How to effectively manage quality systems, protect patients and improve outcomes


Hospitals can prevent adverse patient events and improve safety outcomes by easily implementing a quality management system following ST90 guidelines. 

During a May 13 webinar hosted by Becker's Hospital Review and sponsored by Healthmark, Mary Ellen Fortenberry-Moore, central region manager for Healthmark, discussed current recommendations for establishing a Quality Management System in processing departments. She also reviewed resources and information needed for effective operation and monitoring of the system, and discussed the poor outcomes that can occur when systems aren't used or maintained.

After recognizing hospitals needed a QMS incorporated into recommended practices, the nonprofit Association for the Advancement of Medical Instrumentation developed ST90 in 2017. The guidelines are designed to help healthcare organizations safely, efficiently and effectively process medical devices. In the past, hospitals have been slow to adopt such systems, but with the AAMI ST90, facilities have clear guidance to implement and maintain an effective system for sterile processing and endoscopy settings.  

Outcomes and reimbursement

While delivering quality care has always been the aim of providers, the emergence of value-based care has intensified this focus by linking reimbursement to performance. Under the ACA, the government can cut payments to hospitals reporting high readmissions rates, along with high numbers of infections and injuries. CMS penalizes 25 percent of facilities with the worst quality and safety performances. From 2014 to 2019, CMS penalized 1,756 hospitals, with 110 of those hospitals penalized every year of the program's duration, according to Kaiser Health News

In addition to reimbursement incentives, watchdog organizations and accrediting bodies assess provider outcomes and poor performance on these assessments can harm an organization's brand. The Leapfrog Group, for example, uses CMS data to assess patient safety twice a year at hospitals across the country. Using A-F letter grades, evaluations are based on hospitals' ability to protect patients from avoidable errors, injuries, accidents and infections. In Fall 2019, 33 percent of hospitals earned 'A' grades, 25 percent earned 'B' grades, 34 percent earned 'C' grades, 8 percent earned 'D' grades and less than 1 percent got an F.

To keep patients safe, achieve adequate reimbursement and protect the health system's brand, leaders have to make infection control protocols a top priority. Adhering to ST90 should be a part of any effective infection prevention strategy.

6 major steps for creating a quality management system  

Quality management systems are key factors to ensure patient safety and satisfaction. There are six main components all of these systems should have.

1. Identify critical business functions.

2. Identify and document procedures for each function.

3. Identify and document records showing compliance.

4. Communicate, train and implement procedure and record requirements.

5. Monitor accuracy and efficacy of procedures through quality inspections and review.

6. Review and revise procedures and documents to ensure applicability.

While all steps are extremely important, Ms. Fortenberry-Moore emphasized the need to document all steps, processes and procedures. "If you didn't document, you didn't do it," Ms. Fortenberry-Moore said.

QMS: Management responsibility and staff training 

All levels of management must provide evidence of their commitment to the overall awareness and maintaining its effectiveness. Management reviews should include both positive and negative feedback from stakeholders, results of internal and external audits and supplier assessment, along with follow up action related to previous management reviews. 

Required skills should be maintained through comprehensive training and education. 


Quality is all about the process, Ms. Fortenberry-Moore said, adding that healthcare organizations don't always have to invent the wheel to improve patient outcomes. There are numerous guidelines and resources to help reduce adverse patient events, starting with ST90. 

To learn more about Healthmark, click here. To listen to the full webinar, click here.

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