Advances in Skin & Wound Care:
Richard "Sal" Salcido, MD, is the Editor-in-Chief of Advances in Skin & Wound Care and the Course Director for the Annual Clinical Symposium on Advances in Skin & Wound Care. He is the William Erdman Professor and Chairman, Department of Rehabilitation Medicine; Senior Fellow, Institute on Aging; and Associate, Institute of Medicine and Bioengineering, at the University of Pennsylvania Health System, Philadelphia, Pennsylvania.
In this month's continuing education activity, "Leveraging Certified Nursing Assistant Documentation and Knowledge to Improve Clinical Decision Making: The On-Time Quality Improvement Program to Prevent Pressure Ulcers" is a masterful project that utilizes the principle of continuous quality improvement (CQI). The objective of improved outcomes is achieved by incorporating well-thought criteria, tactics, and techniques. The goal is to give the authority and responsibility to the operators: frontline teams, the practitioners at the bedside, or at the point of service. This practice enhances customer service and provides a learning environment for the organization.
Philosophies surrounding the quest for quality have been evolving across time and industry. During the rebuilding of Japan's industrial complex after World War II, W. Edwards Deming introduced the concept of CQI. Ostensibly, the major concept was to identify variabilities in process and aggressively eliminate any processes that impeded progress, were redundant, or did not satisfy the tenets of quality and customer satisfaction. Later, Deming focused on the people who should be empowered to think, act, and make timely assessments and decisions parallel to the performance of a given task (frontline workers). As the concept of CQI evolved, many other processes were engineered to enhance quality safety and cost-effective production practices-all with the common interest in efficient profit making, reinvesting in research and development, and simply manufacturing better products that consumers would buy.
Some of the better-recognized models are Total Quality Management, Kaizen (Japanese for "improvement" or "change for the better"), and Six Sigma. Six Sigma, in concept, also empowers all stakeholders to operate in a lean environment and eliminate wasteful practices. Although the above concepts and disciplines evolved in the manufacturing of automobiles, aircraft, and healthcare industrial manufacturers, such as General Electric, Siemens, and others, these principles also can be applied to other industries such as healthcare.
In this context, one can potentially argue that wound care professionals and their patients are not as uniform and consistent as collective parts or components on an assembly line, nor are patients (human beings) parts or widgets. If you imagine for a minute that hospitals are the corollary to factories, consider that patients are not homogeneous in their clinical presentations. They come to us with complex wounds, preexisting conditions, and significant comorbidities, such as diabetes; venous stasis; congestive heart disease; generalized vascular disease of the brain, heart, aorta, and peripheral vessels; and substance abuse, which are detrimental and often cause organ failure. Forgive the analogy aimed at the manufacturing metaphor, but we are being asked to build a new person with faulty parts and may not always have the best control over the outcome. Nonetheless, we must begin to identify those processes that lead to better outcomes, especially with significant changes in healthcare. For example, we face new challenges in the areas of electronic medical records and reimbursement for the work that we accomplish on behalf of our customer base-patients, payers, and regulators. If we follow the proactive lead as exemplified in the article on page 182, we must look at the glass as half full and follow the authors' lead.
"If not us, who? If not now, when?"
-John F. Kennedy
Richard "Sal" Salcido, MD
Cesario SK. Designing health care environments: part I. Basic concepts, principles, and issues related to evidence-based design. J Contin Educ Nurs 2009;40:280-8.
Kim CS, Lukela MP, Parekh VI, et al. Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach. Am J Med Qual 2010;25:211-7.
Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med 2006;1:191-9.
O'Brien ML, Lawton JE, Conn CR, Ganley HE. Best practice wound care [published online ahead of print January 28, 2011]. Int Wound J 2011. doi: 10.1111/j.1742-481X.2010.00761.x.