff are indifferent toward quality assurance at best despite the investment you’ve made in the program.

Because any successful initiative starts at the top, the perch from which you view quality management has the potential to set the tone for the entire company. If you see it as an expensive initiative with no ROI, then your staff will see it that way, too. However, if you can wrap your mind around quality management as a differentiator, you have the power and potential to transform your company through your own belief system.

What is quality management?

While most facilities use the term quality assurance, QA is just one component of a successful quality management system. Your quality management system should have one focus: to provide your customers with services that meet or exceed their expectations. Six Sigma confirms that customer satisfaction is the single most effective measurement of the quality of the work done within any organization. Every function of the company must perform according to the high standards you’ve set for them in order to achieve consistent customer satisfaction, and when you perform at these standards, you can feel confident that you’re satisfying the requirements set by CMS and other credentialing bodies.

Many organizations write a policy or statement reflecting their quality management program. However, if you expect a cultural shift, your quality management system should be a part of what every employee in your organization does every day.

The three main components of a quality management system (QMS) that works include:

  1. Quality control. These are the processes you have in place to maintain the standards you’ve set, such as standard operating procedures, work instructions, and policies.
  2. Quality assurance. This is how you evaluate whether your processes are effective and usually consists of internal or external auditing.
  3. Quality improvement. This is the ongoing effort you put into improving the client experience and may consist of correction and preventive action plans, metric monitoring, and trend analysis.

Quality management is not a single department but instead the driving force behind the work your employees do. It’s the effort and commitment put toward doing what the company promises each patient they will do, whether that’s providing compassionate care, seeing them within 10 minutes of their scheduled appointment time, or maintaining the cleanliness of their room.

Creating a cultural shift

The most challenging aspect of quality management is building company-wide buy-in in the program. When the program is represented as rules, metrics, and corrective actions, staff are unlikely to connect with the purpose of quality management and invest in the program’s success. However, when quality management is presented as “what we do and how we do it” to ensure every patient is safe and satisfied without fail, it begins to speak to each employee’s desire to give the patient their best work every day.

Perhaps even more important than the manner in which quality management is communicated is the manner in which it’s supported by key leaders in the company. Support that creates results should include three primary components:

  • Investment
  • Accountability
  • “Roll up your sleeves” help

Investing in quality management

A facility that’s dedicated to quality ensures that every employee has the resources they need to do quality work. When a nurse aide is assigned eight patients, and all must be ready for breakfast within two hours, that allows them 15 minutes per patient (if they don’t need to use the restroom or answer a call light during that time). The best way to determine the feasibility of this arrangement is to review the policies and procedures in place to determine whether the steps can be followed for every applicable procedure in a 15-minute window. Procedures that might apply to morning care include:

  • Transferring a patient
  • Ambulating a patient
  • Providing oral care and/or denture care
  • Providing perineal care
  • Toileting a patient
  • Providing incontinence care
  • Administering a bed bath
  • Providing hair care
  • Dressing a patient and/or dressing a patient with an affected side
  • Making a bed
  • Donning compression stockings

In addition, some policies may include additional steps, such as shaving the patient daily if requested, taking vital signs, removing the laundry, or removing the garbage following toileting or incontinence care.

This exercise demonstrates the importance of investing in quality. In most cases, this investment is applied directly to an increase in staffing levels to ensure every employee is given the opportunity to follow the procedures that are in place. When you expect quality but fail to invest it, no training can bridge the gap.

Creating accountability

The most natural course of action for any employee anywhere (including administrators) is to prioritize their workload based on what is being requested, reviewed, or measured. Expecting quality but not measuring quality or sharing those results company-wide is another common error. Leaders throughout the company should ask about quality as often as they ask about timelines or other daily tasks. Their teams will naturally keep quality at the forefront if they expect to be asked at any given time.

Rolling up your sleeves

The single most important investment an administrator or any leader in the organization can make is hands-on help that drives quality. Every discussion should be accompanied by an authentic offer to assist with the “dirty” work, and then every request for assistance to drive quality should be honored promptly.

If the facility invests in quality, the requests should be infrequent. These requests might include answering a call light when all hands are on deck in the ER or dressing a patient when an aide is out sick. By stepping in to demonstrate that patient satisfaction metrics, and therefore quality, matter at the leadership level, leaders can build rapport and buy-in at every level and support quality in a way that really matters and produces the results the organization desires.

Key takeaways:

  • Quality assurance is not quality management
  • Quality management requires a cultural shift in order to be successful
  • The cultural shift occurs when employees have everything they need to do quality work


Rynae has over twelve years of experience in the healthcare industry, starting in entry-level positions and direct patient care and advancing into healthcare administration. She holds her BS in Human Resources Management and specializes in business strategy, leadership development, and performance management. Rynae is passionate about senior living, life enrichment, and customer service in the healthcare setting.

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