WHO Regional Publication, SEARO, No.

35

Health Care Quality

An International Perspective

Edited by
A. F. Al-Assaf, MD, CQA

World Health Organization

Regional Office for South-East Asia
New Delhi
 ISBN 92 9022 225 5
© World Health Organization 2001

Publications of the World Health Organization enjoy copyright protection in accordance

with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of
reproduction or translation, in part or in toto, of publications issued by the WHO Regional
Office for South-East Asia, application should be made to the Regional Office for South-
East Asia, World Health House, Indraprastha Estate, New Delhi 110 002, India.
The designations employed and the presentation of the material in this publication do
not imply the expression of any opinion whatsoever on the part of the Secretariat of the
World Health Organization concerning the legal status of any country, territory, city or area
or of its authorities, or concerning the delimitation of its frontiers or boundaries.
The views expressed in this publication are those of the author and do not necessarily
reflect the decisions or stated policy of the World Health Organization; however they focus
on issues that have been recognized by the Organization and Member States as being of
high priority.

Printed in India
 This book is dedicated to
health professionals in developing countries
who are striving to improve the
quality of health care at all levels of
their health care systems.
 List of contributors
Editor: A. F. Al-Assaf, MD, CQA

A. F. Al-Assaf, MD, MS, MPH, DCTM, Lutchmie Narine, PhD

FRSH, FAAMA, FACMCA, CQA Assistant Professor
Associate Professor and Co-Director Department of Health Administration
Center for Intemational Health University of Toronto
College of Public Health Toronto, Canada
University of Oklahoma Health
Sciences Center Namita Pradhan, MA
Oklahoma City, Oklahoma, USA Technical Officer, District Health Systems
World Health Organization
Robert W. Broyles, PhD Jakarta, Indonesia
Professor
Department of Health Administration Philip Stokoe, MBBS, MPH, MSc, PhD
and Policy Health Services Consultant
College of Public Health ADB Rural Health and Population Project
University of Oklahoma Health Ministry of Health
Sciences Center Jakarta, Indonesia
Oklahoma City, Oklahoma, USA I.G.P. Wiadnyana, MD, MPH
Avedis Donabedian, MD, MPH Director
Emeritus Professor Health Centers Directorate
University of Michigan Ministry of Health
Ann Arbor, Michigan, USA Jakarta, Indonesia

Tawfik A. Khoja, FRCGP, MBBS, DPHC Abu Bakar Suleiman, MBBS, FRACP,
Mmed, FAMM, FACP, FRCPI, FRCSI, FRCSE,
Director General
FRCP, FRCPE, AMP, FASC
Directorate for Primary Health Centers
Director-General of Health
Ministry of Health
Ministry of Health
Riyadh
Kuala Lumpur, Malaysia
Kingdom of Saudi Arabia
Maimunah Abdul Hamid, MBBCH, MPH
Osama Samawi, MD, MHA
Head, Health Systems Research Division
Administrator
Public Health Institute
Al-Hussein Salt Hospital
Ministry of Health
Kingdom of Jordan
Kuala Lumpur, Malaysia

Page v
Health Care Quality: An International Perspective

Rusnah Hussein, MBBCH, LRCP Dennis Zaenger, MPH

Principal Assistant Director Quality Improvement Coordinator
Medical Development Division Washington Hospital
Ministry of Health Vienna, VA 24450
Kuala Lumpur Austria
Malaysia
Dr Humberto M. Novaes, MD, DR.PH
Ding Lay Ming, MBBS, MD President
Senior Medical Officer INTECH, Institute for Technical
Public Health Institute Cooperation in Health, Inc.
Ministry of Health 12 Pasture Brook Ct.
Kuala Lumpur Potomac, MD 20854
Malaysia U.S.A.

M. A. Kadar Marikar, MD, PGDH

Principal Assistant Director
Medical Development Division
Ministry of Health
Kuala Lumpur
Malaysia

Page vi
 Contents
Foreword .......................................................................................... ix

Preface .......................................................................................... xi

Chapter 1: Health Care Quality: Past to Present .................................... 1

Chapter 2: Quality in Health Care: An Overview ................................. 15

Chapter 3: Quality Assurance Activities .............................................. 27

Chapter 4: Quality Improvement: Tools and Methods .......................... 55

Chapter 5: Health Care Outcomes Management and

Quality Improvement ..................................................... 81

Chapter 6: Implementing Health Care Quality .................................... 95

Chapter 7: Improving Health Care Quality: Strategies

for Implementing Change ............................................. 111

Chapter 8: Lessons in Sustaining Health Care Quality ........................ 133

Chapter 9: The Costs of Improving the Quality of Health Care ............ 143

Chapter 10: Quality Assurance in Primary Health Care:

Saudi Arabia’s Experience ............................................ 163

Chapter 11: QA Project in Al-Hussein Hospital, Salt, Jordan ................. 177

Chapter 12: Quality Assurance in Malaysia ........................................ 189

Chapter 13: Health Care Quality: Experiences in Indonesia .................. 217

Chapter 14: Hospital Accreditation in Developing Countries ................. 241

Chapter 15: The Effectiveness of Quality Assurance ............................. 279

Page vii
 Foreword

H EALTH CARE services of good quality is an integral part of WHO’s

goal of health for all with primary health care as the key approach.
Until now, access to health care services had been given priority by all
Member States of the WHO South-East Asia Region. Based on the
principles of equity, coverage indicators were mostly used to monitor
health services’ performance. This situation is changing - the
effectiveness and efficiency of health services are now of equal concern
to policy-makers, health service providers and communities.

In recent years, the WHO South-East Asia Region has launched

various initiatives with the objective of improving the quality of health
care services at all levels. A movement to ensure quality in health care
services is becoming an integral component of health care programmes
in all Member States.

There is, however, a gap in the availability of reference material

on health care quality in developing countries. The idea of preparing
a book to fill this gap emerged from Dr A.F. Al-Assaf, Associate Professor
and Consultant, Health Care Quality and Preventive Medicine,
University of Oklahoma, U.S.A., when he visited the WHO Regional
Office in connection with the preparations for the Intercountry Meeting
on Quality Assurance in Health Care, which was held in Surabaya,
Indonesia, 16 to 20 December 1996.

Dr Al-Assaf volunteered to take up this challenge. The idea was

also welcomed by the WHO Eastern Mediterranean and Western Pacific
regions as well as WHO headquarters. I would like to express my
sincere appreciation and thanks to Dr Al-Assaf for taking this initiative.

Page ix
Health Care Quality: An International Perspective

In addition to the conceptual aspects of quality of care, strategies and

methods of application by eminent experts, Dr Al-Assaf has been able
to incorporate in this book the actual experiences in the implementation
of quality assurance programmes in a number of developing countries
in various regions of WHO.

I do hope that this publication will further enhance the development

of health care quality in developing countries. Let us make the next
decade the decade of quality.

Dr Uton Muchtar Rafei

WHO Regional Director for South-East Asia
New Delhi, India

Page x
 Preface

Q UALITY is a continuous process of incremental improvement.

Quality is also customer-focused and customer-driven. It relies
on data for effective and efficient decision-making. It is a process that
is continuous, dynamic and organization-wide. Everyone is responsible
for his or her quality outcomes and activities. It is everybody’s
responsibility and not only the responsibility of the “quality department”.

Quality is also global. If it can be applied in one country, it can

be applied in others as well. The results are dependent not on how
much technologically advanced one country is, but on how genuinely
it is supported and how sincerely it is orchestrated. It requires patience,
change agents, resources, and a keen and sincere interest in improving
on the status quo.

This book is the result of the author’s involvement and collaboration

with the South- East Asia Regional Office (SEARO) of the World Health
Organization. It is intended as a communication tool for the
international audience and, in particular, for the countries in the South-
East Asia Region. It is based on experiences of specific countries in
this Region as well as from other regions. The text in the book has
been divided into several chapters and represents both the theoretical
and practical approaches to health care quality with a prominent
international flavour. Therefore, this book describes the process of
health care quality from the conception of an idea to its introduction
and implementation. Accordingly, the book follows the international
quality cycle that describes the health care quality process in terms of
planning, setting standards, communicating standards, monitoring and
steps to be taken for quality improvement.

Page xi
Health Care Quality: An International Perspective

There is a chapter devoted to the definition of health care quality

and its associated terms like quality assurance, quality control, quality
improvement, and quality management. Another chapter is devoted
to the processes of quality assurance. In this chapter the idea of
planning for quality is introduced, and a set of steps and methods are
discussed to provide an understanding of the techniques of setting
and communicating standards in health care. This chapter also contains
a presentation on the process of monitoring and quality control, which
is followed by a chapter on outcomes management and one on quality
improvement and quality tools. The process of implementing quality
in health care and lessons learned for sustaining quality are also
discussed. Related to the process of health care quality are supportive
issues such as effectiveness and quality costs. These two issues have
been described in detail in two separate chapters.

Chapters 10 to 13 of the book highlight the involvement, activities

and accomplishments in health care quality of four countries, viz. Saudi
Arabia, Jordan, Malaysia and Indonesia. All these chapters are
practice-oriented and present case studies of health care quality
activities in those countries.

It is hoped that this book will be widely circulated in the Member

countries of WHO’s South-East Asia Region as well as in other
countries. This book has been written primarily to serve an international
audience, and is intended to provide practical scenarios and lessons
for countries around the world in an effort to support their quest for
quality. The book targets physicians, administrators, nurses, technicians
and all other health care professionals whether they are “quality”
professionals or not, as quality is everyone’s responsibility.

A. F. Al-Assaf, MD, CQA

Oklahoma City, Oklahoma, 1997

Page xii
The Effectiveness of Quality Assurance

Page xiii
 1 1
Health Care Quality: Past and Present
A. F. Al-Assaf, MD, CQA

Q
uality as a concept is and then eventually to outcome again. In
implemented in the same the current era of health care quality, it is
manner and is practised in the evident that health care professionals and
same fashion in any setting. Health care health care organizations are being driven
quality, in general, focuses on the concept primarily by care outcomes as a proxy for
that health care has three major health care quality. There is still, however,
cornerstones: quality, access, and cost. some emphasis on the process and improve-
Although one is dependent on the other and ment methodologies. Therefore, it is safe to
each one can impact one another, quality, say that we are currently in the mode of being
however, has a stronger impact on the two outcome-driven but process-focused. We
other cornerstones. Quality is achieved are measuring our outcomes against a set
when accessible services are provided in an of predetermined 'indicators' that we strive
efficient, cost-effective and acceptable to achieve as a higher level of accomplish-
manner. A quality service is one that is ment, yet we are doing so by focusing on
customer-oriented. It is a service that is the process(es) that lead to these outcomes.
available, accessible, acceptable, afford- Thus, it is becoming evident that most health
able, and controllable. Quality is achieved care organizations are practising selective
when the needs and expectations of the improvements and are trying to improve
customer are met. Of course, in health care those processes that have the most impact
the patient is the most important customer on the desirable patient outcomes. This trend
(Al-Assaf, 1993). has continued for the last few years and it is
predicted that it will continue well into the
It must be noted here that the main
new millennium.
purpose of this chapter is to identify the
trends in the evolution of quality in health All quality methods, when properly
care and not necessarily the exact dates or introduced, should ensure that services
the country where certain events occurred. rendered in an organization are quality
One may note the shift of focus throughout services and that the outcomes are quality
history from outcome to structure to process outcomes. Total quality and, in particular,

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Health Care Quality: An International Perspective

total quality management (TQM) was In the following pages, the evolution
originally introduced by certain quality of health care quality is described. Although
experts in Japan before it was "imported" one must admit that it is heavily based on
into the United States. This 'new' manage- American history, every attempt has been
ment concept was introduced shortly after made to give credit to other countries and
World War II in order to aid the Japanese communities where it is due.
manufacturing industry to improve their
products and ultimately their services. After
seeing major improvements made by the
Japanese, industries in USA took notice and
HOW QUALITY ASSURANCE
started a search for the factors that lay BEGAN
behind this remarkable product of quality
improvement. TQM was not introduced en Quality assessment and quality control in
masse in the US industry until the early health care date back to the mid-nineteenth
1980s. century in England. During that period, there
was an increased awareness of the sanitary
Let us now look at the history of this
problems associated with community
management concept and its evolution as
dwellings and use of minors as labourers.
a leadership paradigm. We will also take
a look at the shift of emphasis in health Dr Edwin Chadwick, a public health activist
care from structure standards to process and a pioneer, published a report in 1842
and, most recently, to outcome standards. which vividly described the unacceptable
sanitary conditions associated with urban
History has noted a considerable and rural communities in Britain at that time.
change in both the concept and application He attributed this problem to the lack or
of quality in health care. Actually, the word shortage of qualified public health profes-
'quality' was perceived differently throughout sionals who could provide quality service to
history. During King Hamourabi's time, the community. He recommended the
quality meant that errors were out of the establishment of guidelines with regard to
question. People making mistakes were the availability and training of public health
subjected to the same consequence as their workers. Influenced probably by Chadwick's
mistake had on others, and that is where
report, in the United States, another public
the famous words "an eye for an eye and a
health physician, Dr Lemuel Shattuck,
tooth for a tooth..." originated.
published a similar report but this one was
Other leaders throughout history took on the sanitary conditions in the town of
a similar approach while still others had Massachusetts. He, too, recommended the
developed specific criteria for a 'quality' improvement of the structural elements of
performance. Quality assurance as a public health sanitation and the establish-
science, however, was not recognized until ment of "sanitary police" to monitor the
the mid-nineteenth century with the work of sanitary conditions in local communities. In
Florence Nightingale. Britain, around 1854, Florence Nightingale

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 Healthcare Quality: Past and Present

served as the leading nurse during the Almost at the same time in the United
European Crimean War (Bull. 1992). States several physicians were conducting
Ms Nightingale was the first to notice the studies on the quality assessment of health
positive correlation between the introduction care. In 1914, a surgeon, Ernest Codman,
of adequate nursing care to wounded of Massachusetts General Hospital, studied
soldiers and the decrease in the mortality rate general surgeries and their follow-ups and
among this group. This concept triggered her was responsible for influencing the adoption
interest in studying the relationship between of follow-up progress exams after one year
the quality of care and positive outcomes. of surgery. This prompted the American
She busied herself after the end of the war College of Surgeons to create, in 1918,
documenting this fact in several studies that the Hospital Standardization Programme
looked at other components of quality. She that provided the criteria and standards for
started looking at the extent of services and accreditation, which were later adopted by
resource utilization and their impact on the Joint Commission on Accreditation of
quality outcomes, and was instrumental in Hospitals.
writing up several quality criteria in nursing
Just prior to this an interest to develop
care. These criteria are considered to be the
structure criteria had been created. In
first nursing care standards in history. A
1910, Abraham Flexnor presented his
period of testing of these concepts was famous report after his study of the
passed and a few other clinicians attempted education of physicians in the U.S. and
to further study the correlation between care was quick to point out the deficiencies in
and outcome. the medical education system. He further
During the early part of the twentieth pointed out that the education of
century a British physician, Emory Grove, physicians was directly related to the
surveyed all hospitals with more than 200 quality of care the patient received and
that medical education needed substan-
beds regarding mortality as a post-
tial reforms. As was expected, this report
operative complication. Even though Dr
forced a considerable number of medical
Grove collected some important data, he
schools to close their doors for their
ran into problems when he attempted to
inability to meet the report's reform criteria.
compare one hospital with another using
It should be noted here that with this report
the same criteria. Still, he noted major
the emphasis shifted from process
variations in mortality between different
elements to structure elements, i.e. the
diseases and, based on this survey,
human and physical resources. Education,
recommended the development of a
certifications and licensure became very
standardized classification of diseases and
important in 'qualifying' a health care
establishment of a follow-up system for
professional and an educational organi-
post-operative conditions over a long
zation. Several professional associations
period of time to minimize complications
were established to provide these services
and reduce mortality. with state licensure and examining boards

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Health Care Quality: An International Perspective

spreading slowly but gradually throughout For health care organizations, the same
the country. interest in structure quality started to take
effect, which influenced the American
Not much was done on health care College of Surgeons to establish, in 1952,
quality during the 1920s and 1930s. This the Joint Commission on Accreditation of
could be attributed to the First World War Hospitals (JCAH) (later changed to the Joint
and/or the economic depression that Commission on Accreditation of Health
followed. Two events are, however, worth Care Organizations (JCAHO). The JCAH,
mentioning. Although not in the area of as it was then referred to, published its first
health care, the 1920s witnessed the list of accreditation standards with which
application of quality improvement through hospitals had to comply in order to receive
process control and improvement as a their accreditation certificate. Hospitals that
result of the pioneering work of Shewhart, met these standards were accredited and
Dodge and Roemig. Their work emphasized certified as a 'quality' institution. It is
prevention management as an approach interesting to note here that this first list of
to quality improvement. Therefore, through accreditation standards fitted on one single
the development of the statistical process page (the list today is compiled in a number
control (SPC) chart and other statistical of manuals of a few hundred pages each).
tools, a process and product could be The then JCAH standards were primarily
closely monitored and acted upon before structure standards which emphasized the
it ever produced defectives. It is on these quality of the credentialing process and the
principles that the theory of total quality risk management standards. Basically the
management (TQM) is based and how it is objective of the accreditation process was
applied in health care, which will be to ensure that care was delivered in a safe
described later in this chapter. physical environment and by qualified
The mid-1930s saw the passage of the providers. Of course, the JCAH thought that
National Social Security Act of 1935 that meeting the structure criteria was equivalent
afforded an increased access to health care to providing quality medical care.
services for the needy and may have had Interest in quality measures continued
an indirect effect on the quality of health care in the 1950s. In clinical practice at least
services, as certain provisions were outlined three American physicians, Morehead,
in the Act which related to the expected Payne, and Peterson, studied the quality of
performance of providers. Access to health medical care delivered by practitioners in
care dominated the trend in global events the U.S. Unlike JCAH, those studies were
and several activities in different countries primarily process-oriented that looked at
emphasized increasing the availability and the process of the care delivered. According
affordability of health care services. Most of to Brook and Avery (1975), one study by
these events, however, were associated with Dr O. L. Peterson looked at the care
improving the structure of health care provided by general practitioners.
resources, both physical and human. Dr Peterson looked at the processes and

Page 4
 Healthcare Quality: Past and Present

procedures conducted during patient statistical quality control which said that
examinations and follow-ups. Another errors could be predicted and further
physician, Dr M. A. Morehead, looked at prevented from happening before produ-
the ambulatory care practice of physicians cing a product. Therefore, a defective
as compared to their peers. The third study product was almost never produced and
was conducted by Dr B. C. Payne who that the consumer would never see one. The
compared the care delivered by a select Japanese learned rather quickly that in
group of physicians in acute care hospitals order for them to survive, four major issues
with a set of pre-designed criteria of care. needed to be realized: the consumer of their
All the three studies concluded that there products must be studied and looked after;
were deficiencies in patient care and that total systems, not components, needed to
the quality of care needed to be be studied in detail; teamwork must be the
continuously monitored and improved. way to do business; and that decisions must
be based on data. They also understood
that focusing on meeting customer needs
THE EARLY YEARS OF TQM and expectations was the only way to
improve their economy.
During the same period and in 1948-1949 It should be noted here that Japan at
Japan was trying to recover from the losses this time was completely broke. The country
of World War II and to find ways to revive had no natural resources such as oil and
its economy. An observation was noted by fuel. The only resource was its people.
several Japanese engineers that quality Japan also knew that for these people to
improvement will almost always lead to be fed, manufactured products needed to
improvement in productivity (Deming, be successfully marketed and sold to an
1986). This observation was extracted outside market. Of course, such markets
through the earlier work of Walter A. were already receiving higher quality goods
Shewhart (1931) and from the literature that the Japanese were not producing.
supplied by Bell Laboratories (through the Therefore, the need for improving the
staff of General MacArthur). This simple quality of products was a must for Japan
observation became the impetus for to survive. Managements started to make
Japanese management to learn the quality the most important target to achieve.
methods of proving it. In 1950, W. Edward Managements further communicated this
Deming, an American statistician, was defect-prevention paradigm to their
invited to Japan to introduce and teach the workers, a paradigm that predicted that
methods of improving quality and TQM. improving quality will cause costs to decline
Dr Deming was instrumental in proving to (less rework, less waste and less errors),
Japanese engineers that improving produc- leading to better use of human and physical
tivity was dependent on decreasing the resources, further leading to improved
variability of processes in a plant. He productivity. As productivity improves, more
emphasized the principle of Shewhart's markets are captured which is paramount

Page 5
Health Care Quality: An International Perspective

for staying in business, thus maintaining to find answers. Soon it became obvious
and creating more jobs. This paradigm was to American industries that quality was
further communicated to every worker with dependent on the worker and that tapping
the emphasis that producing affordable, this potential was important for improving
dependable, defect-free and acceptable productivity. A number of programmes
products was important for them to keep sprung up throughout American companies
their jobs and for Japan to buy its basic that were based primarily on worker
needs. Therefore, it became obvious to all participation and involvement in problem-
workers that improving quality was not only solving. From quality circles to employee
a requirement of their job but was also an involvement to quality of life, all these
individual and personal responsibility. programmes were based on participative
management. These and other
TQM started spreading in Japan's programmes were continued through the
corporations and institutions during the next 1970s with varying degrees of successes
20 years. During the same period the and outcomes.
American industry was almost unopposed
in its products and services. This period, For those companies that understood
although dominated by American goods the cultural change, quality improvement
and products, was detrimental to the was achieved while others were not as
American industry due to the lack of successful. When the commitment of the
incentives for marked improvements and management was not there, all these
'breakthroughs'. programmes that encouraged employees'
participation started to wear off as they felt
It was not until 1973 when the oil their work was not being encouraged and
embargo started to make an impact that appreciated. Managements of these
American industries came to realize their companies (and they were in a majority) did
dependence on other countries for survival. not realize that the stagnation in the
Suddenly the automobile industry started economy and the problems facing the
noticing that foreign cars were getting more American industry were mainly system
and more of the auto market in the U.S. problems and not those of the employees.
The same was noticeable about other These companies did not know these facts
products, especially those from Japan. until June 1980 when NBC aired the
From cameras to electronics to watches, landmark programme on television, entitled
Japanese products started to gain further "If Japan Can, Why Can't We". Dr W.
markets at the expense of local American Edward Deming was interviewed. He told
industries. Japan became an exporter of his experiences and successes with the
many other products not only to the U.S. manufacturing industry in Japan. He
but to Europe, Asia and the rest of the mentioned that a combination of basic
world. American corporations started management skills and statistical process
looking for the reasons of these successes control to reduce variability were major
and began studying Japanese companies factors for improving quality and produc-

Page 6
 Healthcare Quality: Past and Present

tivity. It was only then that major U.S. Medicaid did provide certain incentives for
corporations put this philosophy to the test providers to deliver 'quality' service. During
and introduced it in their settings. This and after this time, JCAH (as it was then
philosophy started to gain in popularity known) was encouraged by the government
among other companies and during the to 'enforce' its accreditation requirements
next several years this 'quality movement' and tighten its standards for certifying the
became a reality for several industries in quality of hospitals. This role, which is
the U.S. considered by some as semi-regulatory, had
a major influence on the establishment of
quality assurance departments in health
QUALITY IN HEALTH CARE care organizations.
Around the same time, in 1966, Dr
Going back to health care, several events Avedis Donabedian, a university professor
happened before health care organizations and physician, introduced his famous three
began to adopt TQM or quality improve- measures of quality: structure, process, and
ment principles. TQM did not become a outcome. He urged health care organiza-
known entity in health care until the late tions to look at all the three measures when
1980s. It was primarily a business manage- monitoring and assessing the quality of
ment practice somewhat foreign to health care. He further described 'structure' as the
care. Of course, in health care, quality was input to the health care system to include
'assured' through the efforts of several both human and physical resources
quasi-regulatory agencies that demanded associated with the delivery of health care
the application of certain care standards. to the patient. 'Processes', as he described
This was evident in the sequence of events them, included all the procedures and
that are discussed below. activities required to deliver medical care
by providers and support systems.
In 1965, President Johnson signed into
'Outcome', on the other hand, included
law two major amendments of the Social
results and outputs of the care process; for
Security Act, namely, title 18 (Medicare) and
example, morbidity and mortality rates, and
title 19 (Medicaid). The main objectives of
patient satisfaction. This model prompted
these amendments were to increase access
different players in health care to use it but
to health care services by certain bene-
its misinterpretation led to the use of these
ficiaries and, in particular, the elderly and
measures separately and independently
the poor. However, the Act also provided
from each other.
mechanisms that promised to ensure the
provision of quality health care services to In the same year, the U.S. government
those benefiting. Here again, quality of care passed two quality-related Acts, the
is promised through an emphasis on Comprehensive Health Planning Act and
structure (providers and institutions) and to the Regional Medical Program Act, both of
a lesser extent on process (the way care is 1966. The first tied spending to better
delivered). Nevertheless, Medicare and planning and the other provided funds for

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Health Care Quality: An International Perspective

research towards improved health care seemed novel at the time, with the potential
services. to decrease the rise in health care cost by
controlling access to 'costly' health services
During the next decade (1970s), the U.S. and to begin the process of 'managing'
government's concerns over cost escalations care. Even though this concept had
in health care continued. In its attempt to potential, its adoption by the insurance
control cost and preserve quality, the U.S. industry was slow and did not show major
legislature passed two bills during this period breakthroughs until late in the 1980s.
which made a direct impact on the quality
of care delivered. One of these bills passed, This trend continued as the U.S.
in 1972, established the Professional government, being the highest spender on
Standards Review Organizations (PSROs). health care, looked for ways to contain a
These organizations were to review the sharply rising and seemingly uncontrollable
standards of care provided to inpatients and health care cost and to maintain quality at
to ensure the delivery of adequate and the same time. The government was first to
appropriate treatment to these patients. The realize that after a decade of PSROs'
PSROs however received several negative activities, health care costs were still rising
reactions from interest groups. The JCAH and the quality of care was not improving.
looked at them as organizations competing Therefore, funding was ceased for PSROs.
for the same market. With the PSROs being This further paved the way to introduce the
physician-oriented, other groups felt that Diagnosis Related Groupings (DRGs) as the
their non-representation was counter basis for the reimbursement of medicare
productive to an effective evaluation of care providers (inpatient services). Reimburse-
processes. Physicians, on the other hand, felt ments were to be carried out under a
that their work and humanitarian efforts to prospective payment system (PPS). PPS
preserve life was being questioned. Repre- became effective in October 1983. The
sentatives of physicians on these organiza- system again provided for a mechanism to
tions found themselves ostracized by their ensure both access and quality of care
peers and were somewhat looked at as associated with an efficient cost-reduction
'traitors' to their profession. All these factors effort. Another measure to control costs was
hindered the real function the PSROs were the establishment of Peer Review
originally created to fulfil. Despite the failure Organizations (PROs) in October 1984.
of the PSROs to achieve their objectives, they
were however the first to influence the The PROs were established to replace
emphasis on process quality. This notion PSROs in their attempt to assess and
opened the door for a new paradigm shift improve the quality of care delivered.
in quality monitoring and assessment. Similar to PSROs, PROs' services extended
only to medicare inpatient services;
The second bill was passed in 1974 to therefore, their impact on the quality of
open the door for the creation of Health care, though considerable, was still limited.
Maintenance Organizations. This concept Again, PROs looked only at the process of

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 Healthcare Quality: Past and Present

care. Unlike PSROs, PROs' membership is tration-physician relationships began to

not necessarily limited to physicians and show some stress, as one started blaming
others have liberal access to them. A PRO the other for the cause of the problems.
can be a for-profit or not-for-profit
organization that can bid for contracts from This situation was further exacerbated as
the U.S. government to meet the mandate physicians relied on practising medicine
of monitoring the care processes. Hospitals defensively. Physicians started ordering more
are required to contract with a PRO to (usually unnecessary) tests before making
review their services. PROs have the any diagnosis on the patient's condition in
authority to enforce quality improvement an attempt to protect themselves from the
measures on the provider by either an potential of a malpractice. Certainly the legal
extensive evaluation process or through system did not help alleviate this situation
monetary fines, among other sanctions, and but on the contrary made it worse. Lawyers
disciplinary measures. PROs also have a were prompting patients to question their
mandate to review other professional providers about any unexpected outcome of
provider services rendered in a hospital and care. Those same lawyers 'volunteered' their
may refer to these professions for advice services to these patients on a contingency
on specific care standards. basis and would accept payments only until
a financial settlement or judgement was
Starting in the 1970s and especially reached (usually 33% - 50% of the award).
during the 1980s and after, hospital quality This trend continued to escalate the misuse
assurance departments and units became and mis-allocation of precious resources
very active in collecting and analysing data and, of course, the expenditures (not the
on patient care and health risk manage- quality) on health care kept rising (Al-Assaf,
ment. This was accomplished in a long and 1994).
painful pursuit of ensuring and maintaining
quality of care. This pursuit became painful Here, again, the U.S. government
as the objectives were to emphasize the stepped in and, as a reactionary measure
structural aspects of a programme, in to the malpractice crisis, passed the
particular human resources, e.g. creden- National Health Quality Improvement Act
tialling and certification. QA professionals of 1986. This Act had two major provisions
felt new 'power' of searching for those 'bad' that encouraged patients to become
providers. These 'bad' providers felt informed consumers of those providers with
harassed by the system and once their a record of malpractice. It called for the
'mistakes' became public, medical liability creation of a National Clearing House of
lawsuits started to rise. This trend negatively providers' malpractice records in the U.S.
affected the providers (including their Further, the Act made it mandatory for
institutions) and their patients. Patient- health care institutions to report incidents
provider relationships started to erode and of malpractice of providers to this clearing
providers lost the anticipated trust owed to house. The Act encourages this effort by
them by their patients. Also, the adminis- providing immunity against violations of

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Health Care Quality: An International Perspective

privacy lawsuits that may be initiated by (JCAHO) to include other health care
those providers. This information therefore organizations besides hospitals as they were
could become available to licensure boards already including other institutions in their
and other entities inquiring about practising accreditation process. In an effort to
providers in different states. Due to continue their tight grip on the market, they,
inadequate funding for the Act, it was not too, announced their Agenda for Change
implemented until 1989. (O'Leary, 1987), which called for a gradual
refocus of JCAHO's standards towards
It is obvious that this Act was passed in outcomes. These events stimulated several
an attempt to 'improve' the quality of other groups to start looking at clinical
medical care delivered, but again the outcomes and physician practice patterns
emphasis was put primarily on structure as qualifiers for health care quality (Daley,
without involving process and outcome 1991).
measures. Yet, this government intervention
signalled another trend where quality had Outcome assessments were later
to be maintained through regulation. explored further by researchers and more
funding became available, especially in the
In the midst of all this, and by the late area of clinical outcomes research. Also,
1980s, the focus of the government shifted in their quest for better outcomes with
from the PROs' process-oriented review and limited resources, the health care industry
away from the JCAH's structure-oriented started looking outside its field for answers.
review to a renewed emphasis on This thinking prompted TQM to enter into
outcomes. In December 1987, HCFA this industry in the late 1980s. Again, the
published the Medicare Hospital Mortality U.S. government provided support for this
Information list (HCFA, 1987). It made movement through the National Demons-
headlines when excerpts from this hospital tration Project, where funding was allocated
mortality list were published in the New York to the introduction of TQM or the like into
Times. Major reactions came from the health care through a number of demons-
hospital industry refuting the validity and tration or pilot projects. Starting with
usefulness of this list. They pointed out that hospitals and followed by other health care
this list did not take into consideration the organizations, the principles of TQM began
case-mix index, i.e. they asked for a to filter into this industry. Leadership
differentiation between the acute care paradigms that were originally designed for
hospitals and cancer treatment ones. manufacturing were modified in an attempt
Despite the flaws associated with this list to make them applicable to health care.
(and the annual lists published thereafter) Quality experts were quick to realize that
it triggered many organizations to start the amount of work necessary to bring this
looking at patient outcomes. The Joint giant industry to the realms of quality
Commission on Accreditation changed its management was tremendous. Thus,
name to the Joint Commission on several of these experts started setting up
Accreditation of Healthcare Organizations companies and subsidiaries to educate the

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 Healthcare Quality: Past and Present

masses in health care on these relatively quality assessment is still strong, a more
new philosophies. Health care profes- traditional trend is returning whereby
sionals, on the other hand, found a processes besides clinical outcomes are
tremendous appetite for learning more of being highlighted again.
this concept and started flocking to institutes
and workshops designed for them by these On the global arena, two large inter-
quality experts. national donor organizations became
interested in health care quality. The US
This trend continued throughout the first Agency for International Development
half of the 1990s and was as active in (USAID) funded a multi-million dollar
1997. Now most hospitals and managed project, the Quality Assurance Project, in
care organizations in the US have either 1990, to introduce QA in developing
started the journey for TQM or are making countries around the world. The U.S.
headway towards that goal (AHA, 1996). contractor, University Research Corporation
A similar trend is visible in the world where (URC), assembled a formidable team of
a number of countries have taken active experts and began its journey for increasing
steps towards the implementation of awareness about QA internationally. URC
quality assurance (QA) in their health care soon set up projects in Chile, the Philippines,
facilities. Indonesia, Jordan, Egypt, Niger and some
30 more countries where QA was the main
Another noteworthy trend here is that theme of solving problems, cost-containment
the concept of assessing quality based on and improving health care outcomes.
outcomes received further boost with the
introduction and funding by the US Similarly, the World Health Organization
Congress of the Agency for Health Care (WHO) realized that quality was extremely
Policy and Research (AHCPR) in 1989. This important for countries in their quest for
move by the Congress was in direct better services and improved health care
response to the call by the Institute of outcomes. During the early 1980s the
Medicine's report of 1989 (IOM, 1989), European Region of WHO sponsored QA
which called for the need to emphasize activities related to laboratories, blood banks
patient outcomes in the delivery and and radiology among many others. A
improvement of health care. This agency considerable number of procedures and
was created to enhance the quality of care protocols were developed and disseminated
by the search and development of clinical in that Region and elsewhere. WHO
practice guidelines (CPGs) based on patient organized an inter-regional conference on
outcomes. The AHCPR became active in Assurance to Quality in Primary Health Care
sponsoring several activities in the area of in Shanghai, People's Republic of China, in
CPGs and to date at least 18 general CPGs October 1990. This was followed by an
have been developed (AHCPR, 1996). This International Consultation on Quality
trend, however, is also changing and Assurance in District Health Systems Based
although the emphasis on outcome for on Primary Health Care at Pyongyang, DPR

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Health Care Quality: An International Perspective

Korea, in 1992. During that conference a becoming more prevalent in the health care
number of experts were invited to present field. At present several of these report cards
their perspectives on QA and its proper intro- are published periodically on health care
duction at the global and national levels. organizations ranging from hospitals to
This conference became the impetus for HMOs to individual providers. These report
future activities of WHO to support QA cards give consumers and purchasers of
programmes in a number of countries health care a fairly good idea of the
worldwide. Thus, several inter-country/ performance level and sometimes the
regional meetings on QA followed with quality of care and services of these
representations from a large number of providers. It is believed that the trend will
countries to share ideas, experiences and continue throughout the early years of the
strategies for QA implementation and new century as consumers are becoming
sustainability. Every region of WHO became ever more prudent in 'shopping' for health
actively involved in the organization and services. Access to information is also
delivery of QA meetings within their own becoming easier with the increasing use of
area. In addition, WHO headquarters in such technologies as the Internet and
Geneva co-sponsored a number of pre- electronic mail.
conference sessions on QA in developing Another trend which is making a
countries at the annual conferences of the 'comeback' as we enter the new millennium
International Society of Quality in Health is the accreditation of health care organi-
Care. Efforts of WHO to introduce and zations. One country after another is
further sponsor QA activities in several of its following suite with the American, the
regions are noteworthy. These include the Canadian and the Australian experiences
sponsorship of short-term consultants, the in introducing accreditation as a system in
organization of training workshops on QA, their own health care. The World Health
the publication of documents directly related Organization has also taken the lead in
to QA in health care, and its applications in organizing such discussions and has
Member countries. In this book at least four sponsored a number of country-specific
countries are featured to describe their technical assistance programmes to advise
experiences in health care quality. on accreditation. A number of WHO
regions are becoming more active in this
Another area that became increasingly area of development where activities have
important in the late 1990s in health care already been planned for the organization
was performance measurements and report of meetings on the subject, including the
cards. This new trend had actually started formulation of policies on the introduction
in the early 1990s when health consumers and implementation of accreditation in
and purchasers started demanding compa- Member countries. A number of countries
rative performance data of health care have already participated in such meetings
organizations. Reporting of performance and are actively preparing for the
data in the form of 'report cards' is introduction of an accreditation system.

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 Healthcare Quality: Past and Present

It is evident from the above discussion 3. Brook R and Avery A. Quality Assurance
Mechanism in the U.S.: From There to Where?
that quality, especially quality improvement
Rand: Santa Monica, CA, 1975.
and management, are fairly new concepts
4. Bull MJ. QA: Professional Accountability via CQI,
in health care. When first introduced, they in Improving Quality: A Guide to Effective
received a mixed reaction. Since quality in Programs. C. G. Meisenheimer (Ed.), Aspen:
health care calls for a cultural change in Gaithersburg, MA, 1992.
an organization, traditional bureaucrats 5. Codman E. The Product of a Hospital. Surgical
fought against its quick adoption. They Gynecology and Obstetrics, 1914, 18:491-494.

have since accepted the change, though 6. Daley J. Mortality and Other Outcome Data, in
Quantitative Methods in Quality Management:
reluctantly, as this leadership paradigm A Guide to Practitioners, Longo and Bohr (Ed.'s),
moved through different levels of manage- AHA: Chicago, 1991, 27-43.
ment with swift steps, backed by consumer 7. Deming WE. Out of the Crisis. MIT: Cambridge,
groups, regulators and accrediting MA, 1986.
agencies. In the next two chapters this issue 8. Donabedian A. Evaluating the Quality of Medical
of health care quality and its late adoption Care. Milbank Memorial Fund Quarterly, 1966,
44:194-196.
is further explored and the factors behind
9. Health Care Financing Administration. Medicare
the change are discussed in detail.
Hospital Mortality Information: 1986, GPO No.
017-060-00206-9, Vol. I - VII, U.S. Department
of Health and Human Services, Washington, DC,
References Dec. 1987.
10. HEDIS 3.0 Requirements. NCQA: Washington,
1. Al-Assaf AF and Schmele JA. The Textbook of DC, 1997.
Total Quality in Health Care. St. Lucie Press, 11. O'Leary DS. The Joint Commission Agenda for
Delray, FL, 1993. Change, JCAHO: Chicago, IL, 1987, 1-10.
2. Al-Assaf AF. Quality Improvement in Health Care: 12. NCQA. Accreditation Standards for Health Plans,
An Overview. Journal of the Royal Medical NCQA: Washington, DC, 1997.
Services, 1994, 1(2).

Page 13
 2 2
Quality in Health Care: An Overview
A.F.Al-Assaf, MD, CQA

INTRODUCTION So what is quality? Is it excellence? Is

it the best? Is it the 'Cadillac' service? Not

W
henever health care issues are necessarily. Quality can be a simple
discussed, three concepts keep measure to achieve the desired objectives
coming up. These are: access, in the most efficient and effective manner,
cost, and quality. Obviously, access with the emphasis on satisfying the customer
involves physical, financial and mental or or the consumer. It is not necessarily the
most expensive way to do things. On the
intellectual access to available care and
contrary, it is a call for efficiency and cost
health services. The issues of affordability
savings. It is not necessarily luxurious items
and efficiency are also important.
or services. It is, however, a product or a
However, services provided in a health
service that is acceptable, accessible,
care institution should have certain charac-
efficient, effective and safe that is
teristics beyond the issues of affordability
continuously evaluated and upgraded.
and availability. It should involve elements
and characteristics of quality. Elements of Quality is also measurable. A system
acceptability by the consumer are actually is usually made up of three components:
the most important. If the consumer (the inputs, processes, and outputs. The quality
patient) does not accept the services of inputs (structure) can be measured. This
provided, he/she will neither seek them nor includes the quality of personnel, supplies,
approve of them even though these equipment, and physical resources. The
services are available, accessible and quality process is also measurable.
affordable. Therefore, the quality of Diagnostic, therapeutic and patient care
services rendered are crucial to health procedures and protocols are all measur-
care. Quality, however, should be from the able and quantifiable. The same is true of
perspective of the consumer, because system outcomes or results. They too are
quality care is acceptable service by the measurable. For example, hospital infection
consumer of that care. rates, morbidity and mortality rates as well

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Health Care Quality: An International Perspective

as patient and employee satisfaction are all • "Quality is meeting the

outcome measures and are all measurable requirements of the customer, both
variables. Therefore, the system compo- internally and externally, for defect-
nents of inputs, processes and outcomes free products and services." – IBM,
have certain quality characteristics that are 1982.
measurable and are important in • "Quality is providing our customers
quantifying the quality of a system. with innovative products and
One issue related to the topic of quality services that fully satisfy their
involves communications and sharing of requirements." – Xerox, 1983.
information. The world is certainly becom- • "Quality therefore is a process of
ing smaller through the advances in meeting the needs and
communications technologies and trans- expectations of the customers, both
portation linkages. Therefore, advances internal and external. Quality can
and accomplishments of health care quality also be referred to as a continuous
in one part of the country must be process of incremental
communicated with other parts. Sharing of improvement." – Al-Assaf, 1998.
ideas and learning from one another is an
Meeting the needs not the wants of the
attribute of quality as well. Furthermore,
customers are emphasized. Certainly, the
quality in health care and services is no
issue of affordability and available
longer being judged solely at local or even
resources should be taken into considera-
at regional level, but it is becoming
tion. Also, one should study the needs and
increasingly important for organizations to
expectations of both types of customers,
compete in these areas at national level.
external and internal. Staff and employees
Therefore, in order to define quality one are internal customers to the administration
may refer to several definitions that present and their needs and expectations should be
the concept most eloquently. Here is a list known and studied and every effort should
of some of these definitions: be made to meet them.
• "Quality is conformance to External customers are represented
requirements or specification." primarily by the patients, but other entities
– Philip Crosby, 1978. that the organization in question deals with
• "Quality is doing the right thing should also be investigated and studied to
right the first time and doing it identify and meet their needs and expecta-
better the next." – Al-Assaf, 1993. tions. Thus, quality has many perspectives
where each customer has specific needs
• "Quality is the degree to which care
and expectations to be fulfilled by the
services influence the probability of
provider organization.
optimal patient outcomes."
– American Medical Association, In conclusion, quality is never an
1991. accident. It is always the result of high

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 Quality in Healthcare : An Overview

intention, sincere effort, intelligent direction Quality control (QC) is defined by the
and skillful execution. It represents the wise National Association of Quality Assurance
choice of many alternatives. (1994) as "a management process where
actual performance is measured against
Now that quality has been defined, expected performance and actions are
what is the difference between quality taken on the difference." QC was originally
assurance (QA), quality improvement (QI), used in the laboratory where accuracy of
monitoring/quality control (QC), and total test results dictates certain norms and
quality management (TQM)? QA is the specific (and often) rigid procedures that
process of assuring compliance to specifi- would not allow for error and discrepancy.
cations, requirements or standards and Thus, it makes an effort to reduce variations
implementing methods for conformance. It as much as possible. QA and QC are
includes planning and design for quality, complemented and sometimes over-
setting and communicating standards and whelmed by QI efforts and processes. QI
identifying indicators for performance is defined as an organized, structured
monitoring and compliance to standards. process that selectively identifies improve-
These standards can come in different ment teams to achieve improvements in
forms; for example, protocols, guidelines, products or services. Therefore, TQM or
specifications, etc. QA, however, is losing quality management in general involves all
its earlier popularity as it resorts to discipli- of the above three processes — QA, QC
nary means for standards compliance and and QI. It involves processes related to the
therefore blames human error for non- coordination of activities connected with all
compliance. It must be noted here that this or any one of the above three as well as
term is widely adopted by the World Health the administration and resource allocation
Organization as the 'encompassing' term of these processes. Quality management
for all other concepts and terms. Several becomes the umbrella under which all
countries around the world also use the processes and activities related to quality
term QA in the same manner as WHO in fall.
that it means all of the concepts combined.
This in itself does not mean that WHO or
any other country using QA as the main THE MYTHS OF QUALITY
and only term do not recognize the
difference between traditional quality According to Peter Drucker, a management
assurance activities and the more contem- expert, people have different stereotypes
porary quality improvement or manage- and beliefs on quality. He calls them myths
ment activities. Therefore, in this section we of quality and they are the following:
will still introduce the difference in concepts
using the traditional terminologies as well • Quality means goodness, luxury,
as the new ones. shininess, or weight.

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Health Care Quality: An International Perspective

• Quality is intangible and therefore according to the simple system theory and
is not measurable. as it was applied to health care by Dr Avedis
• There is an 'economics of quality' Donabedian (1966), each health care
(e.g. "We can't afford it"). system can be divided into three compo-
nents: structure (human and physical
• Quality problems are originated by resources), processes (the procedures and
the workers. activities of care and services), and
• Quality originates in the quality outcomes (the results of care and services).
department. Certainly, each of these components has a
number of quantifiable elements that can
So, let us discuss these myths.
be accurately defined and measured. For
The first describes the notion that quality example, under structure, one might look
does not have to be the most expensive or at the quality of physicians in terms of their
the most prominent approach or product. training, experience and education as one
Actually, quality can be as simple as doing attribute of the total quality of the system
one's job better continuously. A quality car, of health care they work in. In the process
for example, does not have to be a Benz component, one may calculate the variance
or a Rolls-Royce. It may very well be a small of current procedures performed as
or a medium-sized car that is reliable, compared to a standard set of steps to the
requires low maintenance and is same procedure as another attribute of the
economical. A car that can take you from total quality of that health care system.
point A to point B with the least hassle. Additionally, for outcomes, one example
Similarly, a quality care does not have to might be to calculate the level of satisfaction
be only a care provided in the most of patients to the care provided in a health
expensive setting and by the most eminent care setting as a proxy measure of the total
professors of medicine. Health care quality quality of that system and so on. Therefore,
can be as simple as providing appropriate we find from the above that quality is
and necessary care to the right health care tangible and obviously can be measured.
consumer in the most efficient manner,
The third myth talks about the issue of
utilizing the currently available resources.
the relationship between cost and quality.
The second myth describes the incorrect The common belief is, incorrectly so, that
belief by many people that quality is quality is too expensive to achieve, therefore
something 'magical' and undefined to be we cannot afford it. This is definitely not
measured. They often believe that quality true. Quality is based on the principle of
is something of an ideal that cannot be cost-saving. If it is applied correctly, it
calculated or attained. However, we know should save money not cost more. Of
that this is not true. Quality is tangible and course, initially, you need certain 'new'
is measurable. Just think for a moment that resources to start the process of quality, but
health care is a system. Therefore, rapidly one will find out that cost- savings
are a reality. Quality calls for the

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 Quality in Healthcare : An Overview

elimination of waste, re-work and dupli- removed from the system for it to function
cation. Actually, one of the major principles properly. This notion is sometimes referred
of quality is efficiency. According to Suver to as "the bad apple theory" according to
et al. (1992), the costs of quality are three: Berwick (1989). Weeding out the outliers
the costs of prevention, appraisal, and in the system, according to this theory, is
failure (both internal and external). the way to improve the system. Based on
Implementing quality in a health care this assumption several quality experts went
system requires certain resources to provide on proving this theory as wrong. Whether
training in quality methodologies, securing it is Deming (1984), Crosby (1979, 1985)
monitoring capabilities, measuring or Juran (1988), they all found out that
performance and improvement accomplish- more than 85% of the errors could be
ments as well as the collection of necessary system-related while only 15% were actually
data for documentation of the status and human or worker errors. They went on to
level of care. Quality, however, reduces the emphasize the fact that if one would institute
costs incurred by the system by gradually a quality system of proper training, and in
reducing costs associated with failure. the presence of the right work environment,
Internal failure costs such as re-work, these workers will not make mistakes.
duplication and waste can be reduced and Mistakes happen when the system lacks
eventually eliminated if resources are used adequate policies, standard procedures,
wisely and processes are streamlined and tools. Errors also happen when there
effectively. It is also the objective of quality is a lack of systematic methods to document
to eliminate errors and mistakes in processes, study them and proactively act
providing care and service that may have on improvement opportunities even before
a detrimental effect on the external problems could occur. Therefore, a lack of
customer, primarily the patient. Thus, by a quality environment is what causes
doing so, external failure costs that are problems to occur and certainly not
usually the most costly (sometimes tied to because of the faults of the workers.
malpractice and liability issues) can be
further reduced and may eventually be The last myth presented by Drucker
eliminated. Quality and cost may actually suggests that quality is the responsibility of
have an inverse relationship in this model. the quality department. Again, this is
If quality is high then savings are the by- incorrect. The quality department should
product and cost is lower. So, quality is only act as a facilitator, an advocate or a
definitely inexpensive. coordinator of the quality efforts in the
system. It is really the responsibility of every
The fourth myth of quality suggests that worker to provide quality, to practise quality,
workers are the ones responsible for the and to ensure improvements towards
system problems and therefore errors must quality. Quality is everybody's responsibility
be attributed to them. Some people go even and it should originate from the system's
further and say that because of that these units and by the system's workers. Actually,
workers should be 'hunted' and swiftly in a quality environment, there will be no

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Health Care Quality: An International Perspective

need for a quality department as everyone • Pressure of competition, and to

will be responsibly for his/her own perfor- enhance marketing
mance quality. Just imagine that if all the
• Need for improvements in care and
workers of an organization were aware of
services
the responsibilities, and abided by their
standards of performance, why should then • Desire for recognition and to strive
there be a separate department telling the for excellence
workers what to do to achieve quality.
• Competition
Therefore, quality in reality should originate
with the workers and not the quality • Ethical considerations.
department.
As discussed earlier, one of the most
fundamental reasons for quality is to meet
the needs and expectation of the customer,
WHY QUALITY? both external and internal. Patients, of
course, are one important external custo-
Several reasons can be cited as to why we mer who have certain needs and expecta-
need quality and why we ask for quality. tions that providers are required to learn
Some of these reasons are given below, but about, investigate, understand and imple-
the reader is reminded that these are just a ment methods for meeting them. And that,
few reasons as compared to many other too, on a continual basis. Basically, it is a
reasons that can be cited. The reasons that process of effective communication
follow are in no particular order. between the supplier or provider of care or
• Increased demand for effective and health service and the consumer or the
appropriate care receiver of that care or service. It is a
continuous process of dialogue and
• Need for standardization and understanding between the two. Addi-
variance control tionally, one must not forget the other
customers in the system, namely, the
• Necessity for cost-saving measures internal customers, the employees, and the
other external customers such as the
• Benchmarking patients' families, the visitors, the payers,
• Accreditation, certification and etc. Each of them has special needs and
regulation expectations and it is our obligated duty as
health professionals to know them. There-
• Report cards on provider fore, meeting the needs and expectations
performance of the customer is a requirement for quality
and that is the reason why we must have
• Requirement to define and meet quality in health care, whether private or
patient needs and expectations public.

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 Quality in Healthcare : An Overview

As is evident from the above, quality is able to control variance, thus reducing
a desired entity by all health care providers. failure and appraisal costs as described
As ethical considerations above suggest, it earlier.
is the fabric of the very existence of health
care professions. Ethics dictate that one Important to the reasons why we strive
must provide the best and most appropriate for quality is the issue of competition in
care accessible to the patient. It is the basis health care. In the current era of cost
of the humanistic aspect of the health care constraints and limited resources even
system. It is our duty as health care health care institutions must demonstrate
professionals, and because of that we must their ability to provide services most
provide quality care and service to fulfil this effectively and most efficiently. It is a matter
ethical code. of survival in today's volatile market. Non-
price competition is becoming increasingly
Other reasons mentioned above such important as consumers of health care are
as effectiveness, appropriateness, and demanding better care and better access
efficiency are basic elements of a quality to appropriate care. Quality fits under this
system and quality care (Nicholas et al. type of competition where health care
1991). One cannot provide care without organizations would work hard to achieve
regard to available resources. It is true that that desired level of quality care in order
we all would like to provide, and receive, to attract new resources and expand to new
the best care there is, but it is prudent to horizons. Quality stimulates confidence and
do that within the limits of current resources. confidence leads to improved performance
Actually, if this is not taken into considera- which, in turn, attracts consumer trust that
tion then quality is not achieved. Quality would eventually lead to increased
requires efficiency in the use of health care marketability and membership.
resources and effectiveness in the delivery
of care and service. This issue will be further Of course, one cannot talk about
discussed under the section "The dimensions quality without talking about excellence.
of quality". Every prudent health care professional must
aim for excellence. This is what Crosby
In view of the above, it is clear that (1979) calls as 'Zero defect'. In other words,
quality can be achieved most effectively health professionals should do their very
once we know our baseline data and what best to improve their work processes and
we are striving for. The issue is of setting procedures, and perform them with zero
specific but incrementally improving defects. Errors need to be minimized and
standards of care. Identifying and selecting further eliminated to attain excellence. This
appropriate standards for the structure, the status of excellence, whether at individual
processes and the outcomes of care and or at organization level, will attract
health services would provide a guideline recognition in the field and will encourage
to follow and allow minimum variation from other individuals, organizations or systems
these standards. By doing so one would be to emulate and follow. In other words, this

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Health Care Quality: An International Perspective

is called benchmarking. Benchmarking is were led by top management. These efforts

the process of identifying centres (or although believed in individual responsi-
practices) of excellence specific to certain bility but these must be practised and
processes or procedures in order to study actively supported by top management.
and emulate in one's own system. Bench- Deming laid down 14 points for
marking stimulates re-organization, management:
innovation and improvements, all towards
1. Create constancy of purpose for
a higher level of health care quality.
improvement. Each organization must
identify its mission and communicate
its mission to all its employees for
PRINCIPLES OF QUALITY implementation.

Several principles come to mind when one 2. Adopt the new philosophy.
thinks of quality. Quality, as mentioned Organizations should identify their
above, involves the processes of QA, QC customers and learn their needs and
and QI. All of these three concepts expectations. He stresses cooperation
combined produce yet another fairly new and coordination.
concept called TQM, quality management
3. Cease dependence on mass inspec-
or just quality. It was described by several
tion. Emphasis should be on improving
experts or gurus of quality, namely, Taylor,
processes and establishing individual
Shewhart, Dodge, and Roemig as early as
relations.
late nineteenth century through the 1920s.
All these experts discussed the theories of 4. Cease buying based on price tag
'Scientific management' where quality as alone. Emphasis should be on the 'life
well as quantity were taken into considera- cycle costs' of the product or service.
tion in dealing with management issues.
They all introduced new methods of 5. Constantly improve the system of
statistical process control and quantifiable production and service. The key word
means in efficient management practices. is continuous improvement and not for
Based on these principles Dr W. Edward a period of time only. Deming, in this
Deming, a statistician, introduced new point, introduces the cycle of improve-
theories of management. Dr Deming was ment Plan- Do- Check- Act (PDCA)
invited by Japan after World War II to help where you plan (P), implement (Do),
revitalize its dying manufacturing industry. analyse and evaluate (Check) and act
Deming based his theories on the human (A) for improvement. It is a continuous
element and emphasized that developing cycle.
human resources was the best means to 6. Institute training on the job. Deming
achieve and improve the quality of products stresses practical training and active
and services. He stressed, however, that interaction with the customer to avoid
quality efforts were successful only if these problems and improve processes.

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 Quality in Healthcare : An Overview

7. Adopt and institute leadership. It is that if we only evaluate individuals

people-oriented where accessibility, yearly we are losing the opportunity to
support, active involvement and improve their performance during that
empowerment is practised. Leaders are year.
good listeners, promoters and
encouragers of innovation and 13. Institute a vigorous programme of
initiatives. education and self-improvement for
everyone. There should be a strong
8. Drive out fear. Making the work commitment to invest in employees by
environment fear-free of making offering them the opportunity to learn
mistakes, speaking out, taking risks, and develop professionally.
making decisions, enquiring, of
learning, and offering suggestions. 14. Put everyone to work to accomplish the
transformation. Deming here stresses
9. Break down barriers between that management's commitment is
departments. Deming stresses here paramount to the success of the quality
cross- functional teams, inter- improvement efforts. This commitment
disciplinary groups and interdepart- must be genuine and active where the
mental dialogue. This will allow for employee would sense and feel the
experience-sharing and efficient support provided by management.
utilization of limited resources.
Dr Joseph M. Juran is the other quality
10. Eliminate slogans, exhortations and guru. He also helped the Japanese re-
targets for work force. Deming main- establish their economy through improving
tains that these will attempt to shift the their products and services. Dr Juran defines
responsibility for quality improvement quality as fitness for use by the customer.
from management to employees. It will He focuses on three major quality
give false hopes and unrealistic processes:
expectations.
• Quality control and quality
11. Eliminate numerical quotas for the sequence
workforce and numerical goals for the • Quality improvement and
management. These quotas generate breakthrough sequence
result-oriented rather than
• Quality planning and annual
performance-oriented behaviours.
quality programme.
12. Remove barriers that rob people of Quality control attacks special causes
pride of workmanship. Eliminate the (uncommon or sporadic causes); break-
annual rating or merit system. through sequence attacks the chronic or
According to Deming, almost 85% of common causes where it involves great
errors are system (or management) efforts and innovative initiatives to solve
errors and not employee errors. Also, 'system' problems. The annual quality

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Health Care Quality: An International Perspective

programme involves planning or improve- conformance is unacceptable, and

ment implementation and evaluation of that error is not inevitable. He also
these efforts at least on an annual basis. criticizes certain companies that
Dr Juran also calls for continuous improve- would follow acceptable quality
ment and advocates project-by-project levels (AQL). He states that AQLs
improvement. At any point of time simulta- send the wrong message to
neous and numerous processes and workers and external customers
problems are being tackled by a process that making errors was acceptable
improvement team led by managers. Project and that may mean that personal
selection should be based on a return-on- performance for everyone was
investment calculation. Dr Juran has AQL.
published numerous books on quality.
4. The measurement of quality is the
The third quality expert is Philip B. price of non-conformance. Again,
Crosby, author of books like Quality is Free, this absolute is directly related to
Quality without Tears, Leading, and cost-containment where non-
Commitment. Dr Crosby is the reviver of the quality causes problems and
zero-defect concept. He calls for four problems cost money. Costs are
'absolutes' of quality: then wasted to detect those
problems (appraisal costs) in order
1. The definition of quality is confor-
to prevent those problems (failure
mance to requirements. Setting
costs).
those requirements, he believes, is
the responsibility of management Crosby also calls for 14 points of
based on customers' real need. management:
2. The system for causing quality is • Management commitment; active
prevention. This process should be and true commitment.
preceded by a system of detecting
• Quality improvement teams to
potential problem areas and
improve processes and solve
identifying methods for preventing
problems.
the occurrence of these problems.
This concept obviously has a direct • Quality is measurable.
impact on cost-saving efforts where
• Evaluating quality involves cost of
preventing problems from ever
appraisal, inspection and surveys.
occurring or detecting their occur-
rence early may help in saving the • Increase awareness on quality, both
organization the cost of resolving formally and informally.
them. • Corrective action should be
3. The performance standard is zero incorporated only in hopeless
defect. Crosby believes that non- situations.

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 Quality in Healthcare : An Overview

• Management should plan for zero categories of the prestigious Malcolm

defects. Baldrige National Quality Award. The
award is given to a national organization
• Emphasis should be on educating
(service and manufacturing) that scores the
for quality.
highest points in seven categories.
• A day should be planned
• Leadership demonstrations (95
periodically for displaying and
points)
encouraging zero-defect activities
and processes. • Information and analysis of
strategies and systems (75 points)
• Each employee, department and
organization should seriously set • Strategic quality planning efforts
their goals and make every effort (60 points)
to reach them. • Human resource development and
• A system should be in place to management (150 points)
study errors and remove their • Management of process quality
causes. (140 points)
• Deserving employees and • Quality and operational results
departments should be recognized. (180 points)

• Quality activities should be • Customer satisfaction (300 points).

planned and implemented through
Therefore, quality calls for leadership,
an established quality council.
commitment, customer-focus, process-
• Do it over again where continuous based, participative management, indivi-
improvement is stressed. dual responsibility, empowerment of
employees, proactive problem identification
The Japanese also had their quality and solution, continuous improvements, a
guru, Kaoru IshiKawa. He developed the system of employee recognition and inter-
cause- effect diagram or the fish-bone disciplinarity, and education and retraining.
diagram. He is also the author of the total
quality control concept. IshiKawa is a true This chapter has attempted to present
proponent of management's commitment only an overview of the concepts of quality
to quality and individual responsibility. He in health care. Obviously, the field is too
believes that quality improvement efforts are vast to be covered in this paper, but should
the responsibility of all employees and not the reader be interested to learn more about
just of quality specialists. Other issues he the subject, the references below would
advocates are similar to his colleagues', prove beneficial. The field of quality in
Drs Deming and Juran. general and that of health care in particular
is growing rapidly and the reader is
In conclusion, the principles of total encouraged to seek further readings on the
quality are summarized in the seven major subject. It is both interesting and important.

Page 25
Health Care Quality: An International Perspective

References 8. Lecbov W and Ersoz CJ. (1991). The Health Care

Managers Guide to Continuous Quality
1. Al-Assaf AF and Schmale JA (1993). The Textbook Improvement, American Hospital Association,
of Total Quality in Health Care. DelRay Beach, Chicago, IL.
Fl. : St. Lucie Press. 9. NAHQ (1994). Guide to Quality Management
2. Al-Assaf AF (1998). Managed Care Quality: A (3rd Ed.). National Association for Health Care
Practical Guide. Boca Raton, Fl. : CRC Press. Quality, Skokie, IL.

3. Crosby PB (1979). Quality is Free: The Art of 10. Nicholas DD, Heiby JR and Theresa HA. "The
Making Quality Certain. McGraw-Hill, New York, Quality Assurance Project: Introducing Quality
NY. Improvement to Primary Health Care in Less
Developed Countries", Quality Assurance in
4. Deming WE (1986). Out of the Crisis. Health Care, 3(3):147-165, 1991.
Massachusetts Institute of Technology,
Cambridge, Mass. 11. Omachovu VK (1991). Total Quality and
Productivity Management in Health Care
5. IshiKawa K (1985). What is Total Quality Control? Organization. American Society for Quality
The Japanese Way. Prentice-Hall, Ive., Control, Milevauku, Wis.
Englewood Cliffs, NJ.
12. Sahney VK and Warden GL. (1991). "The Process
6. Joiner Associates (1985). The Team Handbook, of Total Quality Management in Health Care",
Wis: Joiner Associates, Madison. Frontiers of Health Services Management, Vol.
7. Juran JM, Gruna FM Jr. and Bingham RS Jr. 7, No. 4:1-56.
(1979). Quality Control Handbook. McGraw-Hill,
New York, NY.

Page 26
 3 3
Quality Assurance Activities
Dennis Zaenger, MPH
and
A. F. Al-Assaf, MD, CQA

I
n this chapter the activities of quality mean the development of standards from
assurance (QA) are discussed and zero level, but it includes such activities
presented in detail as it applies to health as search and selection for the system to
care organizations in general. QA is standardize and the selection of the right
described here as “all the processes and standards for adoption, modification or re-
subprocesses of planning for quality, setting development. These newly-set, developed
of standards, development of indicators, or adopted standards should then be
setting of thresholds (benchmarks) of tested for reliability and validity and further
expected quality, and active communication communicated, actively, to the intended
of the expected quality in measurable terms audience and appropriate users. Once
to the appropriate audience and direct standards have been communicated to
users”. health professionals steps should be taken
to measure compliance to these standards
Although planning is an integral part using an adequate number of key indi-
of the QA process, it is not included in cators related to those standards. The
this chapter as it is presented in the chapter measurement of the variance between the
on “Implementation of health care current practices and the standards set is
quality”. In this chapter we will concentrate what monitoring is all about. Monitoring
on presenting the basic elements of a QA as a system will be discussed further later
plan for a health care organization. in this chapter.
Following the process of planning for
quality, a new set of steps should be taken There are a number of ways to set
before the implementation of this initiative standards, but in this chapter only one
in an organization. Some of the early steps method of setting standards is being
in this initiative is the setting of standards. presented. Here, the given scenario
Setting of standards does not necessarily assumes that the organization is actually

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Health Care Quality: An International Perspective

developing its own standards (from zero). of the airplane. Now that everyone has
Therefore, a step-by-step approach of how made her/his own airplane, they are asked
to develop standards and indicators will be again to “fly” their new and improved
presented. Most organizations, however, models. And guess what? They all have a
rely on other specialized organizations such winner. Almost all of the new airplanes are
as the World Health Organization, the performing similarly and are all reaching
National Committee on Quality Assurance, their targets.
or the Joint Commission to adopt these
organizations’ standards of expected
quality. These same organizations may use WHAT DOES THIS EXERCISE TEACH
the method described in this chapter to
develop additional standards or to develop US?
their policies and procedures, clinical
practice guidelines, or algorithms which are It tells us that without a set of standards
all different forms of standards. there will be a number of variations in the
outcomes. Some of them are meeting our
Take a look at this simple scenario to objectives while a majority of them are not.
illustrate “standardization”. The college Actually, the outcomes are not in control.
professor starts his “quality” class by asking We do not know what to expect, therefore
each student to pull out a piece of paper making it almost impossible to predict what
and start making a paper airplane, is going to happen. Imagine treating a
independently. No instructions are given, he patient with different sets of practices!
just asks them to “make a paper airplane!”
Of course, each student will start the Once we identified the best outcome
process relying on her/his old skills of and taught everyone (communication) how
folding papers learned probably during to achieve it through the improvement of the
childhood. After 10 minutes, the professor process, then everyone was able to achieve
asks, each student to “fly” her/his airplane. the best outcome. Our expectations are now
What do you think happens? As expected, met and the process now is in control while
there will be a lot of variation in the different our outcome has drastically improved.
types, shapes and performance of these Using the steps of this scenario in this
paper airplanes. Certainly, one of these can chapter and the chapters that follow, we
be spotted to be the best. Taking this will be demonstrating further the correla-
scenario a little further, the professor picks tion between setting standards and
up that one “best” airplane and asks the improving care outcomes. Basically this
owner to come in front of the class and process, if followed, will reduce variance,
demonstrate to everyone how she/he made increase the control of resource utilization
that airplane. The class is asked to follow and improve patient care outcomes.
the steps in making such an airplane as the Therefore, in the next few sections this
student takes them step-by-step in the process will be further demonstrated and
process of re-constructing similar models discussed.

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 Quality Assurance Activities

PLANNING THE QA PROGRAMME Thus, accordingly, an organization may

be able to define each step more appro-
The QA plan is a document developed by priately as it pertains to its operation and
an organization that defines the conceptual quality programme and prepare their QA
understanding of quality in that plan accordingly. The following is an
organization, and provides a description of example of a health care organization’s QA
the organizational structure, the resources plan outline:
and the materials allocated to that 1. Title page: 1997 Quality Management
organization’s quality programme. This Plan of Great Health Plan, Inc.
plan may also outline the methods for
applying quality standards to the delivery 2. Table of contents
of care and service of that organization.
Therefore, sources and type of data will be 3. Background and history of the
discussed, as well as providing information programme. A description of the
on the methods of data collection and type chronology of establishing the
of reporting mechanism. These plans are programme and the actions taken to
usually designed according to the Joint secure resources for it. If the
Commission’s 10-step model of quality programme has been in place for a
assessment. This model includes the long period, you may include an
following steps: abstract of the programme changes
that have taken place since its
• Assign responsibility; inception.
• Delineate scope of care and
service; 4. The Organization’s mission and vision:
Here, describe how does the
• Identify important aspects of care organization’s mission fit in the overall
and service; goal of the QA/QM programme.
• Identify indicators;
5. Objectives of the programme.
• Establish a means to trigger
evaluation; 6. Who is involved? Here, describe the
• Collect and organize data; positions of the different personnel
• Initiate evaluation; associated with the QA/QM
programme. List the main duties and
• Take actions to improve care and responsibilities of each position and
service; what are their major activities in the
• Assess the effectiveness of actions programme. A short list of the expected
and assure improvement is qualifications of persons in each of
maintained; and these positions provide a better
• Communicate results to affected understanding of the calibre and
individuals and groups. competencies desired for staff to
occupy these positions.

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Health Care Quality: An International Perspective

7. Organizational structure of the quality accrediting/certifying organization it is

programme. An organizational struc- pursuing.
ture of the programme outlining each
12. Linkages with other services. List and
position and its hierarchy within the
briefly describe all those departments,
organization. Include here the position
services or units that have either direct
(for reporting purposes) of all the
or indirect link or association with the
committees associated with the
QA/QM programme. Provide a
operation of the programme.
description of these activities and tasks
8. List and brief description of all quality- related to quality in each of these
related committees. Include a general entities.
description of each of these committees,
13. List of reports and communication
membership composition, main tasks
mechanism for the programme.
and duties, reporting mechanism, and
frequency of meetings. 14. Synopsis of the annual evaluation of
the programme.
9. Scope of the programme. List all the
major activities of the programme, e.g. Once the QA plan is developed it
risk management, utilization manage- should be circulated to all the key indivi-
ment, case management, credentialling, duals of the programme and then should
etc. be sent for review and approval by the
organization’s top administrator. Any
10. Important aspects. Here you may subsequent modifications should follow the
include a list of all those key indicators same route for approval. This requirement
that the programme identifies and (developing a QA plan and having it
collects data on regularly. List only appropriately approved) is based on the
those areas that the programme is standards prescribed by most accrediting
regularly measuring and monitoring, agencies, thus making it extremely
e.g. patient satisfaction rates, important to follow.
nosocomial infection, adverse occur-
rences, medical records completeness, In the chapter on Quality Implementation
problem identification and improve- we will discuss the steps in implementing
ment and others. For each of these quality in a health care organization in a
areas a level of acceptable standard broad scenario. As mentioned earlier, QA
should be provided, i.e. what is the must include a stage of adequate planning,
threshold of minimum accepted stan- both strategic and operational, to assure
dards beyond which evaluation is the availability of resources and facilitate
automatically triggered. quality assessments and improvements.
Therefore, a comprehensive and well-
11. Standards being followed. Here an developed plan is essential for ensuring the
organization will outline the type of success of the quality programme in that
standards it is complying with and what organization.

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 Quality Assurance Activities

In the following section, a method for ment to address the issue of its quality of
setting standards in health care is presented. care, it must define “quality” in operational
Again, and as mentioned earlier, this is only terms. Standards do just that. The organiza-
one method of setting standards. There are tion ensures consistent, high-quality services
several others that follow the same format through the correct application of stan-
but the objective is the same, which is the dards. This section outlines a methodology
development of a standard that is valid, that has been used in at least two countries
reliable, clear, applicable and timely. Setting to date and in a number of health care
a standard does not necessarily mean organizations worldwide. Early indicators
developing one de novo, but it may include show that it is useful for helping an
the adoption or modification of an already organization begin its quality improvement
existing one. Actually, a standard that has “journey”.
been developed for one organization may
not be applicable for another, and so does
a standard that is developed for the average WHAT ARE STANDARDS?
organization may not be adequate for a
higher quality organization. Additionally, the Standards, broadly defined, are statements
more the efforts are put in the development of expectations for the inputs, processes,
or adoption of a standard the more behaviours and outcomes of health
acceptance will that standard receive. This systems. Simply put, standards tell us what
is especially true when one is dealing with we expect to happen in our quest for high-
the development of clinical standards and, quality health services. Standards are
in particular, clinical practice guidelines. important because they are the vehicle by
These types of standards require physicians’ which the organization translates quality
buy-in and unless these physicians are into operational terms and holds everyone
involved in the development and dissemi- in the system (patient, care-provider,
nation of these standards, it will be very support personnel, management) account-
difficult to have them comply with them. able for their part. Standards also allow the
Therefore, early and active involvement of organization to measure its level of quality.
the target audience of each standard is Standards, indicators and thresholds are the
important to secure a useful and elements that make a quality assurance
successfully practised standard. system work in a measurable, objective and
qualitative manner.

SETTING QUALITY STANDARDS Among health care professionals there

are many definitions and uses of the word
Standards are an important part of health “standard”. The term standard is sometimes
care and have gained prominence in the used to describe protocols, standard
trend to address quality-of-care issues. operating procedures, specifications,
Once an organization makes a commit- criteria for practice, and clinical practice
guidelines. Guidelines are statements by

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Health Care Quality: An International Perspective

experts that describe recommended or performs open-heart surgery differently

suggested procedures (Eddy and Couch, each time by changing the angle of incision,
1991). Guidelines serve as a flexible the manner of suturing, and other small
technical reference that describe what the details of the operation. While the surgeon
health care provider should or should not strives to perfect his performance, it is
do for a given clinical condition, e.g. impossible to perform surgery exactly the
guidelines for vascular injury in frostbite same way each time. Variation is natural
cases (Imparato and Rites, 1989). A and is to be expected in every process of
protocol is a more precise and detailed health care. However, through continuous
plan for a process, such as the manage- quality improvement techniques, health
ment of a clinical condition. A protocol workers can increase their knowledge of
implies a more stringent requirement than and control over variation in the health care
a guideline, such as WHO protocols for system (Berwick, 1991). The objective is to
diarrhoea case management. A standard keep variation within limits of control
operating procedure (SOP) is a statement (Deming, 1986).
of the expected way in which an organiza-
tion’s staff carries out certain activities, such Many sources of variation in medical
as standard operating procedures for billing care should not be standardized completely.
patients. Standard operating procedures Treatment plans and other aspects of care
are usually more stringent than guidelines. need to be tailored to each patient’s specific
A specification is a detailed description of care requirements. However, quality of care
the characteristics or measurements for a can be improved by eliminating or
product, service, or outcome, e.g. the list minimizing unnecessary variation in the way
of technical features of a personal that care is provided. “It is simply unrealistic
computer. to think that individuals can synthesize in
their heads scores of pieces of evidence,
In essence, these are all standards. accurately estimate the outcomes of
They are varying ways that an organization different options, and accurately judge the
explicitly defines what it expects for (1) desirability of these outcomes for patients”
inputs (resources) such as the materials, (Eddy, 1990). Standards help to reduce
drugs, supplies, personnel; (2) the delivery variation by defining what the organization
processes, activities, tasks and procedures, expects for the day-to-day inputs, processes
and (3) the desired outcome (result) of these and outcomes of health care and services.
processes (Donabedian, 1980).
For example, input standards for open-
heart surgery help to ensure that surgeons
have the necessary and appropriate
WHY USE STANDARDS? equipment and staff needed to perform the
procedure. Process standards such as
In every process there is a certain amount
guidelines and protocols help to ensure that
of variation. In every task we perform, we
the surgeon is using current, up-to-date
vary the way it is done each time. A surgeon

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 Quality Assurance Activities

techniques and technology. Outcome organization moves from one task to

standards define what the organization another, it may need to return to certain
expects as results for the procedure. tasks as more information is gathered. The
approach is designed to guide the organi-
Much of the attention in recent decades zation and the people assigned to the task
(at least in the US) to establish standards of setting standards through the various
has been driven by payment reimbursement questions it must consider to define what is
and litigation requirements. Hospitals must quality for the organization and what
demonstrate adherence to accreditation standards are needed to meet that quality.
requirements and to HCFA standards for
reimbursement through Medicare and
Medicaid programmes. Licensing require- Step 1: Identify a function or
ments and litigation concerns also influence system
a health care organization to establish
minimum standards for quality of care (Mills When starting to develop standards, the
and Lindgren, 1991). Due to these and organization will need to identify systems
other influencing forces, standards for or subsystems requiring standards and
almost any aspect of health care now exist select one or two that are of high priority.
in some shape or form in most health care These systems are the clinical and non-
organizations. clinical functions that the organization
engages in regularly. Some primary care
Health care organizations have a examples are acute respiratory infection
growing interest in establishing standards, (ARI) case management, maternal and child
partly to set minimal expectations for health care services, and immunization services.
services rendered and partly to help reduce Some hospital-based clinical examples are
adverse health outcomes and variation
the performance of caesarean sections and
within existing health services.
emergency care services. Some non-clinical
examples are patient admissions and the
use and maintenance of medical records.
A METHODOLOGY FOR SETTING
The organization can identify high
STANDARDS priority functions through a two-step
screening approach. The first screen
The methodology for setting standards identifies high volume, high risk, and
described here can be used step-by-step, problem prone functions or systems
although it is not necessary to do so. This (JCAHO, 1990). High-volume functions are
method is usually used for the development those that are performed frequently or affect
of new standards, but the method may also large numbers of people. High-risk
be used to develop organizational policies conditions or functions are those that expose
while a few of these steps may be used to the client to a greater risk of adverse
modify other developed standards. As the outcomes because of the nature of the

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Health Care Quality: An International Perspective

disease or the case management process. standards are made usually by managers
Problem-prone functions are those that have and department chiefs. Once they have
produced problems for the organization decided where to begin, the organization
and/or clients in the past. typically assigns interdisciplinary teams who
know the most about a given function or
The list produced by the first screening system for which standards will be
will most likely be long enough that the developed.
organization will need to narrow it down
further. Initially most organizations cannot These teams should include the right
afford the time and expense to develop people in order to address issues necessary
standards for every function or system that to complete this task (Brassard, 1989). The
is high-volume, high-risk, or problem-prone. “right” people are those who are best
qualified by virtue of their experience,
To narrow down the list further, the training, and role in the organization. They
organization will need to select additional are the people who are most involved or
criteria by which to judge all the possible most knowledgeable about the function or
functions or systems. Given below are some system. In particular, consider who is
commonly- used criteria for selection involved with each step of the function or
among the possibilities. system, consider including a technical
Importance – Having more expert, and consider including someone of
significance, consequence, and/or authority within the organization. In terms
value relative to the other functions or of the number of members, 5-8 members
systems. will be the most effective team size.

Feasibility – Any changes

recommended for the function or Step 3: Identify the inputs,
system can be carried out by the
organization and personnel.
processes and outcomes
Impact – The recommended changes The team or panel of experts must identify
for the function or system will produce the elements for each of the components
the most positive result relative to other of the function or system. These are the
choices. inputs required to make the processes
happen, the processes that are necessary
Cost – Changes that can reduce cost
for the expected outcomes to occur, and
and produce savings.
what is expected as an outcome(s) for the
function or system.
Step 2: Identify a team or a
Some teams find it useful to look at the
panel of experts
system backwards to better list the elements
Up to this point the critical decisions for inputs, processes and outcomes. In this
concerning what functions or systems need manner, a team first lists the desired

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 Quality Assurance Activities

outcomes for an activity, then lists the Step 4: Define the quality
processes necessary for those outcomes to
characteristics
occur, and the inputs that the processes
require.
Quality characteristics are the distinguishing
Once the team identifies all the attributes of inputs, processes or outcomes
elements, it should decide which of these that the organization or team decides are
elements are critical, or key, for the function essential for how it defines quality health
or system to be carried out and outcomes care. They are the traits or features by
to occur in a manner that the organization which we judge the quality of health care
expects. Not all inputs, processes and elements. For example, a team of physi-
outcomes are critical for a function or cians and laboratory technicians may use
system to be of the quality that an “timeliness” as a characteristic of quality
organization expects. (See annex for a case (among others) when setting or evaluating
study.) standards for hospital diagnostic tests.
Once the team understands and agrees
A number of tools are useful for identi- on a quality characteristic, it can then
fying inputs, processes and outcomes, then define a standard for it. In this example,
gaining consensus on which are critical to the team’s next step is to define what it
the quality of the process. An Affinity
means by “timeliness” in measurable
Diagram (Al-Assaf, 1993) is a useful
terms.
technique for gaining a consensus on the
various inputs, processes and outcomes of A team should use whatever decision-
a health care function or system. Some making process that feels comfortable to
teams couple this technique with flow decide which are the key elements and the
charting (Scholtes, 1988) to visually lay out
quality characteristics. Some decisions and
the steps for the function or system and to
choices may have consensus among the
gain a consensus on critical inputs,
group members with little need for discus-
processes and outcomes. Therefore, as
sion. Other decisions may require more
examples to inputs, we may include
discussion, time and the use of some
patients, personnel, medical records,
decision-making tools and techniques
medicines, buildings and equipments. For
(Scholtes, 1988; Al-Assaf, 1993 and
processes, in a hospital this may include
1998). Some groups may not make
surgical operations, physical examinations,
decisions by consensus, but rather the
patient registration, patient discharge, and
leader may make the decision or the group
administration of medication. Outcomes
may vote. No one decision-making process
will include post-surgical wound infections,
is universally better than another. The group
rate of nosocomial infections, mortality
must decide which is the best way for it to
rates, rate of complications, and patient
make decisions.
satisfaction rates.

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Health Care Quality: An International Perspective

Step 5: Develop/adapt 2. Algorithms. Process standards can be

in the form of an algorithm, which are
standards
presented as a list of steps, or as a few
Once the team has decided the quality sentences in paragraph form, or as a
characteristics for the elements of a function map that outlines a step-wise approach
or system, then it must decide which quality to solving a clinical problem. A
characteristics require standards, then set common algorithm is a flowchart,
the standards. A team may decide it does sometimes called a decision tree, that
not need a standard for all quality will guide the user through a variety of
characteristics, and instead focus on what steps and decisions to lead them to the
it feels is most important. In completing this most appropriate outcome, e.g.
step, teams usually do the following at Comatose Patient Management
some time: Algorithm: “if patient does not respond
to stimuli, then you do.....if responds,
A. Choose a format for standards. then you do.......”
Standards can use several different
3. Case management plans. These are
formats to describe what is expected for
patient care plans that “outline the
inputs, process and outcomes of a
anticipated usual or standardized
system. Most often input and outcome
length of stay and set out the expected
standards take the form of statements,
clinical outcomes, intermediate goals,
but many health professionals and
and interventions involved in the care
organizations have developed a variety
of a given case type of patients....”
of formats for process standards. Given
(Grossman 1991). These plans include
below are just a few of the more
care provided in all clinical settings
common formats you will find for
such as admissions, routine patient
standards.
floors and intensive care units in the
1. Statements. Standards are often written case of, for example, Coronary Artery
statements of what is expected to By-pass Graft (CABG) patient care, or
happen for a function. The statements renal dialysis patient plans.
can be written as specifically or as
4. Critical paths. Process standards can be
generally as the team or organization
in the form of a critical path, which is
decides is necessary, e.g. NCQA’s
“an optimal sequencing and timing of
Standards for Accreditation of MCO’s
interventions by physicians, nurses and
(NCQA, 1997); “The managed care
other staff for a particular diagnosis or
organization identifies important
procedure...” over a period of time
opportunities for improvement” or “The
(Coffey et al. 1992). Critical paths are
organization has adopted guidelines
designed to minimize delays in health
for acute and chronic care relevant to
services and resource use and to
its population”.
maximize the quality of care. The terms

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 Quality Assurance Activities

“critical pathways”, “critical paths of health care organizations are developing

care”, and “care maps” all refer to the process standards for common health care
critical paths described here, e.g. functions and systems which are specific to
critical path for a myocardial infarction their organizational and environmental
patient care episode, which may requirements. A team or organization can
include a list of members of the clinical use these sources, but if it decides that it
team attending to the case and their needs to develop new and original process
specific tasks for that patient for each standards, then the team may require
inpatient day. additional training and resources.

5. Clinical care protocols. Process stan- B. Gather background information.

dards can also be in the form of clinical Developing or adapting standards
care protocols. They are “practice requires the team to gather background
guidelines which are explicit, criteria- information, then process that informa-
based plans for specific health care tion to derive appropriate standards.
problems” (Benson and Van Osdol, Teams can gather information through
1990). Protocols are used to define the methods such as those listed below:
process of care for a primary care
problem, including history, physical 1. Literature review. A worldwide body of
exam, assessment, diagnostic knowledge for most health care
procedures, treatment, and patient functions and systems exists and can
education, e.g. hypertension care be accessed in numerous ways. Much
protocols, or diabetes mellitus patient of this knowledge is found in current
care protocols. health care literature in most medical
school libraries. The Internet may have
Developing process standards can be a number of sites that are dedicated to
a complicated job and may require a certain health care organization and
extensive technical knowledge of a health may have a listing and full text of a
care function or system. They can be large number of clinical practice
presented in a variety of forms in addition guidelines applicable to that organiza-
to the ones described above. The World tion. Whenever possible, teams should
Health Organization, the National consult the medical literature to
Committee on Quality Assurance (NCQA), determine what is commonly accepted
the Joint Commission on the Accreditation for a given health care function or
of Health Care Organizations (JCAHO), the system before inventing, or possibly re-
Agency for Health Care Policy and Research inventing, standards.
(AHCPR), the American Medical
Association, physicians and other health 2. Confer with experts. Sometimes the
care organizations have developed many team does not have all the expertise it
input, process and outcome standards for needs to develop or adapt standards.
a variety of health care functions. Many If so, the team can include an expert(s)

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Health Care Quality: An International Perspective

as an ad hoc member to help guide “seed”, there are several techniques a

them in the technical nature of a team can use to draft their standard.
chosen function or system. Or the team You can use the Delphi Method (Dalkey
can confer with an expert(s) and bring et al. 1972) to exchange and build on
the information back to the team. each other’s ideas, flowcharts to
illustrate sequence of steps in a process,
3. Benchmark. Benchmarking is a or interrelationship diagrams (Brassard,
technique for learning from others’ 1989; Al-Assaf, 1993 and 1998) to
experiences for a function or system show the relationship among the parts
where the team is trying to set standards of a standard. When disseminating new
(Watson, 1993). The term or adapted standards, be sure to
‘benchmarking’ means using someone describe the rationale for its recom-
else’s successful standard as a minimal mended use and the consequences for
measure of what you would like to following the standard (Eddy, 1990).
achieve. Benchmarking can be used to
stimulate creativity by gaining
knowledge of what has been tried by Step 6: Develop the indicator
other similar organizations and modify-
ing it to make it work better for your
for the standard
organization. Once the standard is developed then an
4. Review past experiences. This method indicator can be drafted by using measur-
is similar to benchmarking, but the able terms to convert the standard into an
team examines their own organization’s indicator. Indicators in essence are
experiences to discover what has standards that are stated in measurable
worked and not worked in the past. This terms. For example, if the standard is
is important because if there is some “Physicians associated with an X hospital
organizational constraint that has should be appropriately certified in their
prevented the adherence to standards fields”, then the indicator will be “the
in the past, then that constraint may percentage of those physicians associated
prevent any new effort to set standards with the X hospital that are certified”.
from being successful. Indicators are important for the monitoring
of compliance to the standard and
C. Draft the standard. Experts in setting measuring variance from the desired level
standards suggest that a team begins of achievement of that standard. Indicators
with a “seed” standard. These are however need to be selected based on a
usually input, process or outcome priority system as only key indicators should
standards from other organizations or be selected. Too many indicators and too
some other proposed standard which many non-key indicators can over-burden
a team can consider to help it start the system with excessive and probably
thinking. After beginning with the ineffective data collection and analysis.

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 Quality Assurance Activities

Step 7: Assess appropriateness ting the new standards. Analysis should

of standards and indicators include a compilation of strengths,
weaknesses and recommendations.
Standards should be assessed to ensure that The standards team should review and
they are appropriate for the organization. develop a plan to revise and implement
The team or the organization should the standard.
determine if the standards are valid,
4. Additionally, the assessment should
reliable, clear and applicable before they
determine if the standards have the
are disseminated. Indicators should have
characteristics described below (IOM,
the same characteristics plus they be
1990). If they do not, then the team
measurable. All too often, health organiza-
should revise the standards and
tions develop or adopt standards with little
reassess them to ensure that they meet
or no assessment. Consequently many
these criteria.
standards are not appropriate or are
unrealistic and are simply not followed by Assess standards for validity. Assessment
intended users. In general, the assessment should determine if there is a strong
should be carried out on a small scale, demonstrated relationship between the
using qualitative rather than quantitative standard and the desired result it represents.
data when necessary. The following The team should confirm that if the inputs
procedure may be followed to assess are provided as they have defined them,
standards: and that if the processes are carried out as
they have defined them, then the desired
1. Determine all those in the organization
outcomes should occur. Expert advice may
who will use or be affected by the
be required here to affirm the validity of the
standards and select a representative
standard. Certainly, tests for validity could
group to review the standards. Since
be applied on the developed standards to
the number of users of standards in a
assess their status and affirm validity.
given facility is small, statistical samples
and rigorous qualitative analysis are Assess standards for reliability. Assessment
not advised unless a national or system- should determine if the same results occur
wide effort is under way. each time the standards are used, i.e. the
standard’s measure reproducibility. A
2. Determine the method to use for
reliable standard will result in a small
obtaining information about the
amount of variation in the way the standard
standards from the sample group.
is applied every time.
Possible methods are staff meetings,
anonymous questionnaires, and face- Assess standards for clarity. Assessment
to-face interviews. should determine if the standards are written
in clear, unambiguous terms so that the
3. Analyse the feedback and make any
workers who use the standards do not
necessary changes before dissemina-
misinterpret them. It is important that the

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Health Care Quality: An International Perspective

sample of workers that test the standards may require them to diagnose and treat
represent those workers who will ultimately without allowing them to use their
use the standards. professional judgement. Others may
fear that standards will be used in a
Assess for applicability and reality. punitive manner, to identify and punish
Assessment should determine if the professionals who do not perform within
standards are realistic and applicable given strictly defined limits. Still others may feel
the available resources and training of the that the presence of standards make the
health care workers responsible for practice of medicine like “cook-book
complying with them. medicine” and that may impede their
A word of caution when assessing creative ability in the diagnosis and
standards with a sample population. Make treatment of patient. Of course, the
sure the sample is adequate and represen- other issue is the legal impact such
tative of the target population that will use standards might have or are perceived
and comply with the standard. Assessing to have on the practice of medicine.
sample size and representation of a target These are legitimate concerns and
population is beyond the scope of this require the organization to address them
article, so refer to a statistical sampling text in some constructive manner before
for further discussion (Williams, 1978). developing or implementing standards.

B. Identifying appropriate human,

physical and financial resources.
CHALLENGES TO SETTING Developing or adapting standards
takes time and personnel. Sometimes
STANDARDS the organization must go outside its
staff resource to use experts in the field.
In spite of a large resource of existing
Throughout all this the organization will
standards to adapt to specific needs and
incur certain costs that should be
the growing interest in establishing stan-
evaluated beforehand to determine if
dards by various health care organizations,
the effort is worth the costs involved.
there still exist certain challenges to this
process: The process of setting standards is an
integral part of the cycle of quality
A. Reliance on explicit criteria. Physicians,
improvement. This process is usually
nurses and other health care profes-
followed by communicating standards,
sionals may resist for the reason that
then monitoring compliance via indi-
standards impinge on their subjective
cators. Through monitoring, gaps are
judgement that they have developed
identified between what is expected to
through their practice. Some profes-
happen in health care vis-a-vis stan-
sionals contend that medicine is partly
dards and what is currently happening.
art, partly science, and that standards
Teams are then assigned to analyse

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 Quality Assurance Activities

these problems, identify and implement COMMUNICATING STANDARDS

solutions, and make recommendations
to the organization for adopting the The purpose of developing standards is to
solutions on a wider basis. ensure the delivery of quality patient care.
This last part often entails modifying, To successfully apply a set of standards, they
enhancing or updating standards so that must be successfully communicated to
the organization’s expectations for those who are responsible for their appli-
quality are being met. Here again, cation. Successful communication implies
standards should be periodically that those who are meant to receive the
assessed for validity, reliability, clarity communication actually do so; that those
and applicability. This can be viewed as who receive the communication understand
a continuous cycle of quality improve- it, accept it and accurately implement the
ment. The next section of this chapter necessary tasks.
outlines the process of communicating Remember the paper airplane scenario
standards to the users. presented at the beginning of this chapter.
Setting standards is a necessary compo- Just imagine that once the new improved
nent of defining and improving the standards (best paper airplane) were
quality of health care. Through stan- identified and demonstrated (communicated)
dards, an organization defines what it by the “owner” (expert), then the outcome
expects for the inputs, processes and was improved and the product was a better
outcomes of the services it provides. one. This is what we are trying to achieve
Through their indicators, standards are with communication. Just think of a situa-
an instrumental part of monitoring the tion where a top leader may issue a memo-
quality of care and identifying problems randum to all managers telling them to
and measuring improvements in health follow a certain policy or procedure without
care service delivery. With periodic communicating the need for it and why it
updating and modifications, they was developed, or not including anyone of
become a part of an organization’s cycle them in the decision process. What do you
of continuous quality improvement. think of the probability that this policy will
be followed consistently. It might be
Setting standards can be approached followed for the first few weeks or months
using a seven-step methodology: identify then everything will revert back to where it
a function or system that requires standards; was originally. That is why unless you
identify a team to address standards; actively communicate your standard, the
identify the inputs, processes and outcomes probability of its compliance is diminished.
of the function or system; define the quality
Communication is the vital link between
characteristics; develop or adapt standards;
the development of the standard and its
develop indicators; and assess the appro-
actual application. Communication of
priateness of the standards.
standards needs to be a carefully planned

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Health Care Quality: An International Perspective

process. Standards that are not communi- organization. William Haney wrote that the
cated in an efficient or effective manner may modern organization requires communi-
have many negative effects: dissatisfied cation performance at an unprecedented
patients or staff; wasted time and money level of excellence in order to survive
used for ineffective communication growing conditions of complexity and
activities; loss of staff and patient time; and demand for efficiency (Haney, 1973). This
perhaps most importantly, diminished excellence in communication applies to all
quality of care. “For information to become levels of the organization, from the
knowledge, it must be received, under- leadership down to care-providers, from
stood, and then internalized.” (Dawkins care-providers back up to the leadership,
1992). This raises issues concerning how and across divisional lines from manager
an organization designs effective communi- to manager.
cation approaches and how it measures
effectiveness. It affects education, organiza- Health care organizations that are
tional communications, employee training nationally or internationally accredited are
and new skills development. required to document and communicate
continuous quality/performance improve-
Before continuing with a discussion on ment activities to all those who have an
effective communication of standards, it is appropriate need to know. Some of those
useful to discuss the main elements in any who are appropriate are quality improve-
system of communication. Communication ment teams, key cross-functional staff,
requires a “sender”, one who initiates the medical staff departments and committees.
communication; the “message”, whatever Not only does certification require showing
the sender wishes to convey; and the documentation of communication activities
“receiver”, the person or group who is the such as meeting notes, communiqués and
target of communication. In a two-way bulletins but it also requires integrating the
communication system, the receiver of the information into the organization-wide
information provides feedback to indicate quality improvement strategy and other key
understanding or internalizing of the organizational functions.
message. This is a simple model, but the
reader should keep it in mind as this section In the field of Continuous Quality
discusses measuring of effective Improvement (CQI), communicating and
communication. sharing experiences and best practices is
considered to be fundamental for raising
the organizational thresholds of quality. This
has been proven successfully in the
THE ROLE OF COMMUNICATION industrial and service sector where many
WITHIN THE ORGANIZATION organizations pursue International Standard
Organization 9000 certification to institute
Effective communication is an essential quality improvement structures in their
element for quality management in any company or organization. A large part of

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 Quality Assurance Activities

ISO 9000 certification is creating a informal channels can be tapped to aid in

documentation system and a system for effective communication of standards,
disseminating information company-wide sometimes more effectively than formal
and to all customers. This is often done channels. In all organizations there are
through the quality auditing function of the professionals at each level who are
organization and serves to stimulate change considered to be opinion leaders by their
and improvement. Employees are the peers. Most managers know who these
foundation for gathering data about people are and certainly peer groups know
adherence to company and contractual who they are. Organizations that have
standards and expectations, and that involved these opinion leaders in the
information is consolidated and dissemi- development and dissemination of stan-
nated to the management and back to the dards have found these methods to be
employees. When used well, the ISO 9000 effective. A communication strategy should
certification guides an organization to include identification of those informal
effectively use formal and informal commu- channels and how best to use them to
nication systems to disseminate standards assure effective communication of
of performance and quality improvement standards.
results.
In a study of disseminating clinical practice
guidelines in the Coronary Care Unit of
Cedars-Sinai Medical Center in West Los
COMMON COMMUNICATION Angeles, researchers found that the process
METHODS used in their study facilitated adoption of
the guidelines by private practitioners. First,
Following are some common methods used the guidelines were derived from literature
for effectively communicating standards to and modified by local opinion leaders so
workers. An organization must weigh the that the physicians would have ownership
costs of using these different methods of the final guidelines. Data was collected
against the importance of the message and to support the safety and efficacy of the
the need to demonstrate adoption of the guidelines prior to dissemination. Then the
standard. A mixture of these methods guidelines were communicated to
blended together in a strategic plan helps physicians using a system of physicians who
an organization to maximize more costly were respected by their peers and could
methods (like training) with more offer unsolicited advice to their colleagues.
inexpensive methods (like meetings or Finally, patient outcomes were measured
memos). during periods with and without the use of
guidelines to reinforce the safety and
Endorsement by opinion leaders. While effectiveness of the guideline
organizational communication flows recommendations (Weingarten, 1992).
downward, upward and horizontally, it also While the study did not result in quantifiable
flows through informal channels. These evidence that this approach was more

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Health Care Quality: An International Perspective

effective than others, the researchers found the root cause, then the organization must
that physicians understood and applied the define appropriate training solutions to
practice guidelines routinely. address it, including the use of job aids,
periodic practice and adequate feedback.
Training. Training is often used as one of A front-end analysis helps to identify the
the first approaches in communicating training needs and expected results which
standards. While this appears to be logical leads to designing performance-based
on the surface, it often is misused and leads training objectives and effective training
to ineffectual communication. All health approaches.
care professionals are trained in some form
or capacity in order to be registered in their Performance-based training is a
speciality. Every nurse, doctor and labora- common term used in training today. It
tory technician has been trained to some gained popularity in the military as their
set of standards to be able to practise his training requirements became more
or her profession. When poor performance focused on an effective and safe use of
or inadequate compliance with standards equipment and armaments and perfor-
is not due to lack of skills or knowledge, mance of tasks. It was less important that
training is not an effective intervention. an Army mechanic understood the
Therefore, before beginning long and costly theoretical design of a tank, but more
training programmes to communicate important that he could correctly install a
standards, the organization should conduct tank tractor tread or other parts. So, the
an investigation to determine if training is performance-based training sought the
an appropriate method. most cost-effective way possible to ensure
that he was able to perform this skill every
An assessment phase is the first step in time. Performance-based training focuses
almost all the training models commonly on the behaviours most important in
used. Training is only one of many performing a task. If the trainee already has
interventions that can be used to resolve the necessary skills and knowledge but does
performance problems and it is only not perform for other reasons, such as lack
appropriate if there is truly a gap between of motivation or supplies, then the training
the desired and existing skills and know- will be a costly failure.
ledge. So the organization must diagnose
the “problem” or the existing condition it After the assessment stage is concluded
wants changed. Determine whether it is and if training is determined to be a cost-
rooted in lack of knowledge or skill, or effective intervention, trainers are brought
rather lack of motivation, supplies, in to help analyse the job tasks and the
organizational support or some environ- worker characteristics and specify training
mental factor. Directly asking physicians, requirements, resources available and any
nurses and technical staff who are not constraints. From this information training
following standards helps to determine root developers explore training delivery options
causes. If a lack of skill or knowledge is and determine the key outcome indicators

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 Quality Assurance Activities

by which the success of training will be communication may be used periodically

evaluated. Trainers then design and develop as the need arises such as memos, notices
the training, the training is delivered, then or communiqués.
evaluated to determine if deficiencies are
reduced or eliminated. While these methods are inexpensive
and can be used quickly, they do not permit
Meetings. This is a relatively cheap and workers to give feedback or clarify any
easy method to communicate standards. information. Often, the management will
Most managers consider this method as a officially communicate some new policy or
basic component to promote communi- procedural change via a newsletter, a
cation within and between departments or memo or a new procedures manual. If the
divisions. Documentation of regular management considers this as effective
meetings is a requirement for most communication, they could be wrong
accrediting agencies, especially NCQA and because the workers may have lingering
JCAHO, as well as other types of certifi- questions, be confused, or simply not
cation such as ISO 9000. Meetings can understand the information. Many times
also provide an opportunity for workers to these types of official communications end
give feedback and ask for clarification up in someone’s drawer or on a bookshelf
about standards, both before and after and are never used or referenced. Or
implementation. Quality improvement worse, they end up in the drawer of the
activities that often lead to changes or supervisor and are never seen by the target
modifications of standards can be easily group.
reviewed during regular or special
meetings. However, meetings do not If the implementation of standards is
provide the supervisor or manager a important enough, the management needs
chance to see how well workers implement to follow-up through meetings or normal
standards. supervisory channels to clarify any questions
or confusion. While this does not guarantee
Dissemination materials. Most organi- effective communication, it will help ensure
zations use some form of dissemination that standards are implemented as neces-
materials to communicate policies, proce- sary. Not all information may warrant this
dures or standards. Generally, these can be much follow-up, so the management must
divided into regular and periodic dissemi- weigh the cost of follow-up against the
nation materials. In this age of desktop importance that workers effectively
publishing, many organizations produce implement standards.
low-cost newsletters and bulletins that can
be used to update workers about company Multi-media and electronic methods.
issues, decisions or actions. These are often Multi-media training and presentations
done on a routine basis and provide involve several senses and empowers
mangers an avenue of communication to learners to access, express, refresh and
all levels of workers. Other forms of review information at their own pace, in

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Health Care Quality: An International Perspective

their own time, and when they need it. health care standards and policies via some
However, these methods can be expensive specific sites.
in terms of hardware, software and
organizational support, although costs are The Agency for Health Care Policy and
dropping as they gain wider use. Many of Research (AHCPR) has an Internet site
the systems needed to support multi-media (http://www.ahcpr.gov) that provides
and electronic methods are being installed information about standards, clinical
in organizations already to carry out all practice guidelines, performance measure-
normal business operations. This is one ments, etc. AHCPR-sponsored guidelines
area where an organization really needs to are available electronically through the
do a thorough cost analysis before investing National Library of Medicine’s MEDLINE
a lot of capital. system and the National Technical Infor-
mation Service. Many of these guidelines
Computer-based learning (CBL) is are now available on CD-ROM. As part of
increasingly becoming popular and has its mandate, the AHCPR tries to effectively
been shown to be cost-effective in commu- disseminate clinical practice guidelines as
nicating and training when well-designed well as to develop and test them. To that
and used properly (Clark, 1991). New end the AHCPR has developed a framework
programmes are available on CD-ROM for disseminating guidelines to consumers,
that teach appropriate use of certain health care practitioners, the health care
standard procedures such as IUD insertion, industry, policy-makers, researchers and the
proper physical examination and on a press (VanAmringe, 1992).
number of medical and surgical proce-
dures. There are also numerous Supervision. All organizations have some
programmes available in the market that kind of a system by which all workers are
help an organization use ISO 9000 supervised, from the most basic to the most
certification processes to improve the advanced positions. The supervision system
documentation and dissemination of is used to direct and provide support to
standards and quality issues. personnel so that they can perform their
Many health care organizations have functions effectively. It is used to delegate
an information system that help to tasks and responsibilities, to monitor
disseminate standards and recommended performance and to make quality
practices. Short texts of guidelines appear improvements. A part of this is effectively
on the system and references where health communicating standards to personnel,
workers can access more information. which includes monitoring performance
Electronic bulletin boards and networks and providing feedback and support as
across multiple sites all serve as a means necessary. So, any plan to effectively
for easily communicating to large communicate standards should consider
audiences (Lohr, 1992). The Internet system how the supervision system can be best
allows one to access any number of new used.

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 Quality Assurance Activities

Some responsibilities of a supervisor feedback from the receiver of the message.

are: The supervision system is ideal for this type
of feedback because it is already a
• Help health workers plan, carry out
responsibility of supervisors to take this
and evaluate their work.
feedback, clarify any questions or confu-
• Provide technical assistance sion, serve as the liaison between manage-
required at the clinical level and for ment and personnel, and see to it that
managing programmes. personnel properly follow standards. So the
supervision system is an integral part of
• Motivate health workers when
effective organizational communication. It
necessary.
should play a major role in any plan for
• Deal with work-related complaints effectively communicating standards.
and problems of health workers.
A major role of the supervisor is to
• Serve as the liaison between upper provide technical training as needed to
and lower managements. personnel. Just-in-time training and on-the-
job training are a part of the supervisor’s
In the past, a supervisor’s position was job description. This provides an oppor-
often thought of as an enforcer of company tunity for supervisors to communicate
policy. Gaps between expected and current organizational standards and to be sure
performances were handled in a punitive that personnel understand and are able to
fashion. In today’s workplace, the super- properly implement these standards. The
visor takes on more the role of a coach, supervisor’s role should be considered
supporting personnel with what they need when larger training programmes are
to do their job and providing corrective planned and implemented. Whatever type
feedback. Styles of leadership vary with the of skills personnel are trained in by the
ability and willingness of the individual organization, they should be incorporated
worker to perform his or her job. There is into their job description and supervisors
no one right way to supervise personnel and should monitor the performance of these
the situational supervisor decides on the skills. While this seems obvious, incorpo-
style of supervision to use and the timing rating new skills into the job is often left to
for using it most effectively (Hersey, 1984). the worker and supervisors are left out of
the training loop. All this leads to confusion
Organizational communication that
and ineffective communication of
uses formal channels typically happens in
organizational performance standards.
a one-way fashion such as sending out
newsletters or memos about new or Let us take, for example, an organi-
modified standards without any mechanism zation that wishes to disseminate new
of feedback from personnel. Two-way standards for medical records. In this
communication, which is how we define example, these standards identify the way
effective communication, allows for medical records are organized, maintained

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Health Care Quality: An International Perspective

and filled out. If an organization only and avoid potential problems and pitfalls.
disseminates procedural manuals with Usually, standards are communicated with
memos or communiqués explaining the background information about why they
method of the new standards and the were developed, why they are important,
management’s expectations for their use, who the standards will affect, what tasks will
then it is using one-way communication be altered, and any other relevant informa-
and risks possible confusion and lack of tion that will increase audience under-
understanding by the target personnel. standing, commitment and adherence. A
Result: ineffective communication. plan for communicating standards should
include the following information:
The organization could develop and
implement a training seminar in the new The intended audience. Different
medical records standards, which would audiences in the organization have different
give the users an opportunity to clarify any information needs. Define the appropriate
confusion or misunderstanding about the audience by considering who carries out
standards. Developing and implementing the function that the standard is addressing.
the training seminar carries a cost that the Consider who will be affected by the
organization must consider. Another standard’s implementation. Not all groups
possibility is to train or inform health centre of personnel may be affected equally and
administrators about using the new medical each group may need different levels of
records standards and delegate them to communication or different information.
communicate this information to their Identify areas of concern that the audience
personnel. This also allows supervisors to may have and include ways to deal with
build the standards into the job perfor- those concerns.
mance expectations of personnel. It puts
them in the position of ensuring effective What needs to be communicated. Once
communication of the new standards and the audience is identified, the information
building these performance expectations to be communicated must be formulated.
into how they monitor personnel. They can This is probably more than just the
disseminate this information during staff standards themselves. It will most likely
meetings or other regular meetings with include the background information
personnel. described above, how and why the stan-
dards were developed, who they will affect,
what tasks are altered, and any other
necessary information. The message should
DEVELOPING A STRATEGY FOR include information to address any
COMMUNICATING STANDARDS concerns that have been identified.

An organization should develop a strategy What channels of communication to use.

for communicating standards so it can best The plan should map out the channels of
use various methods for communicating communication that will be used. This

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 Quality Assurance Activities

includes the up/down channels and the • Did the standard reach the
cross-organizational channels. If informal intended audiences and the
channels, such as opinion leaders, are to intended individuals in those
be used, they should be identified here. This groups?
is a good time to map out how feedback • Was the standard communicated
will occur. without distortion?
Source of communication. Identify who will • Was the standard communicated
communicate the standards to the intended within the time frame that was
audience. This should be a person or group originally planned?
that the intended audience views as a • Did the audience understand how
credible authority. The source person or to implement the standard?
group should have sufficient information to
answer all questions and provide adequate • Did the audience implement the
clarification. This source may change for standard?
different audiences.

Sequence and coordination of standards. POTENTIAL COMMUNICATION

Determine if it is necessary to sequence the
dissemination of information or can all BARRIERS
audiences receive information at the same
time. Based on the information needs for Organizations may take care to use well-
each audience, you may decide to established methods for effectively commu-
sequence the delivery of information to nicating standards. However, the organi-
eliminate any potential confusion. zation often can unknowingly create
communication barriers, which can be
Methods of communication. Consider the minimized or eliminated if the target
methods above and any additional audience is consulted while developing the
methods. Determine which are most cost- strategy for communicating. The following
effective and decide which to use. are some situations that create these
barriers to communication and some
Feedback. Since feedback is essential for suggestions about how to deal with them.
effective communication, the plan should
include what types of feedback are wanted, • The standard contains words,
who receives the feedback, how they will phrases or terms that are unclear
receive it, and what will happen with this or are not easily understood by the
information. target audience. This can be
avoided by involving or consulting
Evaluation. To evaluate the effectiveness of some personnel from the target
communicating the standards, you will need audience in the development of the
to answer the following questions: standard. Including a pretest before

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Health Care Quality: An International Perspective

dissemination may also help target personnel during the

overcome this barrier. development of the standard, parti-
cularly when determining the
• The standard was distorted by
appropriate format of the standard.
modifications, deletions or
additions as it passed through • The method of communicating the
various channels of standard was not appropriate for
communication. This can be the standards. For example, a
avoided by building in some check complex standard such as a new
points to ensure the integrity of the medical or surgical procedure may
standard is not altered before it not be effectively communicated
reaches the hands of those who will through disseminating information
use it. passively but better through
training personnel and supervisors
• The standards were communicated
in its use.
at a time when it was difficult for
the audience to apply them. For The target audience may believe that
example, laboratory procedures the application of the standard will result
disseminated at a time when the in a change in their status. This can be
laboratory is shut down and determined and dealt with by involving or
specimens are sent outside the consulting the target audience when
organization. developing the communication strategy.
• The standard does not contain • The target audience may believe
sufficient detailed information to that the standard was developed
adequately meet the needs of the because of their poor job
intended audience. For example, performance. Again, this can be
broad national standards that are determined and dealt with by
not specific enough to provide involving or consulting the target
sufficient guidance for work perfor- audience when developing the
mance. This can be avoided by strategy. Also, including respected
involving or consulting individuals peers in the plan for communi-
from the target audience during the cating can help to reduce or
development of the standard. eliminate this barrier.
• The method of communicating the • The application of the standard
standard was not appropriate for requires different groups to
the target audience. For example, cooperate that traditionally have
disseminating standards on a CD- not cooperated in the past. This
ROM to an audience with poor needs to be considered in the plan
computer skills. This can be and a strategy devised to address
avoided by involving or consulting it.

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 Quality Assurance Activities

IV. MONITORING OF COMPLIANCE are based on indicators and are usually

developed utilizing specific local, national
or international norms (or levels). One
Once the standard has been developed or
method for setting a certain threshold for
set using an already existing standard, an
an indicator is to measure the average
indicator(s) must then be developed and
compliance to that indicator in that
selected for that standard in order to
organization or country and add an
facilitate the next process, which is measur-
additional increment of 5-10% as a goal
ing the variance in compliance of that
for the organization/country to aim for. Both
standard. Measuring of compliance is
the development of indicators and thres-
performed through the collection of data
holds are necessary steps for the monitoring
necessary to measure the selected indi-
process to begin. More scientifically, an
cators. These indicators are in essence a
organization may measure its average
proxy measure of the standard and the
performance against a specific indicator
variance measured from a set of bench-
and set its threshold at plus (or minus) two
marks or thresholds the organization adopts
standard deviations. For example, if the
is an indication of the degree of compliance
average post surgical wound infection rate
to that standard. A description of an
in one hospital has been 5% and the
indicator and its importance is presented
standard deviation is ±1%, then the
in the chapter on Outcomes Measurement.
threshold should be set at 3% (5%-2%).
Thus, an indicator is a measurable variable
That means that this hospital will strive to
(characteristic) that can be used to deter-
improve its wound infection rate from a
mine the degree of adherence to a standard
current 5% to a future 3%. In this way a
or achievement of quality goals. Indicators
threshold is giving the organization a target
have the same characteristics of a standard,
to aim for and achieve. Of course, this
i.e. they should be reliable, valid, clear,
process requires constant monitoring and
applicable, realistic and, above all, measur-
system for data collection and analysis, i.e.
able. Indicators therefore must be expressed
monitoring.
in quantitative terms.
Therefore, monitoring is a periodic
Thresholds (or benchmarks) on the collection and analysis of data for selected
other hand are minimum or maximum indicators which enable managers to
levels of acceptable performance or results determine whether key activities are being
that, when crossed, trigger the organization carried out as planned and whether they
to respond. An example of a threshold is: are having the expected effects on the target
a nosocomial infection rate of more than population. Monitoring is performed to
2.5% triggers further evaluation, or a meet established quality goals, to identify
children immunization rate of less than 95% problems (opportunities for improvements),
triggers investigation of the reasons behind and to ensure that improvements are
under-immunization. Therefore, thresholds initiated and maintained. Monitoring, in

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Health Care Quality: An International Perspective

other words, is an important and critical need to be modified or whether an

process for an organization and just having improvement is necessary on the
a monitoring process is not enough. existing data source(s).
Monitoring must be effective to meet its
objectives. Thus, an effective monitoring • Determination of the data collec-
system will have a number of characteristics tion method(s); review existing
such as: be based on monitoring only key data, or through observation,
indicators, collect only needed data, gather surveying, or direct measurement.
data that are easy to interpret, and provide
• Development of data collection
timely feedback to the information users
instruments; this is especially
(administrators and providers).
applicable if surveying is the
Additionally, an organization may claim method selected to collect data.
to have an effective monitoring process Such issues as sample significance
based on the above characteristics but that and representation, pretesting,
process may run into problems unless validation, bias limitation, etc.,
recognized and corrected. Examples of such should be considered in
problems may include problems with data developing data collection tools.
(too much, incomplete, or inaccurate data),
• Determining the frequency of data
misinterpretation of information, or
collection, analysis and reporting;
inappropriate utilization of information in
considering continuous, ongoing
decision-making processes. Therefore,
or periodic.
monitoring as a process should be well-
organized and well-planned for and should • Determining the types of data
have as a minimum the following analyses and that may include
components: descriptive statistics, distribution,
• Delineation of responsibility(ies) correlations, trends, or statistical
significance based on the type of
and resources available; who will
data collected and the desired
be responsible for managing the
information on a specific service or
process, what kind of resources are
activity. It is also recommended that
available for the process (human
and physical resources necessary), data analysis should be
and the authority given to the accompanied by effective tools for
proper and affective data display.
responsible personnel.
Graphs and charts are easy to read
• Identification of sources of data; and are more effective to attract
also assess the completeness, attention and comprehension,
accuracy, timeliness of data, especially from a busy
whether an existing source of data administrator or provider.

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 Quality Assurance Activities

References 15. Grossman JH. “Emerging Medical Quality

Management Support Systems for Hospitals”,
1. Al-Assaf AF. “Quantitative Management in Total Health Care Quality Management for the 21st
Quality”, in The Textbook of Total Quality in Century, (ed. James B. Couch). The American
Health care, (Al-Assaf and Schmele, eds.). St. College of Physician Executives, Florida, 1991.
Lucie Press, Florida, 1993. 16. Hanely William V. Communication and
2. Al-Assaf AF. Managed Care Quality: A Practical Organizational Behavior: Text and Cases, 3rd ed.
Guide. (1998). Boca Raton, Fl.: CRC Press. Home wood, IL, Richard D. Irwin, Inc., 1973, p.
13.
3. Benson DS. and Van Osdol W. Quality Audit
Systems for Primary Care Centers. Methodist 17. Hersey, Paul. The Situational Leader. Warner
Hospital of Indiana, Inc., 1990. Books, 1984.

4. Berwick DM. “Controlling Variation in Health 18. Imparato A, Rites T. Peripheral Arterial Disease.
Care: A Consultation from Walter Shewhart”. In: Schwartz S, Shires G, Forman S. (eds.).
Medical Care, December 1991, Vol. 29, No. 12, Principles of Surgery. Chapter 21. McGraw-Hill,
pp. 1212-1225. New York, 1989.

5. Brassard M. The Memory Jogger Plus. GOAL/ 19. Institute of Medicine. Clinical Practice Guidelines:
QPC, 1989. Direction for a New Programme. (Eds. Field MJ
et al.) National Academy Press, Washington, D.C.
6. Coffey RJ et al. “An Introduction to Critical 1990.
Pathways,” Quality Management in Health Care
1992, 1(1), 45-54. 20. Joint Commission on Accreditation of Health care
Organizations. 1994 Accreditation Manual for
7. Dalkey NC et al. The Quality of Life: Delphi Hospitals, Vol I: Standards. Illinois, 1994
Decision-Making. Lexington, Mass: Lexington
Books, D.C. Health and Co., 1972. 21. Joint Commission on Accreditation of Health care
Organizations. Primer on Indicator Development
8. Dawkins, Brian. “Hello out there. Is anybody and Application: Measuring Quality in Health
listening?” CMA, The Management Accounting Care. Illinois, 1990.
Magazine, July-August, 1992, Vol. 66 No. 6, pg.
29(1) 22. Lohr, Kathleen N. Reasonable Expectations: From
the Institute of Medicine, interview, Paul M.
9. Deming WE. Out of Crisis. Cambridge, Mass.: Schyve. Quality Review Bulletin, Dec. 1992, Vol.
Mass. Institute of Technology, 1986. 18, No. 12, pg. 393.
10. DiPrete-Brown L et al. Quality Assurance of 23. Mills DH and Lindgren OH. “Impact of Liability
Health Care in Developing Countries. (The Litigation on the Quality of Care,” Health Care
Quality Assurance Methodology Refinement Quality Management for the 21st Century (ed.
Series, The Quality Assurance Project) 1993. James B. Couch). The American College of
11. Donabedian A. Explorations in Quality Physician Executives, Florida, 1991.
Assessment and Monitoring, Vol I: The Definition 24. Scholtes PR. The Team Handbook: How to Use
of Quality and Approaches to its Assessment. Teams to Improve Quality. Joiner Associates,
Health Administration Press, Ann Arbor, 1980. 1988.
12. Eddy D and Couch JB. “The Role Clinical Practice 25. Watson GH. Strategic Benchmarking. New York,
Policies in Quality Management”, Health Care John Wiley and Sons, 1993.
Quality Management for the 21st Century, (ed.
James B. Couch). The American College of 26. Williams WH. A Sampler on Sampling. John Wiley
Physician Executives, Florida, 1991. and Sons, 1978.

13. Eddy DM. “Guidelines for Policy Statements,” 27. Weingarten, Scott and Ellrodt, A. Gray. The Case
JAMA. 1990;263:2239-2243. for Intensive Dissemination: Adoption of Practice
Guidelines in the Coronary Care Unit, Quality
14. Eddy DM. “Practice Policies-Where Do They Review Bulletin, Dec. 1992, Vol. 18, No. 12, pg.
Come From?” JAMA. 1990;263(6):1265-1275. 449.

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Health Care Quality: An International Perspective

Annex

Case Study
Waiting Time in X-ray Department

Quality Assess
Component Elements Standards Indicator Threshold
Characteristics Appropriateness

Input Radiologist Well- trained MD + speciality in Percentage of the 80% will be Reliable Y
qualified doctor radiology doc. that meet temporally Valid Y
standard accepted Clear Y
Realistic Y
Technician 5-yrs’ experience
Clerk Make 200 X-rays/
day
Machine Reliable, well Maintained every No. of the X-ray 85% Reliable Y
maintained, 6 months machines that Valid Y
safe meet the Clear Y
Calibrated daily standards Realistic Y
Process Patient Patient go for The time between % of patients that 80% will be Reliable Y
arriving X-ray prompt patient arriving & wait for 5-min. accepted as a Valid Y
waiting should be 5 start Clear Y
min. Realistic N
Proper method The patient should Number of 0% Reliable Y
of taking X-ray not be exposed to repeated X-rays Valid Y
for one time, no more than one for patients Clear N
duplication X-ray/ time/request Realistic Y
Proper use of X-rays are accurate
machine
Outcome Pt. Finish The pt. waiting Time between X-ray No. of times 10% Reliable Y
quickly time is minimal request & X-ray exceeded the 20 Valid Y
reported should be min. Clear Y
20 min. & in Realistic Y
emergency 10 min.
X-ray film Relevant X-ray The X-ray should The no. of X-rays 95% Reliable Y
ready is ready show exactly what that are relevant Valid Y
the doctor asks for Clear Y
Realistic Y
X-ray report The report is Reports should be No. of X-rays that 95% Reliable Y
ready signed by the signed by the have the doctor’s Valid Y
radiologist radiologist signature on Clear Y
them Realistic Y

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 4 4
Quality Improvement: Tools and Methods
– A. F. Al-Assaf, MD, CQA

A s discussed earlier, when

completing the cycle of health care
quality implementation, improvement
6. Defining the key IOs
7. Organizing a team

initiatives are the next tasks after monitoring 8. Analysing and studying the IOs for
and assessment. Actually, and as discussed root causes
in the previous chapter, the purpose of 9. Developing solutions and actions
monitoring is to measure variance from a for improvement
“norm” or a threshold in order for the
10. Implementing and evaluating
organization to study the causes for that
improvement efforts, then re-
variance and to set in motion a process or
starting the cycle again.
processes to reduce this variance. The
process or processes of reducing variance Items (steps) 5 through 10 are all
is quality improvement. related to improvement processes. Each
item involves a number of activities and
According to the Quality Cycle
tasks. This chapter will not address each of
developed by the USAID Quality Assurance
these items in detail as some of them are
Project, the following steps (or at least some
self-explanatory and the others have been
of them) have to be in place before the
discussed in other publications in much
intervention processes for improvement can
more detail. This chapter, however, will
begin:
concentrate on introducing the quantitative
1. Planning for quality aspects and the tools commonly used in
2. Setting of standards (and indicators) improvement interventions in general. The
background presented here is to form an
3. Communicating of standards
understanding of the need for and the
4. Monitoring (against thresholds) comprehension of data management and
5. Identification and prioritization of statistical thinking in addressing quality
improvement opportunities (IOs) improvement options.

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Health Care Quality: An International Perspective

INTRODUCTION analysis techniques. In each of the above

areas several tools and methods have been
Quality is an amalgam of many manage- presented and illustrated. However, before
ment philosophies presented with a unique we dive into these issues, let us go back to
list of principles that are primarily customer- the QA cycle steps presented earlier. Step 5
oriented. Customer satisfaction means not suggests the identification and prioritization
merely reacting to and addressing com- of opportunities for improvement. How is
plaints but also taking the methodical this done?
approach to researching the origin of As we discussed in the last chapter, the
problems and the magnitude of their purpose of monitoring is to identify gaps
occurrence and impact. Therefore, quality or variance in compliance to commun-
seeks an aggressive proactive customer- icated standards. Therefore, the next step
oriented approach to problem identification is to evaluate these gaps or improvement
and solution. opportunities (IOs) and select those that are
Two approaches can be used to most important for the organization to
evaluate the service provided by an address. This process of selecting the most
organization to its customers - a qualitative important IO is the process of prioritization.
approach and a quantitative approach. A Several tools are presented later in this
qualitative approach is used to satisfy the chapter to assist in this process of selection.
internal evaluation process. This approach In general, one may use specific criteria to
focuses primarily on the “do it right the first compare the different IOs with one another
time” processes. The external evaluation and therefore selecting the one(s) that best
process is best evaluated using the fit more criteria than the rest or fit the most
quantitative approach, which determines vital criteria more. For example, one may
the extent of customer satisfaction. This use such criteria as feasibility for implemen-
approach includes collecting and analysing tation, impact on patients, cost, political
data on the nature and scope of the environment and probability for success.
problems or potential problems that may One may also use the nominal group
face customers. Data should be collected technique to choose the most suitable IO
on the needs and expectations, as well as or the multiple voting technique to do the
trending of occurrences and measuring same (these techniques are described later
levels of customers’ dissatisfaction seg- in the chapter).
mented by specific categories and Once an IO (or a group of IOs) has
experiences. been selected, the next step in the cycle is
This chapter presents three main issues to define the IO in a more “operational”
in quantitative approaches to quality? The terms, i.e. what are the parameters of the
first is the concept of transforming data to IO? In doing so, the following questions
information. The second is data collection need to be answered before a statement is
and display, while the third issue is data developed for the IO:

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 Quality Improvement: Tools and Methods

• What is the IO? Once the members have been selected,

• What is not functioning? the team should be convened. Responsibi-
lities should be assigned to team members:
• What is our desire? leader, scribe, and an external facilitator
• What will the desired outcome look identified to ensure group dynamics and
like? provide background training in quality
• How do we know it is an IO? improvement tools. The addition of a
facilitator, sometimes called a coach, is a
• How do we know when it is fixed?
major advantage for teams to function most
• What data do we need to learn effectively. The facilitator could be function-
more about this IO? ing as a full-time member of the team and
• What effects does this IO have on have voting rights, but it is preferable that
quality? a facilitator be a part-time member and not
part of the team. This individual should be
• How long has this IO been in
well trained in quality improvement skills
existence?
and tools and should be ready to train
• How frequently does it occur? others on how to use these skills and
• What are the boundaries of the IO? techniques when needed. The facilitator’s
Identify a beginning and an end. job should also include providing advice
to the leader in team dynamics and
Additionally, one should state the IO in ensuring that the team develops its mission
a statement that is clear and in simple terms early in the process and encourages
to be easily followed by the assigned team members to focus on that mission.
members. Other conditions defining the IO
are that the operational statement should not Now the process is at a stage where the
contain a proposed solution, nor identify a improvement opportunity needs further
cause, and should not assign blame. clarification and studying. In this step, the
team members should discuss data manage-
Therefore, once the IO statement is ment issues related to this IO and identify
developed, a team should be organized to steps for the transformation of data into infor-
study the IO and identify causes and mation in order to implement improvement.
solutions for improvement. Selection of
team members should be based on the
identification of individuals knowledgeable
in the processes related to the IO and who
TRANSFORMATION OF DATA
are interested in serving on such a team. INTO INFORMATION
Voluntary involvement should be one of the
criteria for organizing the team. You do not Data versus information
want members who are not interested in
serving on the team. They will produce The definition of data can be simplified as
mediocre results at best. all the raw numbers, figures and individual

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Health Care Quality: An International Perspective

responses collected from a sample or a different researcher) it will produce the same
population. Data are unprocessed facts. results over and over again. A tape measure
Data alone are meaningless and are worth- is a reliable measure of the length of a sofa.
less. Information, on the other hand, is Similarly, the number of medication errors
meaningful, interpreted or processed data. is a reliable measure since the same
Whenever one set of data is analysed and measure can be used by another researcher
used in specific relationship with other data at any other time and get the same result,
set, the end product is information. For given the same definition of medication
example, the number 18 is without a errors is applied. Reliability of a measure
meaning by itself, but it becomes meaning- is important to ensure the collection of
ful if it relates to the number of diagnosis accurate data. Accurate and reliable data
coding errors per month in a hospital. are dependent on the level of training and
Therefore, only information can be used to understanding of the data collectors and
make judgement on a hypothesis or answer data processors. Incorrect or missing entries
a research question. in a data set may render that set of data
unreliable, thus any judgement based on
Processed data can be either discrete this data set may become inaccurate and
or continuous. Each is explained as follows: not representative of the true facts.
Discrete data refer to facts that are
explained by yes or no, female or male, Data validity
success or failure. For example, the number
of coding errors, the number of personnel To ensure the accuracy of the data collected
in the nursing department, the number of one must not rely only on the reliability of
discharged patients from a hospital per measures. The validity of the measure is
month, etc. equally important. It is the ability of the
measure to actually measure what it really
Continuous data refer to those facts that
means or what you really want it to measure.
are variable in quantity and can be explained
In our earlier example, using the measuring
by answering the questions of how old, how
tape to measure the length of the sofa is
tall, how much, etc. For example, the
valid since the result indicates the desired
average length of stay in a hospital, the cost
information. Measuring medication errors in
of nursing services for a patient, the response
a hospital is valid if the result answers our
time to an emergency call, etc.
earlier question, that a number of medication
errors did occur. However, this same
Data reliability measure may not be valid if our intent with
this measure is to measure the quality of the
According to Longo and Bohr (1991), a services rendered. To what extent does the
measure’s reliability is the extent of its occurrence or the absence of medication
reproducibility. This means that if the errors indicate that an unexpected adverse
measure is applied repeatedly (even by a condition did or did not occur? Therefore

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 Quality Improvement: Tools and Methods

to measure the validity of a measure one d = the number of cases the test truly labelled as not
diseased
must know the predictive value of a
measure. This can be further understood by Sensitivity = a/(a+c)

explaining the concepts of sensitivity and Specificity = d/(b+d)

specificity. Predictive value = a/(a+b)

Using the principles in Table 1, one can

Sensitivity and specificity relate the measure in our earlier example,
the number of medication errors, to the
The accuracy of a measure or a test is quality of care as shown in Table 2.
estimated by the calculation of its sensitivity
We can then conclude that the number
and its specificity. Sensitivity is the propor-
of medication errors as a measure did
tion of times that the measure or the test is
predict 10 true adverse conditions out a
positive when the adverse condition or the
total of 17 detected adverse conditions, i.e.
disease is present. Specificity is the propor-
a predictive value of 59%.
tion of times that the measure or test is
negative when the adverse condition or the From the above it is obvious that for the
disease is absent. This is to say that the data collected to be transformed to
accuracy of a test or a measure is dependent information, data must be defined in detail
on the minimum occurrence of false positives and their measures must be accurate.
and false negatives. The number of false Accuracy of a measure is dependent on
positives and/or negatives should be very whether it is reproducible (sensitivity of a
low to make the test accurate. To illustrate measure), whether it measures what we want
these points, let us examine the following it to measure (specificity of a measure), and
two-by-two table for measuring the accuracy whether it predicts true occurrences of what
of a test in detecting the presence of a we want it to measure (predictive value).
disease in a population:
Table 2. An Example of relating a
Table 1. Measuring a test validity measure to quality of care

Disease Totals Unexpected adverse

Test Medication
Present Absent Total condition Total
Errors
Positive a b a+b Yes No

Negative c d c+d Yes 10 7 17

Total a+c b+d a+b+c+d No 2 81 83

Total 12 88 100
a = the number of cases with disease that the test
detectezd
b = the number of cases the test falsely detected as Sensitivity = 10/12 = 0.83
diseased Specificity = 81/88 = 0.92
c = the number of cases with disease that the test Predictive value = 10/17 = 0.59
missed

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Health Care Quality: An International Perspective

Data collection and display • Pie charts

• Scatter diagram
One of the main principles of Total Quality
• Histograms.
Management is statistical thinking (Deming,
1985). Using statistical methods in data
collection and analysis increase the credibility Tools for quality improvement
and accuracy of the information obtained. and monitoring
Statistics is a science based on the quanti-
tative measures of data and their elements. • Nominal group technique
It is therefore not surprising to see that quality • Multiple voting technique
emphasizes the use of statistics to accurately • Weighted voting technique
interpret data and produce meaningful
• Rank ordering technique
information to understand, improve and
monitor processes in an organization. • Balance sheets
• Trend and run charts
This section will introduce several tools
• Flowcharts
and techniques utilized in TQM through its
quest for continuous process improvement. • Pareto diagram
Leebov and Ersoz (1991) suggest several • Control charts
tools for use in quality improvement. We • Cause and effect diagram
further categorized these tools in two
• Decision-making matrices.
separate categories reflecting their usual
cited use as follows:
• Tools for identifying, collecting and Tools for identifying,
displaying data collecting and displaying
• Tools for quality improvement. data
Let us describe and present some of the It is imperative to understand that the process
most common tools in each of these of collecting data has several preceding
categories. processes. The objective of collecting data
is to collect adequate, comprehensive,
accurate and representative data elements.
Tools for identifying, Then, data collection processes should be
collecting and displaying data preceded with the identification and listing
of all of the limits and biases the data might
• Surveys
encounter through the collection process or
• Brainstorming during the analysis phase. One must also
• Brain-writing take into consideration the different sources
• Logs of data, both the internal and external
• Check sheets sources. Caution should always be applied

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 Quality Improvement: Tools and Methods

when collecting and interpreting data from The objective(s) have to be realistic,
different sources. Data collection sources measurable and applicable to the target
may be heavily biased against one another. population. For example, an objective of a
Also, the list of data sources should be survey could be to find out the percentage
exhaustive and every effort should be made of discharged patients that have utilized our
to make sure data is collected from all actual “hot line on patient education” during the
and potential sources. If, however, exploring three months after their discharge from our
all sources of data is not feasible due to hospital during a specific year. Objectives
certain barriers (e.g. resources, logistics, etc.) are excellent measuring items useful in the
then a statement to this effect should be evaluation of surveys before, during and
provided with the report on data collection after data collection.
and analysis. Therefore, data collection
barriers should be identified as early as
possible and attempts should be made to
Sample
overcome these barriers as much as The population sample is defined according
possible. Accurate and useful information to the type and size of the target population.
depends heavily on the integrity, validity and First, one must define and identify the target
applicability of data. population. The next step is to see if this
population is accessible, if there is already
existing data on it, and if the size is too
Surveys
large (considering the resources available
One of the most widely used techniques in and logistics) that will require the need for
collecting data has been surveys. Collecting selecting a sample of this population which
data from a target population through is smaller in size.
surveys is considered a simple and a fairly If we decided to survey the total target
accurate measure of the target population. population as in our earlier example, i.e.
There are however several questions that all the discharged patients from our hospital
must be applied when conducting surveys during a specific calender year, then this
to ensure adequate and true representation type of sample is called a census sample.
of the population under study. These This sample is obviously the least biased
questions may include: What is the sample. If, on the other hand, we decided
objective(s)? Is there a need for selecting a to survey a smaller number of individuals
sample of the population? Which method in a population then we would need to
should be used in surveying the population? determine two major elements — sampling
What questions should be asked? method and sample size.

Sampling methods will select either a

Objective(s) probability or a non-probability sample of
Each survey must have an objective or a set the population. A probability sample could
of objectives that the survey is set to achieve. be a simple random sample, a stratified

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Health Care Quality: An International Perspective

random sample or a systematic sample. A techniques one must keep in mind that
non-probability sample could be a conve- samples of these categories may not be
nience sample, a purposive sample or a representative of the target population.
quota sample. The following is a brief Therefore, inferences should be strictly
explanation of each of these sampling related to the sample of the study while
methods: projections on the total population from
sample studies alone should be accepted
Simple Random Sampling is a process
with the caution of potential non-
where the required sample size is selected
representation.
randomly from the total population under
study through the use of a randomly Convenience Sampling is performed to
generated number tables, random number select readily available data. For example,
generating computer programmes, or a we would select those discharged patients
lottery. This type of sampling methodology from the surgery unit during the month of
produces a simple but unbiased sample. March of a given year only. This sampling
Stratified Random Sampling requires the method is considered to be the weakest to
determination of a sample based on one withstand the test of sample representation
or a set of categories, usually demo- of the population or bias.
graphics. In our earlier example we would
Purposive Sampling is a technique used to
select a random sample from the popula-
select a sample for a specific purpose. For
tion by decile age categories or another by
example, following a 30-day probationary
income level categories, etc.
period to re-accredit a hospital, the
Systematic Sampling utilizes generating one accrediting agency will only look at the
random number and then selecting a hospital activities during the probationary
constant interval. Thereafter every case that period.
falls at that interval will then be selected.
For example, if our random number was Quota Sampling is usually chosen to select
nine and the constant interval was six, we a sample based on an arbitrary quota. For
will then select the ninth discharged patient example, we may select only 5% of the
and then every sixth discharged patient target population to be included in our
thereafter, i.e. 15th, 21st, 27th, etc. Here, sample.
of course, we are assuming that those
patients were not discharged using any Sample size
systematic interval.
The other type of sampling method is Calculating the sample size is the second
the non-probability sampling method. element concerning sampling in general.
To determine sample size one would require
Three different sampling techniques are the availability of several preliminary data
discussed below using this method. For the elements. One method of determining the
following non-probability sampling sample size utilizes the following equation:

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 Quality Improvement: Tools and Methods

N = (z/e)2 * p(1-p) questions may cause a problem in accu-

rately analysing the results. Also, mail
where,
surveys require at least three to four weeks
N is the sample size to complete and analyse.
z is the level of confidence determined A telephone survey is a very accurate
by the z score survey but answers could be biased or be
e is the error rate in response to leading questions. Since
human element is involved in actually
p is the proportion of the target collecting the data over the phone, specific
population in the total. training and coaching is required to
accurately record and extract data from the
Once we have determined the sample
respondents. Telephone surveys have the
size and selected a sampling technique, the
advantage of receiving a 100% response
individual “member” of the sample can
rate and can be completed within a
then be identified. To proceed in our survey,
relatively short period of time, especially if
one must then determine the method by
collecting the responses were performed
which to survey this sample population.
electronically.
Selection of any method is dependent on
the availability of resources, both human The face-to-face interview is the most
and physical, time, accuracy, bias, and accurate but again could be biased since
convenience. the identity of respondents albeit protected
is not anonymous. Again, data collectors
There are at least three main methods
(interviewers) should be adequately trained
of surveying a population. Surveys can be
in interviewing techniques and should be
conducted through a mail survey, a
instructed to avoid leading questions to
telephone survey or through an interview.
minimize bias of responses. Interview
All of which require a predetermined and
surveys usually enjoy a much higher
pre-tested questionnaire.
response rate than other types of surveys,
In a mail survey you will be able to but are considered the most expensive and
reach a larger number of individuals with the most inconvenient type of survey due
the least amount of expenditure and human to the scheduling of interviews and
resources. This method also provides you respondents’ availability.
with honest (especially if the respondents’
It must be noted here that the integrity
identity is anonymous) and least biased
of the data collected through any of the
answers. The major problem, however, with
above types of surveys depends on the
this type of survey is the response rate
content and quality of the survey question-
which, if it is too low, renders the responses
naire. A questionnaire should be designed
non-representative of the total population.
to provide information that can answer the
Of course, misinterpretation of the survey
survey objective(s) adequately. Each of the
questions or not completing all the

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Health Care Quality: An International Perspective

questions included should be composed displaying data, it is a quick, simple and

and designed in relation to the sample very useful tool that is equally important in
population. Therefore, questions must be making quality improvement decisions. This
clear, simple to understand, and should technique is usually group-oriented,
require the minimum of effort, and time, whereby a group of individuals meet to
for the respondents to answer. It is generate an exhaustive list of ideas
suggested that closed-ended questions are regarding an area or a topic at hand. It is
easier to answer and are certainly easier a process that stimulates and encourages
to analyse. In other questions where the creative thinking and independency of
opinion of the respondents is needed to be thinking. The concept of creative and
captured and quantified, one may design independent thinking is facilitated by one
the questions in the form of statements. of the rules of brainstorming that will allow
Each statement is succeeded with a choice individuals to list any idea they choose
of several answers (on a numeric scale) without being criticized. The generated list
based on the level of agreement or can either be used to answer a question or
disagreement to that statement, e.g. to trigger other questions in problem
strongly agree, agree, disagree and strongly identification and solving. Brainstorming is
disagree . Once the questionnaire is performed to generate the information
designed and the questions are constructed, needed to proceed for other steps in the
one must proceed to administer the quality improvement process. This
questionnaire to a small number of technique becomes especially useful when
individuals that share the same charac- all members of the group are participating
teristics as the sample population. This and no boundaries of thought are adopted.
process is called “pre-testing” and will The following is a description of the
mimic the survey process in terms of survey brainstorming technique:
process and methodology. Pre-testing is
• Members of a group are gathered
important since it gives the researcher the
to discuss an issue, e.g. the causes
ability to predict the behaviour of the
of high patient waiting time in the
sample population. It also provides the
emergency department. After a few
researcher with feedback regarding the
minutes of thinking about the issue,
design, the quality and the efficiency of the
a group facilitator is selected and
survey instrument. Pre-testing of the
is asked to record the listing of all
questionnaire will provide the researcher the
of the ideas generated from the
chance to modify it for clarity, making it
group on a board or a flip chart
simpler to understand and easier to answer.
to be easily seen by everyone in the
group. Each member will then be
Brainstorming given a turn to voice any one of
his/her ideas on that issue. This is
Although brainstorming is listed here under done by using either a freewheeling
the tools for identifying, collecting and technique (anyone can call an

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 Quality Improvement: Tools and Methods

idea) or by a round-robin can then be sorted into related

technique (going around the table). themes or categories. The final list
The facilitator lists those ideas with is adopted by the group and is put
no discussions, judgements or into use for its original purpose.
criticism. In order that brain-
storming sessions should move Brain-writing
fast, each member is given only a
short period of time (15 seconds) This technique is similar to brainstorming
to voice their ideas. Every idea is where members of a group gather to
recorded in that person’s own generate a list of ideas on a topic. Unlike
words as he/she introduces it. brainstorming, the ideas generated in
Group members can “hitch-hike” brain-writing are evaluated and utilized
on ideas that were generated by aggressively by other members in the
others. Several rounds of soliciting group to expand their list of ideas. Brain-
ideas from the group members writing is performed with each group
may be performed until all member being asked to write his/her list
members have exhausted their of ideas on a piece of paper. All the papers
ideas or an agreed time limit is are then left at the centre of the table or
reached. Sessions usually last for the room for all members to view and
about 15 minutes or less. You can choose from to either add to or modify
have more than one round till all ideas in the lists. Another method is that
ideas are expressed. each member is given 20 to 30 minutes
• The next phase is to examine the to generate ideas and record them on
list generated and discussions are separate flip charts that are then posted
encouraged to clarify each idea around the room. Each member is then
and the objective behind each one. asked to read those ideas recorded by
All members can ask questions others and go back to their sheets to
about any or all the ideas continue listing more ideas that were
generated to reach a level of stimulated by others’ ideas. Brain-writing
common understanding of the true has the advantage over brainstorming
meaning of each of the ideas where on occasions some members of the
generated. group are dominating the idea-generating
process. It also provides all members with
• Once these ideas are further
equal opportunity to participate and
clarified, then the whole list should
eliminate less thought-out ideas. It can
be evaluated and those ideas that
also be designed to be anonymous. Brain-
are similar to each other should be
writing can have the same uses as brain-
consolidated. Therefore, in this step
storming in collecting and displaying data
the list of ideas is revised and
as well as in quality improvement efforts.
duplications are eliminated. Ideas

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Health Care Quality: An International Perspective

Logs Check sheets

This is a tool that is both simple to To answer the questions "What do you want
construct and easy to use. It is useful to to know?" and "What is the most reliable
keep a track of the sequence of events or way to collect data?", one must construct
the time occurrence of certain data for a check sheet. To construct one, check
charting trends or frequency analyses. Logs sheets can be either drawn in the form of a
are constructed by identifying the data table or a diagram. The recorder will make
elements and organizing it into a table. a check mark or enter the appropriate data
For example, one may want to keep a log across from the item in the sheet once the
of all the medical charts reviewed by the observation has occurred or the event has
chart reviewers by date, by time, and by happened. Table 4 illustrates the use of an
finding. Table 3 below shows a log sheet example of an event on a check sheet.
for the reviewed medical charts. It is
Check sheets are useful to collect data
important to keep in mind that logs are
to answer questions regarding resource
constructed to be simple in design and are
allocation, analyse a current problem or
user-friendly. Logs are usually drawn as
identify potential problem areas.
rows and columns with the summary
statistics at the bottom of the log sheet.
Recorders should be given a brief orienta- Pie charts
tion session on the log’s use and should
be encouraged to only record the raw data For efficient and impressionable presenta-
requested and not to try to identify or elicit tion of data, pie charts provide a powerful
a trend of that data. tool to accomplish that. A pie chart is a
form of graphic presentation of data

Table 3. An example of a log

Medical Record Reviewer Date Time Finding(s)

1234567 Smith 8/31/98 8:30 am No lab results

4567890 Jackson 9/1 9:30 No signature

3256701 Phillips 8/30 10:00 No referral form

4100056 Bradford 8/31 11:00 Missing H&P

3255671 Sharp 9/1 9:00 Incomplete ID

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 Quality Improvement: Tools and Methods

elements that are part of a whole. This tool – Pie chart's segments must add up
is useful to visualize the difference between to 100% of the whole.
the several parts of a whole. Pie charts can – The number of segments in a pie
be used in place of bar graphs. chart should not exceed more than
The construction of pie charts however six in order to avoid "cluttering" of
has a few rules which need to be followed: information.
– Each segment should indicate the
percentage amount as compared
to the whole to enhance
Weekly Outpatients Visits
comparability.
– If there are one or more categories
5%
15% that have a zero value, pie charts
should not be used.

Scatter diagram

20% 60% This technique is useful in displaying data

from two variables that may have a
relationship (but not necessarily an
Whites Blacks Asians Others impact) with each other. The data

Table 4. An example of a check sheet

Lab Technician Present (x) or Absent (o)
Days Jones James Lee Dean Ali

Monday x o x X x

Tuesday x x o X x

Wednesday o x x X x

Thursday x x o X x

Friday x x x X o

Saturday x x x X x

Sunday x x o X x

Total (x) 6 6 4 7 6

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Health Care Quality: An International Perspective

collected for each variable is then plotted Histograms are useful to present a pictorial
on a graph with one variable on the X- view of the data elements and to show data
axis and the other on the Y-axis. If a pattern patterns. Histograms are constructed
is noticed then a positive or a negative primarily to display data. For example, the
relationship may be concluded. This X-axis shows the time spent (in intervals) for
technique is considered to be the easiest routine outpatient visits while the Y-axis
way of recording a correlation analysis shows the number of routine patient visits
without actually quantifying the strength completed within each of the time interval.
the significance of the relation between the
variables. It is simple to construct and is A histogram is constructed in steps. In
useful in showing patterns of data and the above example, we collect data by
providing supportive data for cause-and- constructing a table of patient visits column
effect diagram construction (described by time spent (in minutes) in the outpatient
later in this chapter). Although scatter department. We would then arrange the
diagrams are sometimes used to plot pairs time into equal intervals depending on the
of discrete data (e.g. number of charts), range of the times in minutes. The next step
they are most useful when plotting is to construct a check sheet with the
continuous data (e.g. time vs. patient number of patient visits that each fell in one
temperature). of the identified time intervals. An histogram
will then be constructed using the above
information by plotting the number of
Histograms patient visits on the Y-axis while plotting the
time intervals on the X-axis. Each time
This tool is a modified bar graph, where interval will represent the width of the bar
the data on the X-axis are continuous data, while the number of patient visits will
thus the bars are adjacent to one another. determine the height of the bar.
Effect

Effect

Effect

Cause Cause Cause

Positive Correlation Negative Correlation No Correlation

(Direct relationship) (Inverse relationship) (No relationship)

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 Quality Improvement: Tools and Methods

TOOLS FOR QUALITY is done by one of three popular methods

(as described below): multiple voting,
IMPROVEMENT AND MONITORING weighted voting, or rank ordering
techniques. A second list will then be
Once data are collected and other tools generated with the ideas ranked
are constructed to display data, analysis of accordingly and presented for its intended
data begins and several tools can be used use of implementation and process
to aid in this process. Quality improvement improvement. This technique is especially
helpful to decrease the number of ideas to
a shorter list of a manageable number of
“best” ideas.
Number of outpatient visits

Multiple Voting technique

To complement brainstorming and brain-
writing techniques, multiple voting is
another technique that is intended to
shorten, evaluate, critique and rank a long
list of ideas. Multiple voting is performed
by the members of the group that generated
the list of ideas. The group will decide on
8-12 12-4 4-8 8-12 12-4 4-8 a number of votes each member may have
(Time in hours) (usually 1.5 times the number of ideas
present). Each member will then cast his/
tools are important for decision-making and her votes on the set number of ideas.
for evaluating the progress and the success Members can spread their votes any which
or failure of the decision made to improve way they desire on the list of ideas.
a process. There are several process Therefore, one member may cast half of
improvement tools and I will attempt to his votes on idea number 1 and the other
present and explain most of them. half on idea number 3 but none on any
other idea and so on. All those ideas voted
on by group members are posted on a flip
Nominal Group technique chart to be visible by all members.
Discussions will then follow to determine
This technique is a continuation of the which ideas received the most number of
brainstorming and brain-writing techniques votes and whether these ideas are adequate
for the purpose of ranking or prioritizing. to describe the group choices. Further
Once a list of ideas is generated then a consideration of other ideas may be
process of prioritizing or ranking of ideas required if the group decides that more
begins with all the group members. Ranking ideas are needed on the final list. The new

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Health Care Quality: An International Perspective

and final list of ideas is then presented for by each member. The total points received
ideas to be implemented by the processes for each idea is added from all the
involved. members. Ideas are then ranked according
to the number of points each idea
received.
Weighted Voting technique
Example: (Al-Assaf and Shouman, 1998)
Again, this technique, as with multiple
voting technique, is useful in determining • Each solution to be measured
a final and best list of ideas to be according to different criteria that is
implemented by a group of individuals. As supposed to be of importance to the
with multiple voting each member is able organization such as Impact, Cost,
to cast their vote on the full list of ideas or Feasibility, Politics, Reputation,
only on a short list of ideas. In this Relevance, etc.
technique, group members are asked to
provide their individual ranking for each • The solutions that get the highest score
idea based on a set criteria; for example, will be adopted for implementation.
feasibility, cost, impact, politics, etc. If the
idea is most feasible to implement then it • The score range from 3-1, with
could receive a maximum of 5 points and 3 means high score for better solution.
so on for cost, impact, politics or other
criteria present. Each idea is therefore • Example : I- Impact P- Politics
evaluated individually using these criteria C-Cost

Name A Name B Name C Total

Activity R R R R
I C F P R I C F P R I C F P R I C F P R
P P P P
1. Form team 3 1 5 4 2 1
2. Establish Plan
3. Set standards
4. Measure cost
5. Calculate cost
6. Measure
compliance
7. Prepare
statistical data
Score from 1-5
where 1 is least
score

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 Quality Improvement: Tools and Methods

Rank Ordering technique Balance sheets or force-field

In conjunction with brainstorming and diagrams
brain-writing this technique is used to rank
ideas for further consideration and/or This technique is used to help a group of
implementation. Rank ordering technique individuals select a shorter list of ideas,
requires working on a short list of ideas options, decisions, etc. All the ideas under
(ideally less than ten) by the ideas genera- consideration are listed on a two-column
ting group. If the number of ideas is too table. One column will be noted as the
large then use the principle of “one half positives/the advantages/the strengths/the
plus one”. If the number of ideas is 20, then driving forces column.
one half of 10 plus one equals 11. There-
The other column will be the opposite
fore, use only 11 ideas and you may apply
descriptors column. Each idea is then
the same principle again for the rest of the
discussed and a listing is produced by the
ideas. Once the number of ideas is agreed
group members regarding its positives and
upon, each group member is asked to rank
the negatives. After considering all the ideas
these ideas starting with one as the most
on the list, the group “balances” the
important and ending with the least
positives with the negatives, i.e. the forces
important idea. The recorder of the group
for it and those against it, and then
will post the list of ideas on flip chart and
determine if some of these ideas might be
on columns record the ranking given by
eliminated. This technique is again very
each member to each idea. After recording
all the rankings for each idea, these are useful in determining the best ideas for
then added together to get the total ranking further consideration and implementation.
score given to each idea. Since a score of It is therefore another important technique
one is given to the most important idea, in the process of quality improvement.
the idea that receives the least numbers is
therefore the most important and so on for
the rest of the ideas. Trend and run charts
Rank given to ideas A - H A trend or a run chart is a line graph that
Example: visualizes a pattern of behaviour of certain
data over time. It is therefore a pictorial
Ahmed
Jasmin

indicator of the extent of fluctuation of

Susan

Total
Idea

Jack

Jill

performance of a data element during a

A 1 8 2 1 3 15 period of time. Trend charts are very useful
B 4 2 1 7 2 16 in displaying and monitoring the behaviour
C 2 3 4 4 7 20 of data as well as a predictor of the future
D 7 5 5 2 4 23 performance of that data. For example, one
E 3 4 6 6 8 27
F 6 7 3 3 6 25 might chart the number of medication errors
G 5 1 8 8 5 27 on the Y-axis against the months on the X-
H 8 6 7 5 1 27 axis over a year to look for trends.

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Health Care Quality: An International Perspective

Interpreting patterns (see figure below of a process. For example, one could
for examples): all these patterns suggest a flowchart any process in a hospital from
non-random event (special cause, a patient registration to patient admissions
process not in control). and discharges. Each of the steps in the
process is denoted by a symbol indicating
• More than 7 consecutive points above the nature of the action or reaction.
or below the mean suggest a pattern
of change. Flowcharts can be one of several
types: detailed (with loops of rework), top-
• Six points consistently increasing or down (only an outline of the major steps
decreasing suggest a trend (2). in the process), or a work-flow type chart
• More than 7 points in a zigzag pattern based on the actual steps occurring in
suggest a cyclical event (3). relation to a specific work process. Team
members should be collectively involved
in flowcharting a process. Teams should
Flowcharts start by defining the process in considera-
tion, then a determination of a beginning
Flowcharts are a step-by-step sequence of and an end of the process is made. The
processes and sub-processes that pictorially team will then start to write the steps of
include events, reaction(s) or decision(s). the process in the sequence they occur.
This tool provides a detailed list in the form Certain members of the team or with the
of a sequenced diagram outlining all the aid of action teams will be responsible for
actions and steps required for each and flowcharting the technical steps in the
every process in an organization. It also process. Once a flowchart is produced of
provides a common language to be used the process, the team will revise it again
by teams when discussing different elements for completeness and correct any errors.

Time for lab results to return

Time for lab results to return
in minutes

30
time in minute

25
20
15
10
time

5
0
a b c d e f g h i j k l m n o p q r s t u v w x y z aa b cc d ee ff gg

Cases
Cases
(*Adapted from Reinke, 1998)

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 Quality Improvement: Tools and Methods

The final version of the flowchart is then Flowcharts are important tools both for
transferred on a sheet of paper denoting displaying a process and for understanding
the steps of the process in symbols and is the process steps. It supports the principle
put in use by the organization. The that if you understand your processes and
following is a list of some of the more how they work, then you will be able to
common symbols used in the flowcharting identify process requirements and its
processes: “bottlenecks”. Therefore, to analyse the
process using flowcharts, the team might
Although many symbols are used in begin by asking such questions as: Is there
flowcharts, the most common ones are any delay? Are there any bottlenecks? Are
shown in the following figure. there any steps that are missing? Any that
are redundant? Are there opportunities for
improving the process flow? Flowcharts are
management tools that will support the
quality improvement efforts of an
organization.
Start / Stop
Pareto diagram
According to Omachonu (1991), an Italian
Step or activity
economist called Alfredo Pareto (1897) and
an American economist, M. C. Lorenz
(1907), developed a concept that
suggested that only a few of the population
shared most of the total income of the
population. The quality expert, J. Juran,
Decision point
applied this principle to problems of quality
dividing them into the vital few and the
trivial many, i.e. most of the problems are
linked to only a few of the causes. The
procedure that classify these problems is
Cloudy, or uncertain step thus called the Pareto Analysis.

The Pareto concept is further known as

the rule of the 80-20. In health care this
can be applied, for example, by saying that
Connector to another 80% of the documentation errors are
page caused by 20% of staff. Another example
is that 80% of the medication errors are
caused by 20% of nursing staff and so on.

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Health Care Quality: An International Perspective

Sample of a flowchart

Greet patient

No Refer Go to
Appoint- “unscheduled”
ment to Nurse
protocol

Yes
Log in
register

Do
insurance
forms

Chart No Make
available Chart
Yes

Chart to
MA box

Pt. to
waiting room

MA No
available?
Yes
Vitals

Exam room No
Wait
available?

Yes
Pt. to
exam room

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 Quality Improvement: Tools and Methods

One can further analyse data utilizing this temperature, taste, promptness of
principle by the use of bar and line graphs. service, aesthetics, etc.
To do this there are a few steps that need
to be followed to display the data on a 4. Calculate the frequency of complaints
graph according to this principle: by category, e.g. temperature 74
complaints, taste 43, etc.
1. Identify a quality problem to be studied,
e.g. patient complaints of dietary 5. Plot the frequencies of each complaint
services. categories on a bar graph and arrange
the categories in order of descending
2. Determine and carry out a data frequencies from left to right on the
collection method, e.g. mail survey. horizontal axis (X-axis). Two vertical axes
must be designed, the left axis (Y-axis)
3. Categorize the complaints cited by will be divided in equal intervals into
respondents according to type, e.g.

100%

100 80
Estimated effect of Change
No. of Patient Complaints

75%
No. of Patient Complaints

80 60
50%

60 40 100%

25%
75%
40 20
50%

25%
Taste

Taste
Temperature

Timeliness of service

Timeliness of service
Staff courtesy

Temperature

Staff courtesy
Aesthetics

Aesthetics

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Health Care Quality: An International Perspective

the number of highest category to “special” or “common” causes. Special

frequency (74 in our example), while causes have the tendency to occur
the right vertical axis is divided into sporadically and acutely and will therefore
percentages from 0% to 100%. need to be attended to by the management
team. Common causes, on the other hand,
6. Add the percentage values of the bars are long-term causes that have no
and calculate the cumulative total over capability of destabilizing a process but can
each bar. Plot these totals on the same produce slight impact on process variation
graph but as a line graph. away from the norm. Common causes of
Pareto diagrams are important not only a process variation are the result of
to display the causes of a quality problem, interaction of several causes over a period
but also to provide the quality team a of time. Common causes need to be
diagnostic and monitoring device that can studied by appropriate quality improvement
be used to identify and monitor progress teams of the organization. Control charts
in the quality improvement measures being are useful in controlling variation at an
tried. Its importance becomes evident when acceptable level of measurement.
Pareto diagrams are used as incentives for Control charts are basically a run chart
achieving an eventual flattening of those with three additional horizontal lines. One
bar graphs. line represents the mean value (average)
which is drawn in between an upper control
Control charts limit (the mean plus 2 standard deviations)
and a lower control limit (the mean minus
Control charts are tools designed to 2 standard deviations) lines. A process is
monitor a process over a period of time to said to be in control if the trend line lies
study its trend and variation. It is constructed within the upper and lower control limits
to display process stability around a around the average. In this case variation
historical (acceptable) trend with the is caused by common causes and therefore
capability of measuring small changes in an intervention by quality teams is
the process. A control chart provides an necessary. If, however, the trend line falls
analysis of a process behaviour and outside those lines then the process is said
indicates when certain factors had an to be out of control. Here the causes of
impact on process trend. It is a useful tool making the process to fall outside the
in process improvement efforts in that it control limits are considered to be special
identifies the times when process is “out of causes and, therefore, it is the
control”, i.e. outside the calculated control management’s responsibility to resolve it.
limits. It is, therefore, useful in identifying
There is, however, one additional
improvement opportunities of a process. It
element to this concept. The process is
is also used to determine whether process
again considered to be out of control if at
variation from the norms (averages) is due
least three consecutive points on the

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 Quality Improvement: Tools and Methods

process trend line fall below or at least three average number of errors per week at the
consecutive points fall above the average Y-axis. The graph is then examined to
line even though the process trend line is determine whether the trend of medication
still between the upper and lower control errors is in control or if it is out of control.
limits. Here again, special causes are The process is attended to accordingly as
attributed to this type of trend. A few other mentioned above.
rules also apply to the concept of process
control and the reader is instructed to It should be noted here that the above-
consult the reference listing at the end of described control chart is only one type of
this chapter. An important point that needs control chart. This type, however, is
to be communicated here is that control considered to be the most useful in health
limits are not thresholds or standards. They care data. Other less common types of
are measures that describe the behaviour control charts are available and their use
or the nature of a process. Therefore, a and selection depends on the type of data
process that is in control does not to be analysed. The references at the end
necessarily mean a good process, and so of this chapter are selected to provide the
a process that is out of control is not reader with additional information on
necessarily a bad process. control charts.

To construct a control chart one needs

to calculate the averages of a process/ Cause-and-effect diagrams
quality problem over time; for example, the
Sometimes called the ‘fishbone’ diagram
number of medication errors per week over
or the Ishikawa’s diagram, the cause-and-
a five-month period. It is recommended that
effect diagram is a tool useful in the
20 data points are needed to construct a
identification of problem causes and “sub”-
control chart. An overall mean (average),
causes. A cause-and-effect diagram, as the
X, is calculated which will represent the
name implies, is a diagram that displays
middle horizontal line on the chart. The
the root causes of a problem of a situation
standard deviation of the mean, S, is then
in several related categories of causes. Each
calculated, using the following formula:
of these categories further displays several
sub-categories each of which either further
S2 = 1/n(n-1) [n3x2 - (3x)2] branches off into more sub-categories of
displays of a number of causes related to
The upper control limit is then it . Fishbone diagrams utilize a few other
calculated and is equal to two standard quality improvement tools to construct, such
deviations above (plus) the mean while the as brainstorming, surveys, etc.
lower control limit is equal to two standard
deviations below (minus) the mean. A line The cause-and-effect diagrams are
graph of the data points is plotted with the constructed by the quality improvement
number of the weeks at the X-axis and the team in a few steps. Once a problem is

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Health Care Quality: An International Perspective

a. Upper control limit (UCL)

Mean (Average)
Measurement
Upper control limit (UCL)

Time process is in control

b. UCL

Average
Measurement

LCL
Time process is not in control
(special cause)

c. UCL

Average
Measurement
LCL

Time process is not in control

(4 common causes in sequence)

selected for study, the causes of this of variation by category. A separate list of
problem are then listed. The list is further causes may be generated for each of the
refined to reflect realistic and trackable following categories: people, materials,
causes for further study. The list of the machines, methods and measurements.
causes is then classified into categories (and
sub-categories) and these are displayed on
the diagram with arrows directed towards Decision-making matrices
the main problem. Categories are either
A matrix that can be used for decision-
selected randomly by the team or selected
making is composed of a table of rows and
from the standardized list of possible causes
columns. The rows will display the list of

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 Quality Improvement: Tools and Methods

Staff Methods Measures

MA not available Not enough

ill, not replaced instructions Assess orientation
trends
Nurse is busy Lack of walking
schedule
Patient
falls
Patient on Bed too high
medication Broken bed

No bed rails

Materials Equipment

alternative decisions or solutions for important solutions to this problem. Once

improving a quality problem, while the alternative solutions are selected, the team
columns will represent the criteria of judging should then identify the selection or
between those decisions. The criteria can be evaluation criteria for the alternative
given different weights by the team to solutions. This step is considered very
indicate the importance of certain criteria important and a consensus should be
over the others. Examples of criteria are cost, reached on the list of criteria. A weight may
politics, staff support, impact, simplicity of be assigned to each criterion denoting the
implementation, administration, etc. importance of one criterion over the other,
e.g. one may give Cost a 3 multiplier units
Decision matrices are very useful in while Impact a 2 multiplier units, etc. A
making rational and democratic decisions scale of rating each decision is selected,
to solve a problem or improve a process. e.g. 1=low rating while 5=high rating.
The alternative decisions are listed in the Each team member is then asked to rate
left-hand column, while the evaluation/ each decision by criterion from 1-5 and list
selection criteria are listed across the top the score in the related cells under each
row. Also notice that each criterion is further criterion. If, however, there is a weight on
weighted according to its importance and a criterion then the multiplier factor is
feasibility. multiplied by the rating score and entered
A decision-making matrix should be in the cell. Each member will add the total
constructed by the quality improvement scores for each decision (total of scores in
team in a few steps. After identifying and each row). The totals for each decision from
listing the causes of a problem (prioritized), each member are added up to get a team
the team will then decide to study the most total for each decision. The decisions that

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Health Care Quality: An International Perspective

get the highest number are those that are statistical principles to process improvement
rated highly by the team for further study will eventually decrease waste, eliminate
and possible implementation. rework and reduce duplication.

Decision-making matrices are helpful

in selecting an acceptable decision. It shifts
the burden of responsibility of decision-
References
making to an interdisciplinary group of indi- 1. Al-Assaf AF. “Quantitative Management in Total
viduals and away from bureaucracies. It Quality” in The Textbook of Total Quality in
Health care, (Al-Assaf and Schmele, eds.). St.
instills confidence and pride in team
Lucie Press, Florida, 1993.
members as it provides them a sense of
2. Al-Assaf AF. Managed Care Quality: A Practical
responsibility and assures them a role in the Guide. Boca Raton, Fl. : CRC Press, 1998.
decision-making process of an 3. Deming WE. Out of the Crisis. MIT, Cambridge,
organization. MA, 1986.
4. Finison L J; Finison K S; Bliersbach CM. “The
Use of Control Charts to Improve Health care

CONCLUSION Quality”. Journal for Health care Quality,

15(1):9-23, 1993.
5. Goal/QPC. Memory Jogger. Goal/QPC,
This chapter presented an overview of the Methuen, MA, 1988.
more common tools and techniques used 6. Hart MK; Hart RF. “Quantitative Methods for
by quality improvement teams to manipu- Quality and Productivity Improvement”. ASQC,
Milwaukee, WI, 1989.
late data and transform that data into
meaningful information. The list of tools that 7. Joiner Associates. The Team Handbook. Joiner
Associates, Madison, WI, 1985.
can be used to meet this objective is even
8. Leebov W; Ersoz CJ. The Health Care Manager’s
longer than what has been presented above. Guide to Continuous Quality Improvement. AHA,
The tools presented, however, are the most Chicago, IL, 1989.
widely used tools but the reader is 9. Longo DR; Bohr D. Quantitative Methods in
encouraged to seek more information on the Quality Management: A Guide for Practitioners.
subject. The objective of quality improvement AHA, Chicago, IL, 1991.
tools is to support organizations achieve 10. Omachonu VK. Total Quality and Productivity
Management in Health Care Organizations.
improvement in the most rational and cost- ASQC, Milwaukee, WI, 1991.
effective way possible. Use of statistical
11. Ozeki K; Asaka T. Handbook of Quality Tools.
thinking according to Deming (1986) will Productivity Press, Cambridge, MA, 1990.
identify causes of process variations and will 12. Plsek PE. “Introduction to Control Charts”.
lead us to ways to reduce variation. Statistics Quality Management in Health Care. 1(1):65-
in quality management tell us that the result 74, 1992.
of a process is not necessarily equal to the 13. Reinke J “Quality Improvement Activities”.
Managed Care Quality: A Practical Guide. (Al-
summation of all the factors composing it
Assaf, Editor), Boca Raton, Fl: CRC Press, 1998.
but it is the result of the synergistic interaction
14. U.S. Air Force. Process Improvement Team
of these factors with each other. Applying Manual. USAF, 1991.

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Quality Improvement: Tools and Methods

Page 81
 5

Health Care Outcomes Management

and Quality Improvement
A. F. Al-Assaf, MD, CQA

B
efore one can describe outcomes outcomes and, in particular, on the
management, a brief discussion of monitoring of compliance to certain
system components will be useful performance indicators.
and complementary. The Systems theory
states that any simple system is made up Therefore, Florence Nightingale et al.
of three components: inputs, processes, back in the second half of the 1800s
and outputs. These three components were emphasized on outcome as the basis for
later described by Dr Donabedian as quality measurements and impacts. In
structure (inputs), processes, and outcomes 1910, Abraham Flexnor introduced his
(outputs). Structure includes all the report on medical education and training
resources of the system - physical and which relied on structure measures. Until
human. These resources interact with each recently, the Joint Commission on
other in specified activities, procedures or Accreditation of Healthcare Organizations
processes to produce a result, an output (JCAHO) has relied on structure measures
or outcome (s). In the chapter on the history in drafting their annual hospital standards
of health care quality we discussed how for the accreditation manual. Peer Review
health care quality evolved from a period Organizations (PROs), on the other hand,
where emphasis was on outcomes, then relied on process indicators in evaluating
shifted briefly to process as a focus of the quality of care provided to Medicare
quality intervention activities and studies. patients. Currently, however, a new
This era was then followed by a longer movement called Outcomes Management
period of emphasis on structure that is evolving to include a number of areas
continued until the late `80s. The `90s that impact the quality of patient care. It
however saw the introduction of a new field focuses on using outcome measures to
in health care quality that focused on manage quality. This trend toward

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Health Care Quality: An International Perspective

outcomes management is driven by medicine...our unifying goal is the good of

economics and, to a lesser extent, by the the patient. To support this philosophy, I
curiosity of providers and researchers (Al- propose that we adopt a technology for
Assaf, 1993). collaborative action...let's label this
technology 'outcomes management.'"
Outcomes management is the process of
What is an outcome? collecting, analysing, evaluating, and
And what is outcomes disseminating the results of medical
management? processes or procedures to improve the
eventual impact of health care through
The end result of a process is an outcome. collaborative efforts (Al-Assaf, 1993,
Since the main customer in health care is 1994). It is a process driven by results to
the patient, outcomes must be targeted at identify and improve those processes which
improving the medical status of the patient impact these results. The guidelines and
(Lohr, 1987). It is for this reason that protocols for these procedures are agreed
outcome research is important in upon by appropriate and widely acceptable
developing paradigms of efficient clinical bodies. Outcomes management can only
processes and patterns that will improve a be achieved through a collaborative effort
patient's medical status. Examples of by all players of the health care system--
commonly used outcomes include patient patients, purchasers, providers, payers, and
satisfaction, patient mortality, unscheduled regulators. This effort requires total
return to the operating room, readmission integration of the health care system both
within 72 hours of discharge for the same vertically and horizontally (Geehr, 1992).
medical condition, etc. These are obvious Ellwood (1988) introduced four benefits of
direct care outcomes, but other outcomes outcomes management:
should also be considered like behavioural,
• Practitioners will be provided with
physiological and psychosocial outcomes?
widely accepted guidelines and
These may include rehabilitation potential,
standards through outcomes
functional status and quality of life
management.
(Jennings, 1991). Although outcomes are
the end result, they must be analysed as • Outcomes management will pro-
part of the total picture, i.e. the patients and vide the skills and tools necessary
their environment. Thus, we should not use to measure the status and well-
one outcome measure as the basis to judge being of the patient, both clinically
the quality of care. Outcome measures and functionally.
should be part of a system of studying • With outcomes management large
structure, process and outcome. databases will be available and
accessible by providers and
Dr Paul Ellwood (1988) introduced
researchers to provide information
outcomes management as a concept. He
on clinical outcomes data.
described outcome management as "In

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 Health Care Outcomes Management and Quality Improvement

• There will be wide dissemination of (PMCs) and Computerized Severity Index

information, customized as (CSI). One example of an independent tool
appropriate, for decision-makers, could be the Health Status Questionnaire
and updated and modified to or Short Form 36 (SF-36) developed by the
reflect changes in technologies, Medical Outcome Study conducted by the
philosophies, and expectations. RAND Corporation (Nash and Markson,
1991). Other examples of diagnosis-
Geehr (1992), on the other hand,
independent tools are Medis Group and
suggests that outcomes management can
Acute Physiology and Chronic Health
be achieved by focusing on the following
Evaluation II (APACHE II). These tools
four areas:
provide a measure of functional status,
including social, physical and mental health
1. Outcome specification status (Ellwood et al., 1991). Other
process institutions supported by AHCPR's PORT
grants are also developing standardized
We need to answer the questions of: Which tools to collect data for managing
outcomes? What should be measured? outcomes. These efforts are being
From who's perspective? maximized by the use of optical scanners
that can automate the capturing of these
data in the computer, making the process
2. Standardization of outcome
of data input and analysis more efficient
measurement instruments and less cumbersome. For further
The objective is not only to collect reliable, information on these tools, the reader is
valid, appropriate, and comprehensive data advised to review works by Hornbrook
regarding an outcome, but also to collect (1982), Cretin and Worthman (1986),
these data in an efficient, standardized and Lezzoni and Moskowitz (1988), Geehr
error-free manner. Therefore, it behoves (1989), Lezzoni (1989), Ellwood et al.
health care professionals to automate this (1991), Linder (1991) and Markson et al.
process and to agree on a tool or collection (1991), Stewart and Ware (1992), Batalden
of tools to achieve this objective. These et al. (1994), among many others.
tools are either diagnosis-specific or
diagnosis-independent . An example of a 3. Management information
diagnosis-specific tool is the work provided
systems
by Quality Quest (within InterStudy) to
develop tools for severity-of-illness Management information system (MIS) is
measures. These tools are collectively an automated system of data collection,
referred to as TyPE (Technology of Patient input, analysis and retrieval in an integrated
Experience). Other examples of diagnosis- manner. The system should support large
specific tools are Disease Staging Tools databases query and allow multiple users
(DSTs), Patient Management Categories to share information simultaneously. The

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Health Care Quality: An International Perspective

proposed management information system patients in some larger epidemiological

should be supported by a decision support context. Outcomes management will obtain
system that enhances the clinical and feedback (and lots of it) from patients about
management decision-making processes their medical care. This includes the
through the intelligent integration of several efficiency of the treatment, the impact of
databases and logical pathways. Although the diagnosis on the prognosis, the patient's
the technology is currently available for ability to function normally, etc. -- all directly
clinical cases to develop critical pathways, from the perspective of the patient.
future technological advances should refine Additional applications include the easy on-
this function even further. A provider may line access of patient data while in the
be able to test different clinical manage- hospital and use of comparative data from
ment modalities electronically in simulated similar episodes to evaluate potential
case scenarios and then choose the one clinical outcomes to that patient.
with the best possible clinical outcome. This
technology is currently available through
decision support systems application that
4. Continuous improvement
utilizes data queering, telemedicine, and Most continuous quality improvement (CQI)
use of the Internet to have a wide range of paradigms are process-oriented and are
applications and access. either prospective or, more commonly,
retrospective problem prevention para-
Outcomes measurement involves
digms or a combination of both. Outcomes
collecting, analysing, and disseminating a
management, therefore, proves useful in
formidable amount of data. It is almost
inconceivable that the intelligent use of determining the best outcome for a given
collected data to generate useful and process. Managing outcomes will have an
meaningful information can be accom- impact on how processes are structured,
plished without the use of computers. conducted and improved and provide the
Automated information systems are invalu- feedback necessary to develop appropriate,
able in performing this task. Information effective and efficient guidelines. Outcomes
systems improve the availability and access management is highly dependent on CQI
of meaningful patient information that is in achieving such an objective in a manner
readily useful. Furthermore, technology can that is equally acceptable to key players in
provide physicians and clinical decision- the health care system.
makers with the ability to trend care
outcomes and compare them with current Accordingly, the objectives of outcomes
and historical results from similar institu- managements are mainly to improve
tions, with the ultimate goal of improving medical outcomes through the improve-
the quality of care. ment of health care processes. The
following is a list of specific objectives of
As predicted earlier by Ellwood (1992), outcomes management:
computers have allowed doctors to see their

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 Health Care Outcomes Management and Quality Improvement

1. To achieve a better control of the occurs. All the elements that caused or
end-results of medical intervention. resulted in such an outcome should be
2. To identify and prevent variant examined and ways to improve them should
behaviour. be considered and implemented. Another
reason (or myth) cited for difficulty of
3. To facilitate informed decision- focusing on outcome is that health care
making processes. organizations consider outcome to be either
4. To study the courses of proactive physician-focused or, on the opposite
pattern variations and suggest most extreme, dependent on too many indivi-
appropriate ones. duals. Of course, both statements are
5. To engage in patient-focused debatable. Although physicians are vital to
research to improve care patient outcomes, they are not the only
outcomes. contributors. Other health care profes-
sionals too contribute to producing an
6. To collect and disseminate outcome. Certain outcomes, however,
information that will meet the occur without (or with limited) physician
concerns of each decision-maker participation (e.g. patient comfort and diet
most efficiently and effectively during a recent hospital stay, difficulty with
through an integrated system. visitor parking facilities, satisfaction ratings,
7. To involve as many appropriate etc.). Further, an outcome is traceable to
players as possible in the its original source, and the processes
formulation of patient care leading to it can be identified studied, and
guidelines. improved. The focus should not be on
individuals, but rather on processes (usually
a manageable number) which can be
CONSIDERATIONS IN OUTCOMES improved. Therefore, an outcome is not
dependent on too many individuals.
MEASUREMENTS
Caution should be exercised that the
According to an article which appeared in emphasis should not be on outcomes alone
QRC Advisor (1992), health care organi- as there are a few limitations with out-
zations find it difficult to focus on outcomes comes. According to Boyce (1996), there
for two reasons. One is that an outcome are several weaknesses with outcome
must be considered globally, that is, it measures. Outcomes can tell you how well
involves all the results of patient episodes it worked but not why or what caused it to
and nothing less. However, one should work or not to work. Also, waiting for
recognize that results are reached through outcomes to happen before making a
a series of processes performed by a system decision on improvement is counter-
structured to carry them out. Therefore, an productive and, at the same time,
outcome is dependent on structure and consumers usually care about service which
process, especially when an adverse result is more related to structure and process.

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Health Care Quality: An International Perspective

HOW TO DEVELOP AN OUTCOME patient is actually following the instructions

given for diet or medication.
INDICATOR?
Outcomes measurements obviously are
Sometimes the most important step in useful to the extent that they have been
developing an outcome indicator is asking developed accurately and thoughtfully. The
the right question(s). First, the difference objective must be defined and appropriate
between structure, process and outcome questions must be asked when developing
measures must be understood. We must then an outcome measure. To assess measure-
understand whether we are asking a question ment, one main question should be the
that actually measures an outcome. focus: What does it really measure? Does
it measure volume, process, resources and
Examine an indicator commonly used input, or does it measure an outcome, an
by people in academe: The student has impact? To qualify as an outcome measure,
received and understood the learning the answer to these questions must
objectives of the course. This indicator is consistently be outcome. It is also important
meant to measure an outcome (the student to keep in mind that we need to know who
learning from the course), but does it? If will be using it (outcome measure), when
the student received and understood the will it be carried out, and how the data will
learning objectives of the course, does it be collected. Of course, the ultimate test
also mean the student learned? The of any system of measurement is its validity,
indicator should be rephrased to state the reliability, clarity, applicability and useful-
extent to which the learning objectives for ness which is clearly beyond the scope of
the course were achieved. Similarly, in this chapter. However, further readings
health care, an outcome indicator could be found in published work by Al-
commonly used is that the patient received Assaf and Schmele (1993).
and understood his dietary instructions or
his medication regimen. If the objective here
is to measure an outcome, then the only
one being measured is the outcome of the
MANAGING VS. MEASURING
process of giving instruction. This is not an OUTCOMES
outcome that will improve the patient's
health and decrease the possibility of the As previously mentioned, the main objec-
condition recurring. A more valuable tives of outcomes management is to
outcome indicator would be measured by improve the health status of the main health
periodic checks on the patient (by phone care customer, the patient. Therefore, the
or in person) with regard to following and desired outcome of a patient encounter
adhering to instructions given for diet or should be an improved health status of that
medication. In this way, at least one patient, relative to his or her health status
meaningful and useful outcome of a patient before the encounter. The degree of this
encounter will be measured, which is, the desired improvement is dependent on the

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 Health Care Outcomes Management and Quality Improvement

patient's needs, expectations and percep- One model that the author follows
tions and the efforts of the health care team when applying outcomes management to
to meet them. This is the difference between improving system processes in international
measuring the outcome of a process and settings include the following steps:
managing total patient outcomes. The
• Identify an outcome (clinical or
process of outcomes management looks at
administrative) and develop its
the patient episode as a process in measurable indicator
continuum. Outcomes management views
• Choose a team
outcomes in terms of the total process,
• Describe and prioritize the
measuring the extent to which a system
process(es) leading to such an
accomplished its objective of improving
outcome
patient care, all the way from health
promotion and patient education to clinical • Identify the customers of the most
intervention, follow-up, and patient vital process
rehabilitation. • Create the improvement opportu-
nity statement
Therefore, the steps for outcome • Create data collection plan
management are: • Collect data
• Identification and development of • Examine and analyse data
the outcome(s) to be measured. • Identify "bottlenecks" and root
• Data collection and analysis causes
regarding the identification and • Generate and choose solutions
definition of the elements of health • Outline and implement improve-
care structure, process and out- ment plans
come, with emphasis on outcome. • Collect and analyse data
• Evaluation of information through • Assess the impact
an integrated approach, i.e. the • Once improvement takes place,
total care episode within the standardize and document (e.g.
context of the larger database of develop clinical practice guide-
other similar care episodes. lines)
• Development of practice guidelines • Establish ongoing monitoring and
through a collaborative inter- continuous improvements
disciplinary approach. • Re-evaluate the outcome indicator.
• Dissemination of information to
practitioners coupled with educa- Several considerations need to be taken
tion on how to use and what to do into account when measuring and manag-
with this information. ing outcomes. According to Meltzer (1992),
there are at least five considerations:
• Continue monitoring and improv-
ing outcomes through data collec- 1. The skills and knowledge of the
tion and analysis and so on. individual provider should be

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Health Care Quality: An International Perspective

considered as the methods of to patients than the current system based

providing care vary, and therefore on deductibles and co-insurance.
so should the outcomes of their
services.
2. Consider different perspectives in WHO IS INVOLVED IN OUTCOMES
defining and measuring outcomes.
Individual expectations of desired
MANAGEMENT?
outcomes may be substandard
Besides AHCPR and the other work
based on the expectations of
mentioned earlier regarding severity of
another individual. Also, the
illness tools, other organizations have also
desired outcomes from the pers-
been active in outcomes management.
pective of the patient surely differ
One widely monitored organization is the
from those of providers, adminis-
Delaware Valley Hospital Council in
trators, or payers. Also, keep in
Philadelphia. The Pennsylvania Health Care
mind the question of who will
Cost Containment Council (HC4), a state
watch the "watchers"?
agency, was created in 1986 to identify
3. Use severity of illness measures to ways to contain health care costs. HC4
compare apples with apples. continuously collects severity of illness data
4. Consider the quality and compre- (adjusted for morbidity, mortality and
hensiveness of the statistical charges) on 57 diagnosis-related groups
analyses. from every hospital in Pennsylvania with
100 beds or more. They subsequently
5. The following and similar questions
publish a quarterly report ranking the
need to be considered:
performances of these hospitals based on
Where should the line be drawn? Who this information (Nash and Markson,
will draw it? Will a decision by a payer to 1991). Based on these reports, an
stop performing a diagnostic test that has outcome-based project called Buy Right
30% success rate be justified from the rewards the most quality-oriented, high
patient's perspective? What about a 35% efficient provider with more patients (Nash
success rate test or even 5% success rate? and Goldfield, 1989).
Would rationing of health care impact the
JCAHO's Agenda for Change (O'Leary,
outcomes management's efforts to improve
1987) is outcomes-oriented. Since then
the quality of total patient care?
JCAHO's Accreditation Manual for
According to Ellwood (1992), the Hospitals has been redesigned to reflect the
aspect of quality of life dimension is also emphasis on quality improvement and
being considered in most major outcome outcome measures. This change has been
management research activities. Measuring noted in its current 1998 manual. JCAHO
the quality of life surely would be more is also in the process of publicizing its work
valuable in providing efficient medical care on inpatient outcomes indicators and the

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 Health Care Outcomes Management and Quality Improvement

new hospital performance measurements, to measure the performance of those health

called ORYX, has been published (JCAHO, maintenance organizations (HMOs) that
1998). provide care to Medicaid beneficiaries. In
this system a list of indicators are developed
HCFA has established the Health Care and disseminated to HMOs for self
Quality Improvement Program (HCQIP). measurement and reporting. Those who
This programme is a collaborative effort perform consistently below the peer
between HCFA and PROs to collect averages are evaluated further and are
outcomes data and to examine patterns of required to implement improvement
care through the Medicare reimbursement measures. Examples of such indicators
patient database. According to Jenks and include childhood immunization rates, early
Wilensky (1992), HCQIP has four impor- prevention-screening-diagnosis and treat-
tant driving forces: variation research, peer ment methods, as well as prenatal care and
review studies, new quality improvement annual physicals. This system is currently
models, and development of practice being revised and a new system of
guidelines. The major objective behind such performance measurement has been
a project is to establish a centralized developed, which is called quality improve-
Uniform Clinical Data Set (UCDS) to ment system for managed care or QISMC.
capture information on some 1800 This new improved system replaced the
elements from a 10% sample of inpatient QARI system in early 1999. QISMC will
discharges. The goal is for all PROs to use have a number of additional outcome
the UCDS database to compare the indicators (HCFA 1998).
practice patterns of individual providers with
national patterns. This approach, which has Another trend has been taking place
been implemented in 1993, has success- recently in regard to outcomes and that is
fully moved PROs review process towards report cards. Consumers, purchasers and
quality improvement and away from quality regulators alike are asking the question:
assurance. Since then a number of projects how can we make the right decision in
have been completed by the different PROs choosing a "quality" provider? Therefore,
including the Comprehensive Cardio- several large employers such as Xerox,
vascular project, the Flu project, the Asthma GTE, ATandT and the like are developing
project, the Antibiotic Prophylaxis project, their own report cards on providers based
etc. All these projects' results, guidelines and primarily on outcome measures (Mahar,
documentation are available directly from 1996; Magnusson and Hammonds, 1996).
HCFA on the world wide web of the Internet This trend is also being followed by the
at "http://www.hcfa.gov". largest HMO accrediting body, the National
Committee on Quality Assurance (NCQA),
HCFA, in 1995, developed a perfor- with their "Quality Compus" project (http:/
mance measurement system, quality /www.ncqa.org). This database when
assurance, reassessment and improvement completed would provide national, regional
(QARI), using primarily outcome indicators and state averages on a number of

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Health Care Quality: An International Perspective

outcome measures and would rank HMOs processes involved in its development. To
accordingly (NCQA, 1996). Of course, this achieve improvement, all factors, barriers
project is in addition to the current HEDIS and strengths of the system should be
measures (Health plan Employee Data and reviewed, assessed and improved. Out-
Information Set). It is an outcome measure- come measures are important tools to direct
ment system used by NCQA as part of the our attention to the reasons why certain
accreditation process. HEDIS, which is now outcomes occur. They should direct our
in its latest version 3.0/1998, has an excess efforts to finding ways to address these
of 70 measures divided into eight different challenges efficiently to achieve the desired
domains or categories: effectiveness of outcome. This is the difference between
care, access to/availability of care, measuring and managing outcomes.
satisfaction with the experience of care, Managing outcomes is what health care
health plan stability, use of services, cost quality is all about - managing the total
of care, informed health care choices, and system to improve the quality of care
health-plan descriptive information. Each of rendered to the patient.
these domains has a number of measures
or indicators (primarily outcome indicators) According to Bohr and Bader (1991)
that are standardized with specific formulas and Batalden et al. (1994), the Deming
and guidelines promulgated by NCQA. It Cycle of Plan-Do-Check-Act (PDCA) is
is believed that most HMOs will have to congruent with the processes of developing
start reporting their outcomes under the clinical guidelines (an aspect of outcomes
HEDIS measurement system from the management). Appropriate care criteria are
beginning of the new millennium. It is also developed (plan) by asking Who? Does
noted that HCFA's medicare managed care what? When? With what implemented (do)
product will also be relying on HEDIS or and what are we learning accordingly?
similar outcome-based data to rate the Monitored (check) and what have we
quality of medicare providers (HEDIS 3.0, learned? Did original outcomes improve,
1998). and tested and retested (check); those that
prove to be successful are used and those
that do not work are discarded (act).

OUTCOMES MANAGEMENT AND Epstein (1991) presented the same

QUALITY IMPROVEMENT? argument. The principles of the two
philosophies are very similar. In outcomes
management, criteria that are successful in
The main objective of using outcome
improving the outcome of care are
measures is to improve the quality of care
developed and monitored. Variations from
and services delivered by the health care
these criteria are minimized and further
organization to the patient. There is a focus
eliminated through continuous assessment.
on the total care episode in outcome
All these activities are related to quality, with
management. A specific outcome is
all its concepts and applications. The
dependent on all the structures and

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 Health Care Outcomes Management and Quality Improvement

fundamental principle of quality is to achieve a desirable outcome. An outcome

eliminate variation, and this is what should be based on feedback from patients,
outcome management attempts to do: providers and third party payers and take
recognize good outcomes, study them, and into consideration the process of
eliminate variations in the process that may continuous improvement of the system of
lead to undesired outcomes. care.

Geehr (1992) also agrees with this. He Health care decisions are and will
also suggests that quality improvement of increasingly be data-driven. As predicted
structures and processes depends on by Geehr (1992), outcomes management
feedback from outcome measurements. He has been involved in physician privileging
goes on to suggest that this can be done and credentialling, critical pathways (Coffey
prospectively, with the use of practice et al. 1992), practice guidelines, report
guidelines and expert systems, and retro- cards and peer review processes, among
spectively, through assessment of trends and many other processes. However, with vast
outcomes of clinical practice patterns. amounts of data available, the use of
computer technology will increase rapidly.
Therefore, this brings this discussion to Health care professionals will be forced to
the basic fundamentals of quality which is use these technologies to compare their
a customer-focused continuous process of outcomes with those of their peers.
improvement through an efficient system of
feedback and evaluation. Applying
outcomes management to quality, each of
the processes discussed above can be
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Beach, Fl.
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LD (1969). The National Halothane Study: A

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study of the Possible Association Between 20. Geehr EC (1989). Selecting a Proprietary Severity
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26. JCAHO (1997). The Accreditation Manual for
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Outcomes Management in Health Care Quality 27. Jenks SF; Wilensky GR (1992). "The Health Care
Management for the 21st Century. J. Couch, Quality Improvement Initiative: A New Approach
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13. Ellwood P (1992). "Outcomes Management: The 28. Jennings BM (1991). "Patient Outcomes
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A Technology of Experience." The New England and Case Mix." Providing Quality of Care: The
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D (Eds.), Philadelphia, PA: American College of
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36. Luft HS; Bunker JP; Enthoven AC (1979). "Should www.ncqa.org/
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Agenda for Change. Chicago, IL: JCAHO.
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48. Roberts JS. "Linking Outcomes Measurement to
38. Mahar M (1996). "HMOs must now prove that
Continual Improvement: The Serial "V" Way of
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Hospital Performance. Baltimore: Johns Hopkins.
40. Meltzer R (1992). "The Hazards of Outcome
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 6 6
Implementing Health Care Quality
A. F. Al-Assaf, MD, CQA

INTRODUCTION Therefore, in reorganization, a complete

structure of quality steering groups is

Q
uality in health care is an constructed. These groups will plan,
innovative and participative manage and execute all activities related
customer-focused management to quality. This organizational structure
concept that affects every individual in an should be representative of the whole
organization and is sustainable through organization and is designed to gradually
cultural transformation (Al-Assaf and incorporate all the leadership activities of
Schmele, 1993). This management concept the organization. Under training, quality is
has an ultimate goal of process improve- interested in training professionals in the
ments that would have a positive impact definition, principles, concepts and issues
on health care outcomes. Quality relies on related to quality, i.e. increasing awareness
teams and is driven and nurtured by to quality issues. Training also includes
appropriately trained leaders (Deming, planning methods, organization skills,
1986; Juran, 1986; Crosby, 1979; effective meeting techniques, methods for
Berwick, 1989). evaluating and identifying opportunities for
improvement, and learning the skills
In the field and outside the corporate necessary to solve problems and improve
structure, quality is applied operationally as processes through well-organized teams
a management paradigm that encom- (Joiner, 1985; Goal/QPC, 1988; Deprete-
passes four main components: (1) reorgani- Brown et al., 1992; Franco et al., 1994).
zing for quality; (2) training for quality; Another training area that quality in health
(3) quality assurance strategies (QA); and care emphasizes is the area of customer
(4) quality improvement (QI) (Al-Assaf, service because one of its main objectives
1994). This management paradigm is is customer satisfaction. Normally, the
considered the organizational umbrella that customer is first defined and then the
oversees and coordinates these four process of identification of his needs and
components and their numerous activities. expectations follows before utilizing

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Health Care Quality: An International Perspective

available means to meet these needs and organizing teams that are given the
expectations. This is a continuous process authority to study the process problem at
(Ishikawa, 1982; Leebov and Ersoz, 1989; hand, come up with an improvement/
Blumenthal, 1996). In all the above- solution initiative, implement it and then
mentioned training areas, focus is drawn evaluate outcomes. Identifying, analysing
to process improvements through employee and improving processes are all part of QI.
skills development. The third component for Therefore, quality's four components are
applied quality is through QA effort always at work simultaneously to improve
(Meisenheimer, 1993; JCAHO, 1991 ). the status quo with a sharp eye for efficient
Here, what is meant by QA is the process use of resources. Achieving better outcomes
of planning for quality, recognizing high is also an objective for quality in health care
volume/high cost/problem prone to fulfill, thus measurable and tangible results
processes, then developing and setting are always stressed when attempting to
standards for each of them. Standards may evaluate success.
be adopted from national or international
So, how can quality in health care be
guidelines or developed locally de novo.
implemented at national level? Implemen-
Once standards are set they are
tation of quality has been achieved through
communicated to the target population.
a number of models with varying degrees
As discussed in Chapter 3, active of success. Baird, Cadenhead and Schmele
communication, rather than passive (1993) list at least five different models
communication, is emphasized. Active while others add a few more (Al-Assaf and
communication has more impact on the Schmele, 1993; Couch, 1991; Jablonski,
effectiveness of complying with the stan- 1991; Walton, 1986). However, in this
dards. The extent to which an organization/ chapter a specific model will be presented
unit is adhering to standards is measured as it was actually implemented in at least
by a number of key indicators that have three developing countries. The model has
predetermined thresholds. Thus, monitoring been used to implement quality in the public
is the next step in the QA process. The health care sector in both primary care and
monitoring component is important to hospital care areas. Although primarily at
direct the organization toward areas and the public sector, the intervention model
opportunities for improving compliance to described below is designed in such a way
standards (Deprete-Brown et al., 1992; that it can be expanded to other sectors of
JCAHO, 1991). At this stage, the fourth health care with very minor modifications
component of quality in health care comes and planning effort.
into place, i.e. QI or "Kaizen" as the The quality implementation model
Japanese call it (Baird et al., 1993). QI consists of three major phases: strategic
includes improvement of processes, planning for quality; operational planning
resolution of problems and simplification for quality; and the actual implementation
of procedures. The QI activities are usually stages. The following is a discussion of each
carried out through a systematic process of of these phases.

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 Implementing Healthcare Quality

STRATEGIC PLANNING FOR MANAGEMENT'S COMMITMENT

HEALTH CARE QUALITY There are not enough words to describe
The process of planning for quality in health how important management's commitment
care is divided into two components: is to the success of quality, at least in other
strategic planning and operational plan- industries. Time and again, experts have
ning. In strategic planning the level of demonstrated the value of management's
involvement is higher in the organizational commitment to the quality process. In health
hierarchy, where initial decisions and broad care, however, personnel are somewhat
policies are made for the proper imple- different and their values are different too.
mentation of health care quality. It involves Health care professionals are inter-
top management's commitment, securing dependent but less on management
additional support (financial and technical), (although this model is rapidly changing
as well as the organization of structural with managed care). Also, health profes-
support for quality implementation. It is a sionals in the most part have been attracted
complex and necessary process that should to health care not because of profit-making
take place before any implementation but for serving humanity. Therefore, the
activities are begun. values in health care revolve around
helping another fellow human being without
Operational planning, on the other the need for reminders from management.
hand, is more specific and more elaborate Hence, in health care, management's
in design, process and activities. It involves commitment is encouraged but not vital
detailed planning for any and every activity (Boerstler et al. 1996). It is however
that will be taking place during partial or preferred, if one wants to achieve results
full implementation of health care quality. rapidly. Management can "open doors",
In this planning stage, the right individuals facilitate interventions freely, and can
are actively forecasting proper resource coordinate resources easily. In most cases,
allocations, training requirements, employee management has the final say on things.
participation, and types and numbers of They make the final decision. Therefore,
projects to be performed, all at the health care quality implementation can be
intervention level. This level of planning enhanced with management on its part
requires much more time and detail than the supporting and fostering it.
strategic planning level and it, too, is an
essential step before proper implementation So, what is commitment? Deming
of any process, especially health care quality. (1984) says that if management's, that is
What follows is a discussion of the steps and top management's, commitment is not there
activities that should take place under each then he would not even bother imple-
of these planning processes. The discussion menting quality in such an organization. His
starts at the strategic level and is spread to words echo his theory clearly when he said:
the operational level and ends at the "If you can't come, send no one."
intervention/implementation level. Commitment to a cause means being

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Health Care Quality: An International Perspective

involved, being supportive, being active and experienced organizations and professional
being participative in that cause. Commit- associations, a collaborative effort of
ment also means leading efforts, facilitating identifying and selecting the right consultant
activities, and providing resources to make needs to be initiated before actual imple-
that cause a reality and a success. mentation happens. Stressing on the
Commitment to a process or a programme identification of the right consultant is
means taking pride and joy in supporting necessary, one that has demonstrated
it and learning more about it. It is certainly expertise in the specific area needed with
not just rhetoric and oral support, although past experience in similar environments and
even that is better than no support at all! cultures. Another important characteristic
for a useful consultant is one with the
Commitment cannot be achieved
knowledge and a sincere desire for
without adequate understanding of what
technology transfer, one that is interested
you want to commit to. Therefore, para-
in establishing and fostering local expertise.
mount to this step is increasing knowledge
and awareness about the subject needing Early in the process of implementation,
commitment. For quality in health care, it the designated national department should
is even more difficult to get unequivocal select a suitable short-term consultant to
commitment from management without assist the designated key person(s) in the
demonstrating results. Manager are usually strategic planning effort for quality. At this
quick to say: "Show me that it works!" Health stage the consultant may be useful by
care quality must then be based on data assisting in the identification of internal
and should always be driven by outcomes. qualified individuals to work on this effort,
Therefore, emphasizing data management provide an organization-wide awareness
processes are extremely important for seminar on quality to key personnel, draft
quality to win management's support. Thus, with key personnel the mission and vision
with adequate planning and process statements of the national initiative for
design, commitment will be cultivated and quality in health care, and help design and
positive results can be achieved and map this new initiative. A consultant can
reported. be extremely helpful in identifying mile-
stones towards complete implementation of
quality in health care in that country, which,
ROLE OF CONSULTANTS AND in turn, would make it easier to monitor
progress and ensure sustainability.
ADVISERS
Once strategic planning is accom-
As seen from the above, at least early in plished then either the same consultant or
the process, the need for objective another should be selected to guide the
perspectives and specific expertise may operational implementation of the process.
warrant the call for consultants and advisers This individual should have practical
(Newman, 1991). With the help of expertise in training, facilitation and process

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 Implementing Healthcare Quality

improvement team-building. This type of permanent position, which may cause

consultancy requires long-term involve- discontinuity of the process once changed.
ment, at least a year, or until internal But regardless of who this person is, once
expertise becomes available. Quality identified, this individual needs to be trained
assurance expertise, on the other hand, will extensively in health care quality techniques
be needed on an ad hoc basis, especially and prepared for the organization of quality
during the stage of standards setting and council. Of course, the responsibilities of
indicator selection. This kind of expertise is the quality coordinator are numerous,
usually more specialized to the specific among which are:
areas needing standards and internal
• an advocate and speaker for health
resources should be included along with the
care quality;
external consultant to ensure continuity of
the process. • a facilitator of the quality council;
• the designated counterpart of the
consultant;
ASSIGNING RESPONSIBILITY • the coordinator of the strategic and
operational planning for health-
At this stage of strategic planning, the care quality activities and the
person in charge of the national quality in allocation of resources;
health care initiative, usually the Minister
• the initiator of process improve-
of Health, needs to identify an internal
ment teams;
coordinator of health care quality. This
position need not be a full-time position, • the coordinator of the selection of
but would be filled by an individual key personnel in quality;
possessing leadership skills and is given • the coordinator of the health care
sufficient authority. Direct link is necessary quality training plan; and
between this individual and the top
• the facilitator of future expansion
administrator for maintaining credibility and
strategies.
authority. Actually, this is such an important
position that in some countries a key person The quality council (QC) is formed to
in top management assumes this role. This act as the steering body that will direct the
approach, however, has advantages and quality process throughout the health care
disadvantages. A prominent person would system. It works as a coordinating
give instant recognition and support to the committee of individuals representing the
quality movement. It would establish different aspects of the health care system
commitment from day one, which sends a to formulate corporate policies towards
message to the rest of the system that health care quality. Organizing the QC is
quality is important and everyone must not a must, but from the author's experience
follow. The disadvantage, on the other it was found to be a necessity. Certainly the
hand, is that this person is usually not in a membership of the council is as important,

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Health Care Quality: An International Perspective

and careful selection of these individuals are, the purpose for its existence, who its
should rest with the top administrator with customers are, and what it wants to
advice and assistance from the quality achieve. Mission and vision statements
coordinator and the consultant. Again, should be concise, clear, realistic, and
members should be prominent individuals should reflect the true desire of the system.
in the health care system representing That is why real input from other key
different levels, departments and disciplines. individuals is necessary. Once drafted,
Once members are identified a council approved and finalized, these statements
charter needs to be developed with specific should be communicated to the rest of the
roles and responsibilities delineated. The system most actively and most consistently.
roles of the council are somewhat similar Actually, some organizations opt to post the
to the roles of the quality coordinator giving mission and vision statements in prominent
it a collective perspective and establishing places throughout the organization and
itself as the system's resource for quality that even print them at the back of their
the rest of the system may tap into when personnel's business cards. In this way all
necessary. Similarly, QC members need to improvements and other activities of the
be prepared for their roles adequately and organization will be designed and targeted
should be exposed to the concept of quality to achieve the vision along the boundaries
and its strategies early in the process. of the organization's mission.

Once formed, the first agenda item for

the quality council should be to ratify its
charter. Each member should believe in the ALLOCATION OF RESOURCES
charter; therefore, he/she should get
Early in the process, both physical and
actively involved in the revision and re-
human resources are needed to initiate
drafting of the charter so as to reflect actual
change. Resources are initially needed for
involvement in the council. Another agenda
the necessary training and the acquiring of
item that needs to be addressed is the
consultants. Resources are also needed for
process of developing the mission and
information dissemination and increasing
vision statements of the initiative which
the awareness of health professionals in the
should reflect the desire for health care
concept of health care quality. Additional
improvements and the endeavour for
resources may be required later on to
quality. Both statements need to be drafted
disseminate the concept at the grassroot
by the council members with inputs from
level and to the professional staff. Funds
all key personnel in the system. These
should also be set aside for future potential
statements are important in establishing the
structural changes and re-designing in
system's constancy of purpose and will serve
processes or units to fit the required
as a constant reminder of the path the
improvements. In some countries, funds
health system is moving in and a map for
were used to buy reading material and the
its future. Mission and vision statements
establishment of a central library on health
reflect what the system's current activities

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 Implementing Healthcare Quality

care quality. Others used the funds to hire processes of system appraisals and
full-time or part-time individuals as internal monitoring.
quality coordinators, while others used the
additional funds to publish a newsletter on
quality and to hold internal and periodic INCREASING AWARENESS ABOUT
seminars on the subject. Still a few other
organizations opted to use certain funds to HEALTH CARE QUALITY
provide incentives to the process by offering
monetary and capital support to successful Quality as a concept has different facets,
units or individuals that had demonstrated principles, techniques and tools. There is
substantial improvements. also a vast amount of literature that has
been written about it in the professional
Another aspect of resource allocation arena. Therefore, an early activity of the
was the establishment of a new unit within quality council is for its members to
the organization (Ministry of Health) participate in a seminar on quality in
dedicated to health care quality. This unit health care. This seminar is to be followed
can be organized with a number of health by intellectual discussions with the
professionals from within the organization consultant with regard to the application
and linked directly to top management. This of this concept in that particular country's
unit should also be given the mandate for health system, taking into consideration
setting the system's quality standards and available resources, the culture and the
indicators, disseminating information current health status and structure of that
related to health care quality, monitoring system. A similar activity should be
the quality of care delivered and to act on organized to present health care quality
opportunities for improvements in the to other key personnel in health care in
system. The said unit should be provided order to maximize support and to increase
financial and political support from the top dissemination of the concept. One method
administrator with broad authority for introduced in one organization to increase
surveying and inspecting any record within awareness was the writing of newsletter
the organization related to quality issues. articles on the subject with examples for
The objective is to start a nucleus of a potential internal application in clear and
quality unit that will take the responsibility operational language. Another country
of coordinating quality for the organization, sponsored a system-wide "scientific day on
thus ensuring sustainability. This unit could quality" in which the concept and
also take the responsibility of preparing for applications of health care quality were
and coordinating all activities related to introduced. That one day received instant
certification, licensure and accreditation. attention from all levels of the system, and
Other duties may include the coordination with the right publicity it was perceived as
of all committees related to quality such as a testimony of the top management's
peer management, credentialling, utilization commitment to quality. Certainly, the
management, etc., as well as the actual consultant's services could be used to

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Health Care Quality: An International Perspective

present a number of short sessions with projects that require the least amount of
other key personnel and middle-level resources and have the highest
managers to discuss health care quality. probability of success and the potential
These sessions, which should be attended of affecting a large number of
by at least the quality coordinator and beneficiaries. Examples of such projects
some members of the quality council, can may include improvements in the
serve as focus group sessions to get a reception area of the organization, or
feedback on quality implementation and improving the aesthetics of the customer
applications in health care as well as an service area, or selecting a few areas that
avenue to increase awareness about the receive a large number of complaints
concept. Information and feedback from the public and try to improve them.
collected from these sessions can be used Other examples may include the initiation
in the next planning phase of implemen- of a national, but simple, campaign on
tation at the operational level and in promoting health awareness to the
launching pilot projects. members, or lead an immunization
campaign or a health fair during a special
event, etc. Other projects may involve the
formal identification and selection of an
MAPPING HEALTH CARE QUALITY improvement opportunity, either clinical
INTERVENTION or administrative, and the organization of
an interdisciplinary team from the affected
It is found that once strategic planning and process to initiate improvements. The key
a basic organizational structure have been here is to start somewhere and start with
completed, then an early "testing" or pre- simple projects that have a higher
implementation activities need to be likelihood of success.
sponsored in the form of small pilot projects
At the completion of pilot projects, the
or small process improvement teams. This
quality council should analyse the lessons
step is not mandatory but can be very useful
learned and, based on certain criteria
in the early identification of gaps in
described below, prioritize those services
communications, planning, and interven-
for further implementation of quality in
tion. Lessons learned after the completion
health care. Examples of such criteria used
of such projects can be extremely valuable
for the selection of services for intervention
in correcting these shortfalls.
are:
In collaboration with the quality • high volume
council and with information collected • problem-prone
during the planning phase, the quality
coordinator may identify areas in the • high risk
system with an opportunity for improve- • high impact
ment. The identified areas should be • high cost services, procedures,
selected carefully to include simple units, etc.

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 Implementing Healthcare Quality

The quality council, in the next two the operational plan. The final outcome of
steps, needs to decide on whether to start planning meetings should be the develop-
partial implementation within a certain ment of operational strategies for quality
service area or within a number of services implementation. The following strategies
system-wide. Either way, using the above are suggested:
criteria, the quality council will be able to
choose the area or specific service for
implementation. The use of objectivity in Strategy 1: Initiate
selecting a system or an area for interven- communications and
tion is crucial for successful implementation secure commitment
and future expansion. At this stage, the of other professionals
council is ready to plan for the operational
level of health care quality implementation. Council members and/or the quality
coordinator should start early communi-
cations with the "leaders" (Kaluzney et al.,
OPERATIONAL PLANNING FOR 1995). Leaders should be contacted for
support of the initiative and to solicit their
QUALITY IN HEALTH CARE willingness to having their area be a part
of a system-wide strategy on quality. At this
Although the scope of this chapter is to
stage a discussion is necessary with regard
present broad strategies for the introduction
to the benefits of the initiative and the
of quality in health care within a specific
advantage of being an early implemen-
country, it is imperative to present briefly
tation site. A note of caution here is to
the stages of operational planning. As
include everybody who is considered a
mentioned earlier, this level of planning is
"leader" in that system. Being too selective
highly specific and detailed and is usually
might have negative effects.
carried out by the same individuals
responsible for carrying out the implemen-
tation process at the selected service or Strategy 2: Introduce the
system or geographical location. concept of quality
At this stage the key individuals from Hold a number of small group discussions
the selected intervention service or system or small seminars on the concept of quality
are the ones with the primary responsibility in health care. Emphasize the principles,
for assisting the quality council in planning and the advantages. Discuss the resource
the implementation strategies at the requirements and the importance of the
operational level. The quality council in commitment of the internal customers to
collaboration usually carries out this type the success of the process. Try to answer
of planning with middle-level managers. the question regarding the benefits of
These individuals, in direct participation with implementing such a process in that
the quality council, are asked to develop system.

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Health Care Quality: An International Perspective

Strategy 3: Develop broad linked. The suggested advice is that a

structure is needed to ensure sustainability,
internal objectives of quality
but the extent and the mapping is depen-
Again, with key leaders in the community dent on several factors that need to be
develop a number of broad yet realistic considered while determining the best
objectives along with a time table for approach in that country's system. Another
accomplishments. Objectives need to advice is to develop structures slowly and
reflect the local needs and expectations of gradually - never a complex structure at the
the community at large, and not individuals. outset as this will distract from focusing on
Therefore, issues regarding improvements the main issue of improvement and
in health status need to be supported with concentrate on committee memberships,
data, if available, or rely on credible responsibilities and meetings. One other
sources. issue is that one type of structure in one
organization may not be as effective as in
another. A review of the experiences in other
Strategy 4: Discuss plans for similar organizations may be of help in
and secure needed resources accomplishing this strategy.

This is a preliminary planning stage for the

estimated resources needed. Once the next
Strategy 6: Collaboratively
strategies (discussed below) have been plan training requirements
completed, a more rigorous resource
allocation exercise must take place. Again based on only actual needs, training
However, at this stage only a broad may be planned. The goal is to plan for
description of the type of resources needed optimum training. Too much training may
and its uses should be discussed. Specific also have negative outcomes. Another issue
resource allocation is directly dependent on to be considered is, in what mechanism
the extent of quality interventions needed, training should be delivered, i.e. should it
which will be established at a later stage. be delivered in the form of preparation
workshops for potential participants in
quality or whether training should be
Strategy 5: Establish the delivered on needs basis and only at the
quality programme time of the actual improvement process. Dr
Deming suggests that training should be as
organizational structure
an on-job training but others have done it
There are several schools of thought differently, and successfully. But in whatever
regarding the implementation of this mechanism it is delivered, in general,
strategy. The question is whether to establish training on quality assurance and quality
an elaborate but solid organizational improvement skills is required for the proper
structure or to keep the structure loosely implementation of the quality programme.
Also, under this strategy issues related to

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 Implementing Healthcare Quality

training venues, training material, objec- and communicated to the quality council
tives, type of participants, method, content, and the coordinator. In this way obstacles
trainers, time table, and expected outcomes can be identified and corrected early. Thus,
should be developed. Here again, relying adjustments to plans can be made
on previous experiences from other effectively. The method, the type and the
organizations and with the help of an frequency of self-reporting should be
experienced consultant, a good training agreed upon at this stage as well as
strategy can be accomplished. agreement reached on the method for
evaluating and monitoring the progress of
improvement efforts. Reporting and
Strategy 7: Plan pre- evaluation should be encouraged for the
implementation assessment purpose of learning and not judgement.
Health care professionals should be given
A full assessment of quality in the health assurances that this intention will be
care system should be done. Planning for followed.
the assessment activities is required. In
planning for such activities, issues related
to method, assessment population, by Strategy 9: Establish an
whom, for how long, and the resources effective mechanism for
needed are addressed. The objectives of incentives
this assessment are two-fold: first is to
identify problem areas to aid in the selection Agreeing on the type of incentives is one
of improvement interventions, and second issue and actually making them work is
is to provide planners a baseline data of another. From experience, it is found that
the status of health services (and potentially this area is the most sensitive and the most
their members) of that system before deficient area for answers in health care
improvements. Any future improvements will quality implementation. Questions like
then be easily measured using comparative "What's in it for me?" or "Why should I do
data. it?" continue to be asked. Answers to these
questions may include providing monetary
Strategy 8: Develop incentives, non-financial rewards, different
kinds of recognition, or simply making the
progress reporting participation in quality a job requirement.
mechanism and methods In most current employee appraisal systems
for evaluation there is no provision for rewarding
improvements. As one individual says, "As
This is the strategy that is so crucial yet long as you stay away from making
missed or de-stressed the most. Progress changes, the likelihood of making mistakes
towards meeting the objectives of the is low and therefore the likelihood of being
quality initiative need to be documented scrutinized is low". This is the type of attitude

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Health Care Quality: An International Perspective

that needs to be changed and a system of In that country, assessment took different
incentives may very well be linked to the approaches. A geographical area was
employee performance and appraisal selected as the site for the pilot project of
systems that are already in existance in quality implementation. A team of consul-
health care organizations. tants was assembled and met with key
leaders representing different service areas
of that pilot site. After presenting their
IMPLEMENTATION STAGES intended methods of assessment, they were
teamed up with a number of local health
In this section, again, only broad strategies professionals to assist in data collection. A
will be presented as specific approaches pre-designed survey instrument was used to
cannot be developed for all scenarios and conduct personal interviews with key health
for different settings. The intent of this professionals of the different health care
section is to introduce the five different organizations in that district. Focus group
stages of implementation with a brief sessions were organized separately with both
description of each stage. Further informa- staff members and patients. Additionally, an
tion about each stage can be obtained actual review of existing health care
separately as it is beyond the scope of this documents and medical records was carried
chapter. There is an abundance of literature out to review the quantity and quality of
on planning, training, improvement and health services rendered. Statistical reports
evaluation of the implementation processes on service utilization in that location were
and the reader is encouraged to seek also collected. A representative sample of
additional information. satisfaction surveys were conducted for
patients as well as for physicians and staff.
This extensive data collection effort took two
Stage I: Assessment weeks to accomplish, while data analysis
and reporting took an additional four weeks.
In the last section, the issue of planning for Therefore, based on the findings, the quality
a comprehensive assessment of the status project steering committee selected the areas
of health services in the system was of intervention that required the most
discussed. In this stage of implementation, improvements using a certain prioritization
actual assessment activities should take scale. Opportunities for improvement were
place. Again, depending on the method, divided into three categories: those problems
the resources available, and the time table requiring low cost to fix, others with
allotted in the plan, thorough assessment moderate cost, and a third group with the
should be completed before any interven- highest fixing cost. One aspect that was
tion can be planned, authorized or carried missing in that system's experience was the
out. To explain one method of assessment unavailability of measurable baseline data.
here is a description of one country's The objective of the team's assessment
experience. however was to identify problem areas and

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 Implementing Healthcare Quality

not to actual measure their extent. That committees very gradually and only as
approach led to some problems later on needed. Each committee should have a
when there was a need for evaluating results. separate and specific charter, a defined
It is, therefore, highly recommended that the membership, and an identified reporting
development and measurement of indicators mechanism. All committees will be reporting
be a part of the assessment outcomes. their findings and activities to the system's
quality coordinator, if present, who, in turn,
will present the reports to the quality council
Stage II: Re-organization or the top administrator of the system for
and training monitoring and further action.

A combination of both centralized and In regard to training, several seminars

decentralized approaches to improvement have been developed and delivered. Again,
interventions is desired but with more the objective here is not to over-train but to
emphasis on decentralization. Several optimally train on the needed skills and to
activities will take place in this stage. From the right individuals. In some organizations
the setting and communicating of standards several workshops have been delivered on
to the monitoring of compliance, and to the health care quality. There are workshops in
organization of quality structure, all need to awareness, basic and advanced skills of
be considered at this stage. One considera- quality improvement, standards- and
tion to be made is what, how and by whom indicators-setting workshops, team-building
the development or adoption of standards workshops, customer service, and cost-
and indicators (clinical and administrative) analysis workshops. Other organizations
will take place. A specialized or several delivered only a few workshops and only to
specialized committees could be formed to active process improvement teams, while still
tackle these tasks. One effective method to others delivered a set of workshops in
develop key indicators is to ask a represen- gradual complexity in an effort to rapidly
tative from each service unit in the system to develop a cadre of in-house professionals
develop or identify three to five key indicators that will take the burden of training others
specific to that service unit. Prioritization of later on. The most important piece of advice
these indicators will then be made to select is that training be delivered according to a
the most effective ones in measuring well-written training plan with well-thought
compliance to quality standards. out objectives in order for it to be
accomplished in a systematic manner.
Quality committees can be formed,
gradually, to address specific issues related
to the quality programme. As mentioned Stage III: Improvements
earlier, committees have been formed on
peer management, credentialling, utilization Under this heading a total process of quality
management, utilization review, operations, assurance and improvement should be
etc. The key issue here is: form these carried out. Any model of the process can

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Health Care Quality: An International Perspective

be used. Figure 1 shows the model used variance to standards and initiating
by the QA project of the USAID in countries processes for action to reduce this variance.
around the world with very positive results. Monitoring is a necessary step for the
The major issue to be considered is how to proper selection and consideration of
measure and monitor improvement and quality improvement projects and studies.
that is where standards-setting could be of It can also provide the organization an
importance (Benneyan and Kaminsky, indication of the status of care and services
1995). Ideally, however, a set of key quality provided at any point in time. In advanced
improvement indicators and data analysis systems of health care elaborate and
are developed at the central level while data comprehensive systems of monitoring have
collection and reporting would be carried been developed that utilize members'
out at the service levels. medical records for the abstraction of
specific data elements which, in turn, are
It is outside the scope of this chapter fed into a central database for analysis and
to discuss the specific steps of quality monitoring. Each service unit will then be
assurance, monitoring, and quality receiving a periodic report showing
improvement as presented in Figure 1. aggregate data of health care indicators
Several chapters in this book have discussed compared to their specific set of data for
these issues in much more detail. The the same indicators. Variance from the
reader is also encouraged to seek addi- mean is then studied and acted upon using
tional information from the literature the QA/QI process mentioned above.
available on these subjects.
A few words need to be said about the
issue of continuous improvement here.
Stage IV: Re-assessment, Improvements are not one-time activities.
evaluation, monitoring When a team has worked on a process and
and CQI improvement was accomplished, this does
not mean that it should abandon this process
A practice that should be encouraged is to for ever and move on to the next one.
measure pre- and post-improvements of Improvement is a process, and a process is
every project. In this way re-assessment will continuous. Monitoring should continue and
be much easier to accomplish. Re- improvements should be initiated every time
assessment and evaluation may use the it is needed. The other principle involves
same method applied earlier in the incremental improvements in the standards
assessment and planning phase through once compliance is achieved. If high or even
different methods of data collection and perfect compliance to a specific standard has
analysis. been documented, then upgrading this
standard is the next prudent step to take,
Monitoring, on the other hand, is based otherwise the organization will stay in the
on specific and measured indicators related status quo stage without further
to standards. It is a process of measuring improvements taking place.

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 Implementing Healthcare Quality

Stage V: Dissemination site and at what point in time, as readiness

of the staff for expansion is essential for its
and expansion
success. Similarly, methods of expanding
A successful process ought to be taught to the process to other locations can follow
others and accomplishments ought to be the same path as outlined in the partial
shared. Actually, even failures give us ideas implementation process discussed above.
for improvements. For these reasons,
It should be stressed here that the
dissemination of activities in health care
above model is by no means the only
quality is encouraged locally, nationally and model for implementation. There are a
internationally. number of different approaches to achieve
The process of dissemination may have the same outcome and the reader is
different approaches. One method is the advised to seek more information and
organization of a monthly lecture on the knowledge on the subject from other
progress in health care quality in the sources to get an idea of the different
country, or the organization of quarterly or perspectives. A model that may be appli-
annual seminars on quality activities. cable in one setting or country may not be
Another method is to develop a newsletter applicable in another.
on quality or use a section in an already Therefore, not surprisingly, implementa-
established newsletter to disseminate tion stages are described under the
information on health care quality and its
following headings, which are typical of the
activities. One country, for example, started new processes:
organizing study tours of professionals from
other parts of the country to the health care • Perception: "We are already doing
quality implementation site to expose others this."
to the process. Dissemination is essential • Awareness: "We can improve."
to attract further support and to maintain
• Education: "Let's learn how to do
momentum of staff. It also provides an
it."
avenue for the recognition of staff and can
prove to be a useful method of incentive. • Partial Implementation: "Let's
start pilot projects."
Expansion, on the other hand, includes
• Full Implementation: "Let's involve
the extension of implementation to another
everybody."
location or spread of implementation
nationwide. Expansion should be done very • Culture: "Way we do things."
slowly and gradually and only when • Achieved Quality: "Let's share
complete assessment and planning has accomplishments."
been performed. Hasty mistakes may
happen easily, which may jeopardize the The process of health care quality
success of the whole process. Caution implementation is a long and hard road
should be exercised when choosing the next but it is certainly worth following.

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Health Care Quality: An International Perspective

References 12. Crosby PB. Quality is Free: The Art of Making

Quality Certain, Fourth Edition, New York, NY:
1. Al-Assaf AF and Schmele JA. The Textbook of McGraw-Hill, 1988.
Total Quality in Healthcare, St. Lucie Press, Delray, 13. Deming EW. Out of the Crisis. MIT Press,
FL, 1993. Cambridge, MA, 1986.
2. Al-Assaf AF. "Quality Improvement in Healthcare: 14. Franco LM; Newman J; Murphy G; Mariani E.
An Overview", Journal of the Royal Medical Achieving Quality Through Problem-Solving and
Services 1(2): 1994. Process Improvement, Bethesda, MD: QA Project,
3. Al-Assaf AF. "International Health care and the 1994.
Management of Quality" in Quality Management 15. Goal/QPC. Memory Jogger Plus, Methuen, MA:
in Nursing and Healthcare, Delmar Pub., 1996. Goal/QPC, 1988.
4. Baird R; Cadenhead S; Schmele JA. "The 16. Deprete-Brown L; Franco LM; Rafeh N; Hatzell
Implementation of Total Quality" in The Textbook T. QA of Health Care in Developing Countries,
of Total Quality in Healthcare, St. Lucie Press, Bethesda, MD:QA Project, 1992.
Delray, FL, 1993.Al- 17. Jablonski JR. Implementing Total Quality
5. Benneyan JC; Kaminsky FC. "Another View on Management: An Overview, San Diego, CA:
How to Measure Health care Quality", Quality Pfeiffer & Co., 1991.
Progress, 120-124, Feb. 1995. 18. Joiner Associates. The Team Handbook,
6. Berwick D. Continuous Improvement as an Ideal Madison, WI: Joiner Associates, 1985.
in Health Care", New England Journal of 19. Juran JM.; Gryna FM Jr.; Bingham RS Jr. Quality
Medicine, 1(2):44-50. Control Handbook, New York, NY: McGraw-Hill,
7. Blumenfeld SN. "Quality Assurance in Transition", 1979.
PNG Medical Journal, 36:81-89, 1993. 20. Leebov W; Ersoz CJ. The Health Care Manager's
8. Blumenthal D. "Quality of Care - What is it?", Guide to Continuous Quality Improvement.
New England Journal of Medicine, 335(12):891- Chicago, Il:AHA, 1989.
893, 1996. 21. Ishikawa K. Guide to Quality Control, White
9. Boerstler H; Foster RW; O'Connor E; O'Brien JL; Plains, NY: Quality Resources, 1982.
Shortell SM; Carmen JM; Hughes EFX. 22. Meisenheimer C. Improving Quality, Chicago, Il:
"Implementation of Total Quality Management: Aspen, 1993.
Conventional Wisdom versus Reality", 41(2):143-
23. JCAHO. An Introduction to Quality Improvement
159, 1996.
in Health Care, Oakbrook Terrace, Il: JCAHO,
10. Brown LD. "Institutionalization Issues for Quality 1991.
Assurance Programs", International Journal of
24. Walton M. Deming Management at Work, New
Quality in Health care, 8(1), 1996.
York, NY: Perigee, 1991.
11. Couch JB. Health Care Quality Management for
the 21st Century, Tampa, Fl.: ACPE, 1991.

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 7 7
Improving Health Care Quality: Strategies
for Implementing Change
Lutchmie Narine, Ph.D.

INTRODUCTION what circumstances. Fortunately, there are

some general principles of quality change

W
hen faced with the challenge of that are applicable across settings, which
improving health care quality, can provide some guidance to health care
health care managers have a managers. Thus, the purpose of this chapter
dilemma about what should be changed is two-fold: (i) to provide managers with
and how it should be done. This is partly conceptual tools to better appreciate the
due to the multifaceted nature of health dynamics of quality change processes they
care entities which present a broad observe around them, including those
spectrum of features that could be described in other chapters of this book,
leveraged to achieve change, and the and (ii) provide guidance on how to
variety of approaches, processes and proceed with change in the context of their
techniques that are available to managers own institutions.
to effect improvements in health care
quality. This, in turn, means the precise To achieve this two powerful ways of
nature of change in health care quality, will thinking about health care quality change
vary with the peculiar characteristics and
(i.e. Kilmann's model and Nadler and
circumstances of each institution. Thus,
Tushman's typology) are described, and,
there is no one way or limited set of ways
using their concepts, we learn what are key
to implement health care quality change.
organizational features that may be used
However, the variety of approaches and to bring about quality change, when it is
innovations in quality improvement often best to use these features, and how to apply
leave managers confused as to what strategies and techniques to effect required
aspects of the change process are more changes. Kilmann's barriers to success
important than others and which to use in model reveal organizational features that

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Health Care Quality: An International Perspective

may be key leverage points for improve- WHAT TO CHANGE?

ments in health care quality. The seven
features of the model are the setting, The issue of what to change actually asks
organization itself, the health care manager, two questions: (1) what are the key aspects
group decisions and results, and organi- of the health care organization that are the
zational culture. The features that become best leverage points to improve health care
targets for quality change and the extent to quality; and (2) once aware of these
which they are modified depend on the type leverage points, what are the best change
of change required. Nadler and Tushman's strategies to apply so that health care
typology of change illustrates the various quality is maximized. Deciding on what
kinds of change situations health care organizational aspects affect health care
managers and institutions can be faced quality pits one expert's target of change
with. The four dimensions of the typology against another's. Can change be
are reactive, anticipatory, incremental and accomplished by new reporting systems, by
discontinuous change. realigning corporate cultures, by a new
strategic plan, or by a different reward
When quality changes are initiated system? It seems that each expert has his
health care managers can expect to face or her favoured intervention and thinks
three basic problems. There is resistanced significant change can take place only
from change recipients, difficulties in through that method (Kilmann and Covin,
maintaining commitment to the change 1989). This paper will not provide the
over time, and the impact of health care answer to the best change target or the best
quality change on organizational power way to achieve change. However,
managers can benefit from some general
dynamics. There are a number of strategies
principles which they can use in deciding
and techniques that could be employed to
what should be done in their specific
address these problems and several are
situations. With respect to key leverage
presented in this chapter.
points of performance Kilmann (1989)
presents a model which highlights some of
The what, when and how of health care the features of organizational life that have
quality change described in this chapter are been most talked about in the current health
illustrated with examples reflective of the care management literature.
reality of health care organizations'
experience with quality changes. Also,
additional readings of field examples of
successful quality efforts are provided for
BARRIERS TO SUCCESS MODEL
readers who would like to learn more about Kilmann suggests a model of seven features
the practical application of the concepts which, if not properly aligned, can stand in
discussed in this chapter. the way of health care organizational
success. This model is known as the Barriers

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 Improving Health Care Quality: Strategies for Implementing Change

to Success Model. Four of these represent, Dynamic complexity and external stake-
at the surface, aspects of a health care holders are highlighted as being significant
organization - the setting, the organization, environmental features that play an
the manager, and group decisions and increasingly important role in the life of
results. At the heart of health care organi- health care organizations. Dynamic
zational life are its culture, assumptions, complexity refers to the rapid pace of change
and psyches (see Figure 1 below) modern day health care organizations have

Figure 1. Barriers to Success Model

(Adapted from Kilmann, 1989)

The Setting
Dynamic complexity
External stakeholders

The Organization Culture The Manager

Strategy-Structure Assumptions Management Skills
Reward System Psyches Problem Management

The Group

Decision-making
Action taking

The Results

Morale
Performance

At the top of the Barriers to Success to face and the growing interdependencies
Model is the setting, which is considered to between health care organizations. External
be the most inclusive category. It provides stakeholders are individuals, groups, or other
the environmental context in which the health institutions that have some stake in what the
care organization's internal elements and health care organization does. They are the
dynamics are understood and aligned. contributors to the dynamic complexity health

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Health Care Quality: An International Perspective

care organizations face. There can be managers have been thought of principally
tremendous differences in expectations as decision-makers, i.e. people who choose
among stakeholders about the quality of among sets of alternatives to arrive at an
care and operational performance of health optimal solution. This was acceptable when
care organizations. Also, new stakeholders alternatives were pre-determined and the
can emerge at any time - such as new rules for choosing among them clear-cut.
competitors with improved production However, in today's situation of dynamic
methods, new regulatory agencies, and new complexity it is often not clear what the
customers with different needs. health care organization's basic problem is,
far less what the other choices are. Hence,
On the left side of the model, three modern health care managers are required
main features of the formal organization are to be more problem-managers i.e. identify-
emphasized - strategy, structure, and reward ing and defining problems rather than
systems. decision-makers choosing and
• Strategy refers to the documents implementing solutions.
that signify the organization's
At the core of health care organi-
direction, such as statements of
zational life are below-the-surface features
vision, mission, goals and
such as culture, assumptions and psyches.
objectives (Kilmann, 1989).
• Structure refers to the way • Culture refers to the shared values,
resources are put together to norms and expectations organiza-
achieve the organization's strategic tional members hold about their
direction including the design of institution and the work they do.
reporting relationships, policy They are the unwritten rules that
statements, job descriptions, formal members follow in their day-to-day
rules and regulations. work.
• Reward systems refer to the docu- • Assumptions are the beliefs that
mented methods that are used to people take for granted but which
motivate employees to high levels under closer inspection may turn
of performance, and mechanisms out to be false. Underlying almost
to attract and retain high quality any decision or action are largely
personnel. unstated and untested assumptions
that health care managers think to
On the right side of the model are the be unquestionably true such as: no
qualities and skills of the health care new competitors will enter the
manager. In the past, models of organi- industry, government's regulatory
zational behaviour did not emphasize as activity will continue to be
Kilmann's model does the importance of restrained, or the economy will
managers to the performance of health care steadily improve.
organizations. Until recently, health care

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 Improving Health Care Quality: Strategies for Implementing Change

• Psyches refer to the assumptions and the current stage of the health care
workers make about human organization's life cycle. History has been
nature, i.e. what people want, fear, shown to have an impact on the success
resist, support or defend. of change strategies. Once an organization
embarks on a change, there is an imme-
These underlying features are the
diate increase in the likelihood of additional
invisible force behind the observable
changes of the same type (Amburgey, Kelly
aspects in a health care organization, and
and Barnett, 1993). Past history is therefore
constitute the social energy that motivates
seen to determine future solutions. Also, it
health care workers to action. They are
has been suggested that health care
important because they can steer beha-
organizations respond and change in
viours away from what is required by job
different ways depending upon their stage
descriptions and procedures or demanded
within their life cycle as they must respond
by supervisors and more senior managers.
to external events differently at different
The lower part of the Barriers to Success times in their evolution (Pettigrew, Ferlie and
Model shows the decisions and conse- McKee, 1992; Shortell, Morrison and
quences that arise from group efforts. Robbins, 1985). Creating a successful
Although individuals are capable of making change process in a stable, mature
decisions and taking actions on their own, organization may be more difficult than in
contemporary health care institutions a newer, more entrepreneurial health care
require multiple contributions from its organization.
constituent groups to deal with complex
Diffusion research is a methodology,
problems. Under conditions of dynamic
which analyzes the spread of new informa-
complexity and shifting stakeholders, a
tion or technology among organizations.
group or team approach provides the most
This information spread is analogous to an
comprehensive source of expertise and
organizational change process. Renshaw
information for problem-solving. The team
and associates (Renshaw, Kimberely and
approach is, of course, integral to the
Schwartz, 1990) found that early adoption
health care quality improvement process.
of technology in hospitals was associated
The Barriers to Success Model can alert with large size, the existence of teaching
health care managers to factors they should and research facilities, the type of ownership
be considering when making changes to and urban location. Also, Ginn (1992) has
enhance health care quality. Of course, observed that size, system membership,
there will be differences among various ownership, and severity of case mix was
health care organizations. Recent research positively associated with health care
has identified that change initiatives organizations being more proactive in their
undertaken by health care organizations are development of strategies. These findings
affected by certain organization-specific suggest that organization size, teaching
factors such as organizational history, size, status, location and ownership can all have

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a bearing on the implementation of change payers' dissatisfaction with the cost versus
in health care quality. quality of care provided). Here, change is
initiated without a clear and present
The impact of these factors on organi- environmental demand, but in anticipation
zational changes suggests the need to of environmental pressures that are likely
design change initiatives which reflect the to occur in the future. This type of change
specific needs of the health care is referred to as anticipatory change.
organization.
The second dimension of change is
concerned with continuity or the degree to
TYPES OF CHANGE which change paths depart from current
patterns of organizational behaviour and
Nadler and Tushman (1995) have levels of health care quality. In some cases,
developed a framework which can help us changes build on work that has already
to better appreciate the different types of been done and do not depart very far from
change that health care organizations face. the pattern of operation that has already
They propose that change can be thought been established. Change here involves
about on two dimensions. The first dimen- tinkering with components to improve the
sion is concerned with the dynamic functioning of the health care organization
complexity of the health care organization's in relatively small increments. Such
setting, in particular the strength of the changes, which do not necessitate funda-
environmental forces for change. In some mental shifts in the frame of the health care
cases the forces of change are so strong organization, are referred to as
that health care organizations are forced incremental change. It is important to
to respond immediately to changes in the note that incremental changes are not
environment (e.g. government imposition of necessarily small. They can involve large
regulations requiring the reporting of health commitments of resources and impact on
care quality statistics to consumer groups). many people. They are incremental only in
Such changes are referred to as reactive the sense that the changes are continued
change in that they are necessitated by on from the ongoing pattern of health care
some clear environmental event. In other organizational life. On the other hand,
cases, the forces of change are relatively changes that depart substantially from the
weak and are not clearly identifiable. The current organizational context are referred
forces that precipitate change might not yet to as discontinuous change. These involve
have affected health care quality but people redefining the organizational role - its
in the health care organization may sense vision, identity, strategy and even its values
that something more is needed to stay (Nadler and Tushman, 1995).
ahead of the competition or to be prepared Discontinuous change challenges the very
for environmental shifts looming on the context or frame within which the health
horizon (e.g. sensing employers' or other care organization operates. This type of
change can reshape or bend the frame,

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 Improving Health Care Quality: Strategies for Implementing Change

while in more extreme cases it breaks the consumer tastes, new technology or
frame and moves the health care organiza- government regulation may make it
tion to a different configuration. When these necessary for the health care organization
two dimensions - dynamic complexity and to respond or suffer negative consequences
continuity - are combined, the result is four (Nadler, 1988). However, the consequences
types of changes as shown in Figure 2. are not life-threatening and the response
does not require a fundamental departure
Figure 2. Types of Health Care from the frame within which the health care
Quality Changes organization operates (e.g. complying with
(Nadler and Tushman, 1995) requirements to publicly report quality of
Tuning Reorientation care statistics may be an extension of work
already produced for internal purposes). As
Adaptation Re-creation in the case of tuning changes, adaptation
changes also involve the re-engineering of
processes to effect incremental adjustments
TUNING in work systems. The change targets are
also similar i.e. lower order features of the
These changes are made in the absence of health care organization and group
any immediate need or problem but in decision-making and action-taking. The
anticipation of future environmental events. difference is that adaptation changes are
They are done in the hope of making minor done in reaction to specific environmental
gains or efficiencies on already proven cues, and hence the re-engineering process
health care quality systems, and are often is more focused and can be more extensive.
aimed at changing the way work is carried
out, i.e. re-engineering work processes
(Keidel, 1994). However, the re-engineering REORIENTATION
efforts tend to be unfocused and are done
in a piecemeal fashion. In terms of the This type of change is made in advance of
Barriers to Success Model, the targets for anticipated external events. They often
tuning changes would be the group and occur early in the cycle of a shift in overall
lower order features of the health care industry patterns, and involve a funda-
organization such as the way jobs are mental redirection of the health care
designed and rewards allocated. organization. Reorientation changes are
typically led through restructuring efforts i.e.
reconfiguring organizational units and
ADAPTATION redesigning reporting relationships or
administrative groupings to redefine the
These changes are made in reaction to nature of the organizational enterprise
external conditions in the environment. The (Keidel, 1994) (e.g. the adoption of quality
actions of a competitor, changes in work teams and processes in the 1980s as

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a response to the quality improvement prosper. The re-creation process involves

movement in the automobile and other a change in the patterns of understanding
manufacturing industries). As the formal that the health care organization and its
structure of the health care organization members have about its identity (who we
changes, there is a concomitant need to are, what do we stand for), its purpose
change the number and types of managers (mission, for whose benefit do we exist), and
who will manage the new organizational methods and procedures (how we do things
units and groupings. The process also to satisfy our clients) (Hernandez and
involves some modification to other aspects Kalunzy, 1988). This kind of change is
of the health care organization such as its relevant to health care manager's attempts
strategy, group processes and even its to foster a total quality management culture
culture. However, these changes are and way of thinking among hospital and
frequently put in terms that emphasize other types of health care workers. The
continuity with the past (particularly values target of re-creation is not the actual
and norms of the past), as the intent of process or structures in the health care
reorientation is to bring about major organization, but rather the individual or
change but without too sharp a break with collective mindsets that exist about the
the existing organizational frame. As such, components of the health care organi-
reorientation represents a frame-bending zation. Once the thinking has changed then
rather than a frame-breaking change. In the the appropriate changes in organizational
context of the Barriers to Success Model, components will follow. Hence, the key
the organizational components most organizational feature targeted by re-
affected by reorientation changes are higher creation change is the inner core of the
order features of the health care organi- Barriers to Success Model, i.e. the health
zation such as its structure and strategy, and care organization's culture, assumptions,
its managers. and psyches. In targeting this inner core,
re-creation changes directly challenge the
existing organizational frame. Often there
RE-CREATION is breakage, old mindsets are discarded,
and a new frame is created.
Health care organizations which have
The above classification scheme
visionary leaders who can anticipate
provides a background on the types of
environmental changes and devise appro-
change and the potential effects of these
priate responses are quite fortunate.
different change types on health care
However, in other cases senior managers
organizations. This model, together with the
are forced to bring about discontinuous
Barriers to Success Model, provides the tools
change in reaction to severe environmental
that health care managers can use to
pressures. The health care organization
determine what to change. Once this step
faces a fundamental crisis that requires it
has been completed, the question becomes
to re-create itself in order to survive and
how to successfully change health care

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 Improving Health Care Quality: Strategies for Implementing Change

Figure 3. Summary of action steps in quality change

(Adapted from Morris and Raben, 1995)

Problem Implication Action Steps

Resistance Need to motivate 1. Surface dissatisfaction with the present state.
2. Promote participation in health care quality
change.
3. Give rewards for behaviour in support of health
care quality change.
4. Provide time and opportunity to disengage from
the present state.
Commitment Need to manage 5. Communicate a clear vision of the future quality
the transition process.
6. Use sequenced leverage points
7. Establish appropriate transitional devices.
8. Build in feedback and human resource
mechanisms.
9. Use leader behaviours to influence health care
quality change.
Power and Need to shape 10.Assure the support of key individuals and power
politics the political groups.
dynamics 11.Use cultural devices.
12.Build in stability.

quality. It is generally accepted that people problems has different implications for the
like variety more than change as it tends to management strategy to be employed and
be unsettling no matter what the circum- the action steps flowing from the chosen
stances (Pettigrew, Ferlie and McKee, 1992). strategy.
Morris and Raben (1995) note this leads to
three universal problems encountered in the
implementation of health care quality HOW TO CHANGE?
change. These are: resistance on the part
of the recipients of change, difficulties in
maintaining commitment in the face of the Managing resistance
uncertainty associated with change, and A good deal of the tension that arises in
problems in dealing with the impact of health care quality change is a direct result
change on organizational power structures. of the disjunction between those directing
As summarized in Figure 3, each of these the change and the recipients who must

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Health Care Quality: An International Perspective

adopt and adapt to change. The individual contrasted with the uncertainty and often
response to change includes: inquiry, incompleteness of the proposed quality-of-
denial, pessimism, education and analysis, care improvements. If the proposal for
decision-making, action, response, and change persists then targets of blame are
acceptance (Thompson, 1994). These sought. The usual targets are decision-
responses can fundamentally reshape any makers who are held responsible for the
change process. Hence it is vital to a evils wrought by the change. As the change
successful change effort to understand the gets under-way there is an increase in
dynamics of recipient response and how to 'corridor talk' and an associated loss in
manage resistance. Resistance to change productivity. People seek each other out to
occurs for a number of reasons: compare their interpretations of what the
change really means. As the hall corridor
• Change can be perceived as a intensifies factions begin to form as people
threat to one's autonomy and self- seek out the company of those who share
control. their point of view about the change. Out
• It may challenge familiar ways of of these factions informal leaders emerge.
doing things and force employees The presence of these leaders emboldens
to find new ways of managing their the faction's opposition to the changes and
work environment. change leaders begin to have their
convictions and support for the quality
• Some recipients may perceive that improvement initiative tested. This stage of
the eventual consequence of resistance is a critical time for the senior
change will involve some personal management team, as failure to present a
loss either in reduced status, unified front can sharply undermine the
authority or pay. change initiative. If all else fails, individuals
will appeal to managers and others with
• Others may resist for cognitive whom they have personal relationships to
reasons, either on ideological modify the consequences of change in their
grounds, arguing that the change particular case.
violates an important principle, or
out of concern that the health care Experience and research has taught that
organization may be losing sight of in the face of resistance to change the best
its mission. strategy for health care managers is to
somehow motivate constructive behaviour
Whatever the reasons, there is a among change recipients. This can be done
predictable pattern of resistance behaviours through a variety of action steps including
which health care managers should expect surfacing dissatisfaction with the present
to see when change takes place. Initially state, promoting participation in the change
change is fought against with rational effort, rewarding behaviours supportive of
arguments in support of retaining the status change, and providing opportunities for
quo. Familiarity with the present is resisters to disengage from the present state.

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 Improving Health Care Quality: Strategies for Implementing Change

Surfacing dissatisfaction with fosters ownership in the process. Participation

can also facilitate a better exchange of
the current state
information about the change between the
This is particularly important for tuning and change leaders and recipients and provide
re-orientation changes, where the change feedback that might enhance the effective-
is done in anticipation of future environ- ness of the change. Participation devices can
mental events. In the absence of an obvious be by soliciting recipients' views via
crisis it is difficult for many change recipients questionnaires and interviews and/or
to see why there is any need for changing including their membership on task forces
health care quality. Hence, health care and committees.
managers have to create a sense of urgency Health care managers often find the
about the change by encouraging feelings issue of participation a contentious one.
of dissatisfaction with the present state. Participation means giving up some control,
Techniques for doing this include educating and including divergent interest groups can
people about what is happening in the health create conflict and slow the process of
care environment that is driving the need for change. However, most change theorists
change. People are given the tools to believe the benefits from some form of
recognize the economic and business participation outweigh the costs of no
consequences of not changing. Closely involvement at all. The task for health care
related are techniques such as benchmarking managers then is to decide when, where and
which emphasize the discrepancy between how to build participation into the quality
current and desired states. Another method improvement plan. Participation can occur
is to provide opportunities for people to in the problem diagnosis, planning or
experience in a personal way the reasons execution stages of the change process.
underlying the need for change. This can be Individuals or groups invited to participate
achieved by setting up self-diagnostic or may differ on the basis of the skills and
study teams to collect information on expertise they can contribute to each stage.
customer and other stakeholder views. If participation is direct then a large number
of people will be involved; if indirect,
Promoting participation participation will be limited to a small
number of representatives.
One of the most consistent findings in the
research on change is that participation in Rewarding supportive
the planning and implementation of health
care quality change tends to reduce
behaviours
resistance and motivate recipients to make When health care managers announce a
the change work (Coch and French, 1948; quality improvement initiative, organization
Vroom, 1964; Kotter and Schlesinger, members often wait for signals that say they
1979). Involving people in making change are serious or they mean it. One effective
choices enhances their sense of control and way to signal management's commitment to

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health care quality change is to acknowledge plan for organization members to

new heroes, recognize new achievements, disengage from the present state. The fear
and offer special incentives that reinforce is that focusing on the break with the past
behaviours that are consistent with the while the new state is still in the making
direction of the change. Health care might have the opposite effect of
managers often fail to use rewards properly promoting resistance to the change
to support the change process, either process. However, there is increasing
because while they expect individuals to evidence that change often creates feelings
behave in new ways they continue to reward of loss for familiar ways of doing things
them for old conflicting behaviours or they that are not unlike those associated with
do not take actions at their level to death. Indeed, Lippitt (1982) refers to this
demonstrate that rewards have changed as a period of mourning, and has outlined
(e.g. continuing to structure rewards around
seven stages that are common to the
patient volumes i.e. numbers of patients
experience of loss associated with health
served rather than the quality of care
care quality change. Hence, when
provided or based on consumer satisfaction
possible, it is wise to allow individuals the
reports). This latter failing is particularly
time and opportunity to bring some
problematic in frame-bending or frame-
psychological closure on the old state.
breaking changes when culture and psyche
modifications require health care managers Techniques that health care managers can
to adopt new behaviours and skills. All too use to help health care professionals to
often efforts to change management come to terms with letting go of the past
behaviours are undermined because the include small group sessions where people
promotion system continues to run as normal are encouraged to talk about their feelings
and leaders remain reluctant to remove or of loss, or rituals or ceremonies that help
demote health care managers who do not people to symbolically say farewell to old
demonstrate the required behaviours. practices.
Hence, in cases where the perception of the
seriousness of the change needs to be Not all changes are equally amenable
reinforced, health care managers should to allowing health care providers to mourn
restructure the reward system - compensa- the loss of the familiar. Adaptation and re-
tion, bonus, promotions, job assignment, creation changes are reactive and often do
recognition, and status symbols to ensure not have the luxury of time to avoid
that they are aligned in the direction of the completely psychologically disruptive
health care quality change. departures with the past. An important
feature of tuning and re-orientation
changes is their anticipatory nature, which
Opportunities to disengage allows time for relatively gradual quality
from present state change, making it easier to address the
feelings of loss experienced by recipients
Many change leaders struggle with the
of the change.
issue of making allowances in the change

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 Improving Health Care Quality: Strategies for Implementing Change

MAINTAINING COMMITMENT health care managers to clearly and

consistently articulate a vision of the future
One problem for health care managers is will not facilitate change in members
to help the recipients of change cope with cognitive interpretations about the character
the ambiguity of the transition period, while of the health care organization, which in
trying to keep the change process moving. turn can undermine acceptance of the
Action steps that can help change leaders change, especially in the critical period of
successfully manage the transition include: transition. But the health care manager may
communicating a clear vision of the ask, how can I articulate a clear vision when
change; using sequenced leverage points; I have only a general idea of where we are
establishing appropriate transitional going? In fact, a general idea is clear
devices; using feedback mechanisms; and enough. Change of mindset does not
supporting human resource systems. require the explicit detailing of every aspect
of the new quality improvement process.
Rather, a description of what the new key
Communicating a clear principles will be and how they will look in
vision operation is sufficient. They can serve as
guides or goals around which members can
It is important for health care managers to go about rethinking what are desirable
communicate a clear vision of what the attributes for their health care organization.
future will look like because organizational
There are two basic ways health care
members interpret change or other types
managers can guide the rethinking process
of management initiatives through the prism
and ultimately the evolution of members'
of their existing mental models or mindsets.
organizational identity:
A key feature of change, especially frame-
bending or frame-breaking changes such • One way is by providing oppor-
as re-orientation and re-creation, is the tunities for members to engage in
need for new mindsets that reorients sense-giving activities that blend
members' basic assumptions about the their mental models which the
nature of the health care organization (e.g. vision managers have of the future
reducing costs while improving quality of for health care quality in their
care is both possible and desirable). One organization. These kinds of
of the most powerful mental models held opportunities are particularly
by organizational members is the set of important in obtaining physicians'
beliefs they have about the organization's participation as one wants to avoid
identity, i.e. what is central, distinctive and physicians interpreting proposed
enduring about the health care organization changes as yet another manage-
(Reger, Gustafson, DeMarie, and Mullane, ment fad rather than a real attempt
1994; Reger, Mullane, Gustafson and at improving quality of care.
DeMarie, 1994). Failure on the part of Indeed, it is often possible to get a

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Health Care Quality: An International Perspective

physician to do all sorts of things can be a very convincing argument

in the name of "quality" that he or in favour of making health care
she would not show interest in if quality improvements.
the same activities were called
There are two essential aspects of
"management". Sense-giving
communication throughout the change
opportunities might be provided
process. The first is the timing of the
indirectly by involving physicians
messages, and the second is the amount
and other staff members in deve-
of information to be communicated. There
loping a written description of the
has been limited empirical study of how
change or constructing an impact
these aspects of communication affect the
statement that outlines the effect
success of the health care quality change.
the quality change will have on
Experienced change agents have indicated
people and organizational compo-
that during the times of significant quality
nents. A direct and more effective
change, managers rarely communicate
sense-giving technique is the
frequently enough or with sufficient volume,
conduct of focus groups between
but no one is really clear about how much
health care managers and other
is enough (Burke, 1995).
organization members where
champions of the quality initiative
can share their vision and Sequenced leverage points
interpretations.
Previous authors have suggested that
• The second way is by creating
because of the interrelated nature of health
opportunities for members to learn
care organizational components, all
how others think about the health
elements should be changed almost
care quality change being
simultaneously (Roitman, Liker and Roskies,
proposed. The opinions of
1988). However, this may be neither
outsiders can be a significant
necessary nor practical. Use of multiple
stimulus for change among
simultaneous leverage points is only
organization members (Reger,
required in the case of frame-breaking or
Gustafson, DeMarie, and Mullane,
frame-bending changes such as re-
1994). A particularly effective
orientation or re-creation. However, as has
practice of making members more
been pointed out in this chapter, there are
receptive to change, by raising
many different types of health care quality
awareness about organizational
changes, not all of which involve large-
shortcomings, is direct customer
scale changes to many organizational
interaction. The realization that
elements.
customers are not happy with the
organization's performance, or Indeed, experience has taught that
hold ideals for the organization that different parts of health care organizations
are quite different from one's own, can differ with respect to their readiness for

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 Improving Health Care Quality: Strategies for Implementing Change

quality change. For example, awareness of training in statistical charting processes and
the need for quality changes is unlikely to other quality control techniques). Planning
take place among medical staff as a whole change in a phased way has been found
or all at once. More likely, the recognition to be a beneficial approach, which is also
of problems will vary by specialty groups confirmed by experience (Reger, Mullane,
and over time. Family practitioners or Gustafson and DeMarie, 1994).
internists would not be expected to be as
alarmed over deficiencies in anesthesiology
services as would other clinicians be whose Establishing appropriate
work is more directly affected such as transitional devices
surgeons or obstetrician-gynecologists.
Failure to recognize differences in the When the desired state of health care
capacity and willingness of organizational quality in the futre is substantially different
elements to change can give rise to overly from the current state, a transitional design
ambitious change efforts with unfortunate may be required to manage the transition
results (Roitman, Liker and Roskies, 1988; (Beckhard and Harris, 1977). Such
Hess, Ferris, Chelte and Fanelli, 1988). organizational arrangements may be more
Also, from a practical standpoint, just relevant for discontinuous changes rather
changing one part of the health care than incremental changes. Frame-bending
organization such as the reward system is and frame-reaking changes such as re-
a major effort on its own. If at the same orientation or re-creation usually involve
time the health care organization tries to major departures from the current quality
change the way work is done, how it recruits state and impact on many more organiza-
and trains managers, and so on, the tional systems. Change leaders have
change agenda can be overwhelming. available to them a number of standard
transitional management devices such as
Thus, it is common to think in terms of steering committees, design teams, transi-
sequencing the leverage points over time. tion teams, task forces, a transition
Depending on the type of change involved, manager, and transition plans.
key organizational features are changed
first to be followed by others. This gives the The purpose of these devices is to
health care organization time to install each ensure that members know who is to do
change in a manner that does not overload what. Transition designs can take on a life
members with too many new ways to be of their own. An important consideration
learned. The preferred sequence of change in the choice of transitional organizational
is to start with high leverage changes that arrangements revolves around the issue of
produce good initial results (e.g. first how hands-on senior health care managers
reorganizing into quality units and CQI should be involved in the change. Should
work teams). This should be followed by they take an active part in the day-to-day
other changes that support and comple- work of transitional structures, or should
ment the original changes (e.g. provide they delegate this to others at lower levels

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Health Care Quality: An International Perspective

of management? In general, incremental future that it requires senior managers to take

changes seem to require that health care a hands-on approach to change
managers play a supportive role and management. In a re-orientation situation,
effectively delegate quality change tasks to change management may grow to be a
the right people. On the other hand, major part of the senior team's responsi-
discontinuous change requires active and bilities. In re-creation change, management
intimate leadership from senior health care becomes the primary task of the senior team.
managers. For the chief executive officer (CEO), his or
her sole agenda is to lead the health care
Specifically, in tuning changes where organization through the frame breaking
there is not a dramatic break from the past, change. In re-orientation or recreation, the
much of the change management work can
transitional structures employed are different
be done through existing structures and
in character as they must accommodate the
processes. The ease with which normal
active involvement of members of the senior
processes can deal with tasks related to
management team.
tuning changes depends on the level of
competence the health care organization
has with project management and other Feedback mechanisms and
basic implementation mechanisms. Normal human resources
health care management processes are
unable to handle the more complex change The goal-setting theory indicates that the
management tasks presented by adaptation best quality levels are achieved when
changes. Here, senior health care specific quality performance goals are set
managers find it useful to set up special and feedback is provided on the attainment
quality improvement structures that allow of these goals (Amburgey, Kelley and
them to manage the change through Barnett, 1993). Once the vision or end-
delegation. They provide guidance on the goal has been set, the health care organi-
general direction of the quality change zation and its members require ongoing
while not getting directly involved in the day- feedback on the implementation of the
to-day work of these transitional structures. quality changes.
This is often accomplished by having major
change issues appear for review and In the case of large health care quality
decision-making on the agenda of meetings transitions, many existing organizational
of the senior management team. feedback mechanisms are destroyed,
requiring a conscious effort to re-establish
In the case of re-orientation and re- them early in the change process. With re-
creation changes, the basic ways of doing orientation and re-creation change initia-
things in the health care organization tives, the need for feedback mechanisms is
become the focus of the change in quality the greatest, as these change approaches
improvement. This is often so destabilizing represent radical departures from the status
and of such importance to the organization's quo.

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Health care managers have both what types of behaviours and actions are
formal and informal feedback mechanism valued and rewarded by the health care
available to them. Formal channels are organization. Continuing to reward
vested in the organizational structure and outdated behaviours is a sure way to cripple
may include personal and group meetings a health care quality improvement initiative.
with change recipients, articles in the
organization's public relations and informa-
tion publications, and use of formal reward Power and politics
and recognition programmes. The informal Quality changes in health care organiza-
mechanisms can include corridor chats and tions often involve some disruption to the
informal social events. The method of political dynamics of the organization. Since
feedback presentation should be targeted they do not challenge the basic processes,
to meet the needs of identified organiza- tuning and adaptation changes primarily
tional members. This may mean that affect the more formal aspects of power
different feedback approaches are used for within the health care organization. Re-
different groups or individuals, requiring orientation and re-creation changes are
health care managers to ensure that focused on frame-breaking or frame-
messages are consistent within the target bending, and thus have a greater impact
groups, and that messages provide the on the informal power relationships that
feedback information necessary for the develop among health care organizational
quality change process to proceed. members over time. There is a need for
change leaders to shape and manage these
The human resources function within
political dynamics throughout the transition
the health care organization becomes even
period to build and keep support for the
more important during times of significant
change process.
health care quality change. It is essential
to ensure that human resource processes
such as performance appraisal, rewards Use leader behaviours to
and recognition, and training and develop- influence change
ment are structured to reinforce the change
process and support and enhance quality During times of change people look to
improvement. For example, on implemen- health care leaders to provide assurance and
ting TQM some organizations might the motivation to persevere in the face of
replace traditional incentive awards like uncertainty and turbulence. Hence, the
plaques or pen sets with rewards like books behaviour of senior leadership is a significant
on how to improve job performance or trips factor in the management of the political
to quality improvement education dynamics of both the formal and informal
programmes. Many health care organiza- organizations. With the force of their
tions attempt to make substantial changes, personality and behaviours they can
while keeping existing quality management generate energy and enthusiasm, mobilize
systems in place. Employees quickly realize groups, be a role model, and send important

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Health Care Quality: An International Perspective

signals in support of the quality improvement (Salancik and Pfeffer, 1977), e.g. traditional
process. Through the power of their office quality assurance workers seeking to
health care leaders can build support for redefine TQM principles to fit quality
quality change by rewarding appropriate assurance functions. Obviously, change
individuals or behaviours, removing road- leaders must be aware of the formal and
blocks, disseminating a positive vision of the informal power structures within the health
future quality state among change recipients, care organization and the potential impact
and providing needed resources. Given that on the change initiative.
leadership is so fundamental to the manage-
Once key power groups have been
ment of the quality change process, it is
identified, health care change leaders must
relevant to many of the action steps
begin to obtain their support. Steps that can
previously described and to the steps
facilitate this include participation,
mentioned below.
bargaining and isolation.
• Participation refers to getting
Assure support of key groups or individuals to become
individuals and groups involved in the quality change. As
they do so they may begin to take
Power in health care organizations is ownership and see it as their
normally held by those who cope with change, not something that has
critical organizational problems, since been imposed on them. However,
resources are provided for the resolution in some instances those opposing
of these critical problems. Health care the change can use participation
quality change can therefore be facilitated to increase their power and
by reallocation of resources in accordance forestall any further change.
with the new directions. Apart from shifts in
• The use of bargaining identifies
resources, those in power can be further
individuals who may be persuaded
threatened by the loss of their control of
to accept the change and provide
information. For example, the standards
incentives to reinforce their support.
emphasis phase in implementing QA
Incentives may be the promise of
programmes can make management or
a new position or additional
care processes, previously only the preserve
responsibility within the restructured
of professional managers, more transparent
health care organization.
and comprehensible to lay managers,
making possible a redistribution of power • In cases where participation or
and control within the organization. bargaining is not effective and
However, those in power may not easily give individuals continue to resist or
it up, and, as a result, the quality change undermine the change, it may be
initiative can be sabotaged. Individuals with necessary to isolate them to limit
power can structure the change in ways that their impact on the change
favour their continuing to have power process.

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 Improving Health Care Quality: Strategies for Implementing Change

This can be done by moving individuals managers. However, some researchers

to assignments outside the organizational have suggested that cultures can be used
mainstream such as business development by health care managers to mould quality
work, government or regulatory liaison or improvement behaviours and practices. It
participation in executive development has been found that organizational myths
programmes. In extreme situations where and stories (Martin and Powers, 1983), and
other approaches have been tried and core organizational symbols and rituals
proved unsuccessful, it may be necessary to (Tompkins and Cheney, 1985) can be used
either remove recalcitrant individuals from to manage conflict in organizations and can
the scene through transfer to another health reduce the transaction costs in structuring,
care organization or by outplacement. monitoring and rewarding behaviour
(Jones, 1983). These results suggest that
health care managers must be aware of the
Use cultural devices different cultures within their organization
and the reactions among these cultural
Resistance to change can also exist when
groups to the quality change process.
the health care quality change is seen to
Different cultural groups may require
be inconsistent with current cultural norms
different approaches in the planning,
(Reger, Mullane, Gustafson and DeMarie,
communication and implementation of
1994). Organizational growth, increasing
large-scale quality changes (see Narine and
professionalism (Van Maanen and Barley,
Einarson, 1991; Jick, 1993 for one
1985), high degrees of task differentiation,
possible approach).
significant technology (Martin, Sitkin and
Boehm, 1985), and mergers and acquisi-
tions (Walter, 1985) have all been identified Build stability
as supporting the establishment of sub-
cultures within health care organizations. There is a limit to the amount of
The underlying proposition of organiza- uncertainty which individuals and health
tional subcultures is that employees develop care organizations can withstand, after
these subcultures to differ from and which dysfunctional effects may occur,
potentially challenge the imposed which may include extreme defensive
management culture (Wuthnow and Witten, behaviour, panic and demoralization.
1988). Hence, while uncertainty can be a useful
impetus to making quality improvement
Recent studies have identified the
changes, to be effective, it needs to be
presence of organizational subcultures, with
tempered with elements of certainty and
divisions most likely among occupational,
permanence. Without sources of stability,
status, or divisional lines (Wuthnow and
whether in terms of structures, people or
Witten, 1988). Pettigrew (1992) suggested
physical space to provide an anchor in the
that the cultures of professional groups are
midst of turbulence, health care leaders
strong, resilient and outside the control of

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Health Care Quality: An International Perspective

may find it difficult to sustain support for unique individuals, organizational history or
the change process over time. the nature of the local market. Hence,
health care managers who are change
One early action step that can help to leaders need to tailor their quality improve-
deal with this potential problem would be ment efforts to meet the requirements of
to provide advance notice of the quality their specific situation. Their approach
change so people can psychologically should be diagnostic rather than prescrip-
prepare themselves for it. Another tactic is tive, as there are no cook-book recipes for
to preserve existing visible aspects of the health care quality transformation. How-
organization (e.g., organizational names) ever, health care managers can benefit from
that recipients of change have identified some general principles, which they can use
with in terms of what the health care to design the most effective quality
organization is and who they are within it. improvement change process for their
This, of course, is more difficult to manage organization.
in the case of re-orientation or re-tuning
Kilmann has summarized some of the
changes. Also, by merely being consistent
key leverage points that can impact on
in their statements and behaviours, quality
health care quality, and thus may be
change leaders can provide some measure
potential targets for change. These include
of assurance and stability. Change leaders
at-the-surface features such as the setting,
can alleviate the fear that everything is
the organization, the manager and group
changing by indicating in their statements
decisions and results, and deeper aspects
what specific things in the health care
at the heart of health care organizational
organization and specifically in the quality
life like its culture, assumptions and
management system will not be different
psyches. The relevance of these targets, in
after the change is complete. Even when
turn, depends on the type of quality change
this is not possible, change leaders can required. In their broad forms, types of
provide a source of balance to change changes can be either incremental or
recipients by articulating a vision of the discontinuous and within these there are
direction and aspirations of the quality sub-types depending on the extent to which
improvement programme, which is able to they are frame-bending or frame-breaking
capture the imagination of change such as tuning, adaptation, re-orientation
recipients. and re-creation. Irrespective of the type of
quality change, health care managers can
expect to encounter three universal issues
CONCLUSION to some degree - resistance, commitment
and power. To address these implemen-
While there are general patterns associated tation problems they will have to help
with health care quality change, each health motivate the health care quality change
care organization will have its peculiar process, manage the uncertainty of the
characteristics due to the presence of transition period, and shape the power and

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 Improving Health Care Quality: Strategies for Implementing Change

political dynamics arising from the change. 11. Kilmann RH, & Covin TJ (1988). Themes in
Corporate Transformation. In R. H. Kilmann & T.
Specific action steps that may be taken
J. Covin and Associates (Eds.), Corporate
within these areas have been discussed in Transformation: Revitalizing Organizations for a
this chapter and are summarized in Competitive World. San Francisco: Josey?Bass
Figure 3. Publishers.
12. Kilmann RH. (1989). Managing Beyond the
Quick Fix: A Completely Integrated Program for
Creating and Maintaining Organizational
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10. Keidel RW (1994). Rethinking Organizational 21. Pettigrew A, Ferlie E & McKee L (1992). Shaping
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SS. Mick and Associates (Eds.), Innovations in Additional Reading
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Publishers. 1. Barnette JE & Clendenen F (1996). The Quality
Journey in a Comprehensive Mental Health
25. Roitman, DB, Liker JK & Roskies, E (1988).
Center: A Case Study. Joint Commission Journal
Birthing A Factory Of The Future: When Is "All At
on Quality Improvement, 22(1): 8-17.
Once" Too Much? In RH Kilmann & TJ Covin and
Associates (Eds.), Corporate Transformation: 2. Coker M, Sharp J, Powell, H, Cinelli P, French M
Revitalizing Organizations for a Competitive & Colley-Ogden T (1997). Implementation of
World. San Francisco: Josey?Bass Publishers. Total Quality Management after Reconfiguration
of Services in a General Hospital Unit. Psychiatric
26. Salancik GR & Pfeffer J (1977). Who Gets Power
Services, 48(2): 231-236.
And How They Hold On To It: A Strategic
Contingency Model Of Power. Organizational 3. Omaswa, F, Burnham, G, Baingana, G,
Dynamics, Winter(5), 3?21. Mwebesa, H & Morrow, R (1997). Introducing
Quality Management into Primary Health
27. Shortell SM, Morrison EM & Robbins S (1985).
Services in Uganda. Bulletin of the World Health
Strategy-Making in Health Care Organizations:
Organization, 75(2); 155-161.
A Framework and Agenda for Research. Medical
Care Review, 42(2), 219?266. 4. Rouse, LW, Toprac, MG & MacCabe NA (1998).
The Development of a Statewide Continuous
28. Thompson L (1994). Mastering the Challenge of
Evaluation System for the Texas Children's Mental
Change: Strategies for Each Stage in Your
Health Plan: A Total Quality Management
Organization's Life Cycle. New York: American
Approach, Journal of Behavioral Health Services
Management Association.
& Research, 25(2): 194-207.
29. Tompkins P & Cheney G (1985). Communication
5. Sirchia G, Rebulla P, Lecchi, L, Mozzi F, Crepaldi
And Unobtrusive Control In Contemporary
R & Parravicini, A. (1998). Implementation of a
Organizations. In R. McPhee & P. Tompkins (Eds.),
Quality System (ISO 9000 series) for Placental
Organizational Communication: Traditional
Blood Banking. Journal of Hematotherapy, 7(1):
Themes And New Directions. Beverly Hills: Sage.
19-35.
30. Van Maanen J & Barley S (1985). Cultural
Organization: Fragments of a Theory. In P. Frost
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Beverly Hills: Sage.

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 8 8
Lessons in Sustaining Health Care Quality
A. F. Al-Assaf, MD, CQA

S
ustaining quality in health care is both challenges and new ideas; where
an art and a science. It requires consumers are satisfied with the product of
leadership skills to keep the care and service they receive or have a
momentum of improvements going and the "user-friendly" and accessible processes to
staff morale high, while trying to maximize resolve complaints and dissatisfaction. It is
positive impact and producing actual and the status that leads to eventual institu-
measurable improvements in processes and tionalization of health care quality in an
outcomes (Al-Assaf, 1994). It is a systematic organization or a system.
process of continuous employee involve-
ment, empowerment and teamwork. It is a In this chapter, the system of institu-
cultural transformation. tionalization of health care quality and the
process of sustainability has been presented
Sustaining health care quality means and explained. "Bullets" format will be used
that all the activities related to performance to present the different lessons and tips for
measurements and improvement become institutionalizing quality. The method of
spontaneous and perpetual. Individual presentation will be such that only practical
workers will have the individual responsi- introductory remarks are given on the
bility necessary to initiate process interven- proper methods of implementing health
tions and improvements without the need care quality in an effort to achieve a system
for the management to prompt him or her or a culture where quality is institutionalized.
to do that. It is a status where additional Remarks presented in this chapter are based
resources are not necessary to keep the on the actual experiences of the author
momentum of quality assurance, control, gathered from different health care quality
improvement and management strong and projects implemented nationally and
continuous. It is a status where change is internationally. Every effort has been made
not a challenge any more and individual to ensure applicability of these remarks and
workers are willing to take on new practice tips to international audiences.

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Health Care Quality: An International Perspective

Institutionalization as a system is responsibility of a department or another

achieved only after the process of full individual. In such a culture each individual
implementation of quality has been is responsible for his/her tasks. Individuals
completed in a health care organization. will then own their quality structure,
Since it is a system, it must be built gradually processes and outcomes. At such a stage,
and at the same time as the processes of employees will be making every effort to
implementation are taking place and make sure that the processes of QA are
planning activities and improvement maintained, i.e. planning, standard setting
strategies are being developed and applied. and monitoring. In such a culture,
After full implementation of health care employees are also practising QI, i.e. they
quality in an organization has been identify opportunities for improvements and
achieved, the next expected milestone is an set the motion individually or in collabora-
established "quality culture". Total health tion with others to make improvements. It
care quality, coupled with a quality culture, is also a situation in which employees are
is a status of institutionalization of health empowered to achieve their goals which
care quality. In a system where there is are, in turn, aligned with the organization's
quality assurance (QA), monitoring, quality mission and vision statements. A quality
improvement (QI) and quality management culture is therefore achieved when indivi-
(QM), institutionalization becomes eminent. duals carry on "quality"-related activities on
Therefore, institutionalization is achieved a routine basis and that working in teams
when appropriate health care quality becomes a norm in that organization.
activities are carried out effectively,
efficiently and on a routine basis throughout
a system or organization (Brown, 1995). It LESSONS IN SUSTAINABILITY
is a state of achievement whereby health
care quality is practised and maintained The following are lessons learned in
without additional outside resources. In implementing health care quality in health
such a state, expertise is available from care institutions. These lessons, if learned
within and commitment is fully integrated well and applied effectively, may lead an
and maintained. organization to a system of institutiona-
lization of health care quality. The applica-
A quality environment or culture is
bility of each lesson listed here may vary
achieved when quality activities become a
from one organization to another, but
matter of routine and happen on a daily
generalization has been intended.
basis. Such activities are not separate from
the normal activities that are carried out • Effectively plan for the change.
daily by the system and its personnel. It is Introducing new concepts and
a state where each employee is aware of ideas may cause a change or at
the health care quality concept, believes in least a fear of change; therefore,
it, practises its principles and makes it a part every effort should be made to plan
of his/her responsibility and not the for this change adequately, effec-

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 Lessons in Sustaining Healthcare Quality

tively and in a timely manner. The method on how to achieve this

change process is dramatic. It objective is to conduct a strategic
could be a change from no or little planning workshop and invite all
quality to a complete system of key personnel to attend. This
standards-setting, compliance workshop should be held as early
measurements, process improve- as possible in the change process.
ments, etc. Therefore, planning for Also, all resolutions and decisions
this change is very important and made at the workshop should be
extremely necessary before actual documented and further distributed
implementation takes place. to all parties involved. A ground
rule should be reached that if any
• Planning for quality should be done
change in these decisions is desired
systematically and thoroughly.
in the future, a strict guideline for
Delineation of responsibility,
systematic group decision must be
identification of the scope of
established and adhered to before
involvement, the allocation of
making any amendments. This
resources, and the anticipation for
practice will avert (at least mini-
the impact of the change on
mize) frequent amendments that
organizational behaviour should
potentially may take place in the
be completed before the other
likely event of changes in personnel
activities in QA or QI are begun.
or minds.
Also, include as many key indivi-
duals in the planning process as • Discuss strategies for implemen-
possible and always get the written tation. Methods for implementing
approval of the top administrator. the change need to be discussed
thoroughly and explicitly with the
• Priorities need to be set early in the
key individuals in the organization
process with true buy-ins from the
and these individuals must under-
key personnel of the organization.
stand them very clearly. Answers to
Priorities, of course, should be set
the how, when, who, what and
by these individuals from within the
where should be available early
organization and not by their
and before the implementation
consultants. Therefore, a team of
starts. All decisions should be
key personnel that will be impacted
documented in writing and agreed
by the change need to discuss,
upon by all sides. Here, a widely
brainstorm, and identify priorities
used management tool such as a
in the change process. Certainly,
Gant chart or development of a
priorities should be realistic,
work plan with times, tasks to be
feasible, have a high probability of
accomplished and responsible
accomplishment and have the most
party may prove to be extremely
impact on the bottomline. One
helpful in meeting the objectives of

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Health Care Quality: An International Perspective

specificity and accountability of the intended audience internally and

implementation process. externally and should be displayed
publicly as a constant reminder to
• Securing commitment from the
the staff regarding their duties and
management is helpful and can
customers' expectations, for
make the process of implementa-
achievement.
tion move rapidly. The involvement
of top managers in the early stages • Identifying a local leader or
of planning is essential. Commit- champion(s) to lead this movement
ment here means active participa- is highly recommended. A qualified
tion in teams and tasks as well as individual with authority, credibility,
allocation of adequate resources enthusiasm and interest can be an
for quality. It involves behavioural asset in the acceleration of health
change to act as role-models for care quality sustainability and its
the rest of the organization to institutionalization. This individual
follow and take lead. Make sure can act as a facilitator and cheer
that the commitment is genuine leader for health care quality
and sincere, as oral rhetoric alone initiatives. In several health care
is not sufficient to sustain and organizations, this individual has
institutionalize quality in an been traditionally a nurse with
organization. some background in utilization and
case management. However, on
• Develop a mission statement for
the international scene a physician
quality early in the process. A
is usually more appropriate. With
mission statement that is well
the right qualifications persons
prepared and developed in colla-
trained in other disciplines can also
boration with senior staff will have
be as good in leading the health
a higher chance of survival even
care quality process.
with any amount of turnover of
managers and staff. Mission state- • Consider the adoption of certain
ments should answer questions standards that have been promul-
about the purpose of the organiza- gated by specific international
tion, specific objectives of the organizations or agencies such as
organization in quality, scope of the World Health Organization.
interventions, and the customers of These standards are usually well-
the process of quality. This mission written and are valid. Also, stan-
statement must coincide with the dards are the basis for quality
organization-wide mission state- assurance activities and subse-
ment. Also, once developed, quently improvement activities. A
mission statements should be good quality system (structure,
communicated effectively to the processes and outcomes) with

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 Lessons in Sustaining Healthcare Quality

good standards for each of its structures of committees and

components is a foundation for a councils early on may shift the
sustainable quality system which, in focus on organization per se and
turn, is conducive to away from the actual mission of
institutionalization. health care quality. The focus
should always be primarily on
• Organization of a steering
incremental and continuous
committee or council of national
improvement and then on structure
representatives would give the
as a foundation for such improve-
health care quality process credi-
ment. Also, adding structure may
bility, sustainability and
require additional resources that
momentum. A document on the
may not be necessary at the early
tasks and duties of the council or
stages of implementation.
committee should be prepared and
agreed upon by all parties • Identify the customer of the organi-
involved, while all members should zation and the audience of the
have a copy of this document and system. An attempt should always
understand it as their charter. It be made to identify the customer(s)
should not be changed without the of both the organization and the
explicit consent of all parties health care quality process, but this
involved. The committee's meeting activity should be undertaken early
times and schedule (at least once in the process. Answers should be
every month) should be adhered to identified to such questions as: Who
and a regular place for their is the customer of the quality
meeting should be assigned during process? What are their expecta-
a convenient hour (meetings tions? And how to meet those
should not last more than two expectations? These customers and
hours). This group will be respon- their expectations need to be
sible for approving implementation identified and every effort should be
strategies, intervention activities, made to continuously meet these
dissemination materials, etc. This expectations. Managed care plans
committee is extremely important should take this issue seriously and
for the sustainability of the start surveying and communicating
implementation process. with their members periodically and
frequently. In this way, members'
• Forming the structure for health
needs and expectations can be
care quality should be gradual and
identified, defined and addressed by
methodical. It should be based on
the appropriate personnel.
the progress and understanding of
the concept and practice of health • Staff at the beginning of implemen-
care quality. Organizing large tation should concentrate more on

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Health Care Quality: An International Perspective

learning and understanding the occurs, which, in turn, leads to

concept and principles of health more training thus more dissemi-
care quality and practise it daily to nation will take place. And that is
achieve positive results. Too many how you sustain a system of
committees with too many meet- profound knowledge and practice.
ings, and too many tasks distract
• Always have an alternative plan in
from focusing on expected goals.
case one is slowed down due to
An important principle of health
staff changes. Making a habit of
care quality is to design activities
not relying on one single individual
as outcome-driven but process-
is helpful when trying to implement
focused. Thus, improvements are
health care quality effectively. Train
targeted and always measured to
a number of individuals and
identify impact.
prepare several qualified staff
• Plan and provide appropriate and simultaneously. This practice will
on-time staff training. As Deming allow for a wider selection of
(1985) suggested, training should coordinators, and will enhance
be on-job and as needed. It sustainability efforts. Flexibility is
should, however, be done in a expected and desired in change
formal and systematic manner processes and is a sign of cultural
where an effective training plan has maturity.
been developed that includes such
• Keep quality activities closely
issues as type of trainers, type of
related to the organization's main
courses, content areas, to whom,
activities and its mission without
by whom, where, what resources,
unnecessary changes in the organi-
etc. Every lecture given, every
zational structure and allocation of
workshop delivered, and every
additional resources. At least at the
meeting conducted should have,
beginning of implementation,
as one of its objectives, the
health care quality activities may be
capability of enabling the partici-
delegated to an existing staff
pants to duplicate the effort and
member or department as part of
pass it on to others. Training in
their normal responsibility.
quality methods must be stressed
because as you train people you • Prepare for answering questions
increase their awareness, and as related to the incentives for attrac-
you help them perform the tasks ting staff to participate in health
learned in the training you solidify care quality activities. Staff will start
their learning. Therefore, train asking such questions as "What's
people to make them trainers. As in it for me?" or "Why should I do
more trainers develop, more this?". As long as health care
dissemination of health care quality quality activities are not required as

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 Lessons in Sustaining Healthcare Quality

an integral part of their job perfor- authorship of articles in the local

mance, employees will question newsletter. All or some of these
their role in participating in these incentives could be instituted in an
activities. Quality expectations and organization to stimulate employee
measurement indicators should be participation and involvement.
written down in these activities as
• Document improvements by
part of their performance evalua-
measuring pre- and post-status.
tion and job descriptions. A system
Always have quantitative data
of employee rewards and recogni-
available for comparisons and for
tion based on health care quality
the measurement of the effective-
achievements may be necessary.
ness. It is also useful if cost savings
Therefore, a recognition and
are calculated to measure effi-
reward system for people working
ciency. These indicators are
towards quality outcomes should
especially attractive to adminis-
be designed and instituted by the
trators. Providing measurable
organization early in the process.
parameters gives credibility and
This should also include an incen-
sustainability to the process of
tives system that encourages
health care quality.
people to be involved in QA/QI
activities. As mentioned earlier, • Therefore, identify tangible out-
answers and mechanisms to these comes. In several projects, it was
questions could not be found. found that if the final product did
not have tangible outcomes, it was
• The issue of incentives is a sensitive
taken to mean that nothing had
one with differing ideas about the
been accomplished. Therefore,
how and what of the incentive
always make sure to identify and
issue. Incentives, however, need not
look for tangible outcomes early in
be monetary in nature. Actually,
the game or at least make it as a
monetary incentives are the least
by-product of the change process.
effective to make an impact, but
Numbers before and after, dollars
the presence of some incentives will
saved, measurable outcomes,
be helpful to the sustainability of
results achieved are all examples
health care quality. There have
of tangibles. These types of tangi-
been several examples of recogni-
bles should be kept in mind during
zing deserving individuals such as
the writing of the work plan and
recognizing teams with plaques,
certainly during the course of the
newsletter announcements, letters
project.
of gratitude from the organization's
CEO, certificates of excellence • Actively disseminate achievements
given to deserving individuals by a and health care quality awareness
special committee, as well as information to as many individuals

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Health Care Quality: An International Perspective

in the system as possible. Make vention, you should also answer

sure that participation is voluntary the "So what?" to that improvement
and is open to anyone and every- outcome. Will this "improvement"
one as opportunities for improve- intervention make an impact?
ment are identified. Do not make
• Disseminate ideas, standards,
it a "private club". Keep everybody
improvements and results. In
informed and involved. Quality is
dissemination, an active method of
everyone's responsibility and it is
communication should be
based on individual responsibility.
followed, i.e. dissemination is not
Therefore, if everyone becomes
writing a standard or a guideline
involved in improvement activities
and copying it to all concerned.
and in the documentation of
This is passive communication. To
outcomes, institutionalization can
make the communication effort
be achieved easier and faster.
more effective, active communica-
Improvements do not have to be
tion efforts should be targeted, like
big as long as these are
focus group meetings, con-
continuous.
ferences, newsletters, workshops,
• Although you may want to involve direct personal contacts, etc.
as many people as possible in Therefore, as dissemination is
health care initiatives, caution contemplated, one should consider
should be exercised in involving what needs to be disseminated, the
everybody in projects that may methods to be used, the desired
detract from the main mission of target population, the perceived
the health care organization, which impact, the resources available,
is providing health care. Therefore, and the cost-effectiveness of the
resist the temptation of involving activity.
too many departments and units in
• Use of consultants and the identifi-
too many projects simultaneously
cation of their roles may be
and early. Building an effective
considered. The organization
process in one area is more
should ask, "What is the objective?
important that starting several
Is the consultant the change agent,
incomplete processes in different
or is he/she/they the implementor
areas. Keep the implementation
of the plan? What are the objec-
process focused and desirable.
tives of identifying and working with
Provide an answer to the question
a consultant? Does the consultant
"So what?" to every improvement
agree with the purpose?" Weigh the
intervention strategy you are
options of full-time short-term
planning to take, i.e. if you think
consultant with that of periodic
you are going to make improve-
long-term consultant. The role of
ment by making a specific inter-

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 Lessons in Sustaining Healthcare Quality

the consultant can change from a care quality, especially on the

starting role as an organizer, a international scene. On several
convenor, a trainer, an expert, and other occasions organizations fall
an initiator to a coach, adviser, and in the trap of agreeing to hire a
a strategizer very quickly. Certainly, qualified "large" consulting firm.
this is a good sign and an ideal Soon after that the organization
path for the consultant to be at as becomes a field of experiment for
long as the momentum of the the newly-hired and somewhat
implementation process is kept at inexperienced "consultants" this firm
a high level. Still, however, it is has on its staff. Therefore, it
found that although dependence behoves the organization to check
on the consultant diminishes soon and double check the qualifica-
after the start of the process, it tions of each individual staff of the
never ceases. consulting firm that will be given
permission to participate in the
• Consultants, on the other hand,
implementation process.
should position themselves as early
in the process as possible to act • Always keep adequate funding
as advisers and mentors and move available for the development of
away from the temptation of new projects and activities not
participating in each activity. originally planned for. This will also
Another issue related to consultants give you the flexibility of shifting
is credibility. Both qualifications additional funds to needed areas
and experience are needed to earn where improvements are taking
individual credibility by the host. place more effectively. Adequate
This is especially important for funds will increase the likelihood of
technical assistance and training sustainability.
capabilities. Consultants should be
• Finally, encourage and foster an
adequately prepared and have the
environment of learning not judge-
experience to make appropriate
ment. In particular, rely on data
decisions and act on them effi-
and facts in making judgements.
ciently. Besides scientific know-
Avoid the antiquated disciplinary
ledge, the desired qualifications of
method of management. Here
consulting staff should include
again, Dr Deming (1985) suggests
interpersonal skills, sound judge-
in his 14 points of management to
ment, organization skills, and crisis
"drive out fear" from the organiza-
management capabilities. In
tion. Drive out the fear of creativity,
several situations, any or all of
the fear of speaking up, the fear
these characteristics proved highly
of correcting processes that do not
essential for consultants to be able
work, and the fear of improvement.
to operate in the field of health

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Health Care Quality: An International Perspective

Organizations that agree to References

provide an environment of learning
rather than judgement will always 1. Al-Assaf AF and Schmele JA. The Textbook of
Total Quality in Health care, St. Lucie Press,
succeed in achieving its quality Delray, FL, 1993.
goals faster and more efficiently. 2. Al-Assaf AF. "Quality Improvement in Health care:
An Overview", Journal of the Royal Medical
Institutionalizing health care quality is Services, 1(2): 44-50, 1994.
the ultimate goal of the process. The road 3. Al-Assaf AF. Managed Care Quality: A Practical
towards it is usually long and full of Guide. Boca Raton, Fl. : CRC Press, 1998.
obstacles. The objective, however, is to plan 4. Al-Assaf AF. "Health Care Quality: An
for it properly and to move slowly but International Perspectives", Journal for Health
gradually towards full implementation and Care Quality, 21(1), 1999.

sustainability. Institutionalization requires 5. Brown L DiPrete. "Lessons Learned in

Institutionalization of Quality Assurance
time, appropriate staff, adequate resources Programs: An International Perspective",
and an abundance of patience. International Journal of Quality in Health Care,
7(4): 419-425, 1995.
6. Deming WE. Out of the Crisis, MIT Press, Mass
1985.

Page 142
 9 9
Cost of Improving the Quality of Health Care
Robert W. Broyles, Ph.D

OBJECTIVES able outcomes, TQM requires the health

service organization to: (1) establish specific

T
he control of health care costs while quality goals; (2) incorporate the improve-
maintaining or improving quality is a ment of quality as a responsibility shared
seemingly intractable problem and an by all employees; (3) educate and train
illusive policy objective. Traditional wisdom employees; (4) formally recognize efforts to
suggests that as the quality of care is improve quality; (5) identify specific projects
improved, spending on health services that promise to improve quality; (6) provide
grows. In contrast to the traditional view, necessary resources, both real and
however, Total Quality Management (TQM) financial; (7) regard employees as not only
and related Continuous Quality Improve- a provider but also a user of the services
ment (CQI), are managerial philosophies or results produced by antecedent events
that are predicated on the general pre- in the process of rendering an episode or
sumption that better quality is less expensive regimen of care; and (8) focus continuously
(Arikian, 1991). As summarized by Suver, on methods of improving the quality of care
Neumann and Boles (1992), TQM and (Slee and Slee, 1991; Gillem, 1988 ).
CQI may enable health service organiza- In short, the primary objective of TQM
tions to avoid the costs of poor quality, is not only to focus on the needs of the
improve fiscal performance and reduce consumer, a concept that includes
systemic expenditures on health care. employees and patients but, also to lower
costs by improving quality and reducing
The approach to quality management
waste (McLaughlin and Kaluzny, 1994).
is predicated on the notion that the poor
design of procedures or processes, rather This chapter has three objectives.
than the performance of employees, Adopting the approach suggested by
produces sub-optimal care and results in Simpson and Muthler (1987) and by Hagan
unnecessary costs. To avoid these undesir- (1986), the first is to summarize a topology

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Health Care Quality: An International Perspective

that describes the costs of TQM and CQI. development of a system to monitor,
The second is to present a method of evaluate and control quality, but also the
estimating the expenses of implementing planning, design and implementation of an
programmes to improve quality, and the third administrative infrastructure that forms the
is to describe approaches that might be used foundation for TQM. When viewed from
to assemble the information that is required an operational perspective, activities such
to estimate each component of the cost as the education of employees and the
taxonomy. When viewed from the joint maintenance or calibration of equipment
perspective of the health service organization represent a stream of prevention costs.
and the health delivery system, the chapter
concludes with a discussion of assessing the The second category of costs are those
financial impact of TQM and CQI. that are traced to the appraisal of the
quality of service or a process related to
the provision of care. Accordingly, appraisal
costs are retrospective in nature and are
TOPOLOGY OF COSTS incurred after service has been delivered or
a related process has been completed. As
As is well known, the development of
such, appraisal costs are attributable to a
instruments that measure quality with
wide range of desperate activities to include
precision is a difficult, if not impossible,
an assessment of purchased items, evalua-
problem. Although quality is frequently
ting vendors, auditing the services or
characterized as excellent, good, fair or
processes of health care delivery and
poor, the costs assigned to activities or
documenting the services provided or
projects that are designed to improve
processes used by the health service
quality can be measured with relative
organization. Also included in the set of
accuracy. As described by Simpson and
appraisal costs are expenses related to the
Muthler (1987) and by Hagan (1986), the
assessment of billing systems or medical
costs that are related to quality might be
records and evaluations performed by the
assigned to one of three categories, namely,
utilization review committee or external
the expenses associated with failures,
auditors such as professional review
prevention, and appraisal.
organizations.
As the name of the category implies,
The third set of costs are related to
prevention costs are expenses that are
failures in the delivery system and consist
attributable to any process that is designed
of two components. The first of the two
to avoid errors, such as the misuse of
components consists of expenses that result
service, or to improve the quality of the
from an internal failure, a term that is
process by which care is delivered. As such,
reserved for situations in which corrections
prevention costs are incurred prior to the
are required prior to the delivery of health
delivery of service and include not only the
care to the patient or the use of the
identification of the client's needs and the
procedure by another provider. Internal

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 Cost of Improving the Quality of Healthcare

failures and related costs frequently occur of failure costs are related, indirectly, to the
during the process of delivering care. For provision of sub-optimal care or a defective
example, it is possible that a defective service. Contingent on diagnostic nomen-
laboratory test may prevent definitive clature, adjusted for case severity, a
diagnosis, implying that the procedure must premature or delayed discharge might
be repeated in order to obtain results that expose the patient to additional health risks
are useful to the physician. Similarly, system or result in an adverse health outcome that
delays resulting from equipment failure may precipitates malpractice litigation or a
require the health service organization to deterioration in the reputation of the health
postpone the delivery of service. In such a service organization. An inappropriate
situation, the health service organization surgical procedure or one that is performed
may incur an opportunity cost in the form poorly might contribute to the set of external
of foregone revenue or extend operating failure costs. Similarly, an incorrect
hours in order to reschedule the proce- diagnosis resulting from an undetected
dures, an outcome that may result in higher defect in a laboratory test, may contribute
overtime costs. As suggested by these to an inappropriate regimen of care and
examples, an internal failure results in the provision of a mix of service that results
added expenses that are attributable to: in pain, suffering or perhaps even the death
(1) the identification of defective proce- of the patient. These observations suggest
dures; (2) the provision of additional that the organization's reputation and long-
services that are required to correct an initial term viability in competitive markets may
error or a defective procedure; (3) the depend on avoiding the set of external
unnecessary use of related resources; and failure costs.
(4) in the case of system delays, an increase
in unplanned idle capacity and associated Although the three cost structures are
foregone revenue. separate, prevention, appraisal and failure
costs are highly interrelated. A simple view
The second component of failure costs of the interrelation among the three
refers to the expenses that occur during or components is illustrated in Figure 1.
after the delivery of service to the patient. Consistent with the topology of costs, the
The external failure costs frequently are figure assumes that the TQM process is
caused by: (1) the provision of additional initiated with an evaluation or appraisal that
procedures to correct defective services focuses on differences between quality
returned to the unit by other providers; (2) goals and actual performance. Based on
patient dissatisfaction and the need to the evaluation, undesirable differences
respond to complaints; (3) a deterioration between performance and quality objectives
in the organization's reputation; (4) the might be identified, an outcome that
potential exodus of physicians and related enables the organization to focus on areas
decline in patient volume; (5) a decline in or processes that might benefit from the
patient revenues; and (6) higher premiums implementation of preventive programmes.
for malpractice insurance. As such, the set When combined with an evaluation of

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Health Care Quality: An International Perspective

Figure 1. The interrelation of appraisal, prevention

and failure costs

Identification of areas
Appraisal
requiring preventive
programmes

Report
results Evaluation of
Internal quality costs
failure costs and results

Evaluation of
quality costs and External
results failure costs

quality, the development and implemen- expenses, to include the opportunity costs
tation of preventive programmes are of foregone patient revenue, exceed the
expected to improve quality and lower not increment in spending on prevention and
only failure rates and the number of appraisal. A simple extension implies that
defective services but also failure costs. TQM and CQI result in a net financial
benefit if the savings produced by lower
As indicated by Figure 1, the prevention failure rates exceed the additional costs of
and appraisal costs typically are regarded appraisal and prevention.
as expenses of operating an internal control
system, implying that the costs of prevention
and evaluation are inversely related to ESTIMATION OF COSTS
failure costs. In particular, as additional
resources are diverted to prevention and As described by Stiles and Mick (1997),
related expenses increase, internal and conventional accounting systems fail to
external failures should decline, an measure the costs of the transactions or
outcome that lowers failure costs. Further, activities that comprise a process, such as
as the rate of internal and external failures quality management or the provision of
declines, the health service organization service. As a consequence, traditional
might reduce the complement of resources methods of accounting fail to generate data
committed to the evaluation or appraisal that depict the expenses that are caused by
of quality. Viewed from a purely financial providing service or completing a process.
perspective, the health service organization As an alternative, Stiles and Mick (1997a)
should continue to improve quality if the and Horngren and Foster (1991) contend
savings that result from lower failure that a reliance on Activity-Based Costing

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 Cost of Improving the Quality of Healthcare

(ABC) and a focus on the set of the each of the activities that comprise the
transactions that comprise the process of process.
health care delivery enable the health
service organization to identify the activities As indicated, the accurate definition of
that precipitate the use of resources and activities or cost drivers is essential to the
the appropriate recognition of related development of an accurate estimate of
expense. In ABC, the set of activities or cost appraisal, prevention and failures. In
drivers form the foundation for assembling general, the set of activities or cost drivers
the costs of appraisal, prevention and might be large or small, an outcome that
failures, both internal and external. Each is influenced by the nature of the cost
component of the topology developed in objective and the environment in which the
the previous section consists of a set of process or procedure is performed. For
activities or transactions. In turn, the example, the number and complexity of
activities are regarded as a cost objective required activities are influenced by the
or a "cost driver". A cost objective is any resources that are used, to include the
unit, item or phenomenon for which costs capital complement and the mix of
are assembled and analyzed separately employees, the number of set-ups that are
while a cost driver is any activity that causes required, the number of steps or functions
the health service organization to incur a that must be performed, the number of
cost. vendors, and the need to transport
materials. As might be expected, costs
Accordingly, the objective of this section usually increase as the number of transac-
is to develop a method for estimating the tions or activities associated with a
costs of each activity associated with procedure or process grows.
prevention, appraisal, internal failures and
external failures. The cost of each compo- Activities also might be separated into
nent is the sum of the expenses assigned two components. As described by Suver,
to the activities or cost objectives that Neumann and Boles (1992) , activities such
comprise the component. For example, the as the movement of patients or materials
appraisal function might be defined in terms from one location to another, idle time
of performing a utilization review. In turn, caused by equipment failure or inefficient
the utilization review process is comprised scheduling and clerical functions contribute
of a set of activities such as selecting little, if any, value to the care process.
records, preparing records for review, Hence, an implicit objective of identifying
review of the records by members of the and assessing the set of activities associated
utilization review committee, and preparing with a procedure or process is to reduce
a final report depicting the findings of the or eliminate those activities that contribute
committee. Each of the activities consumes little or no value.
resources and results in a cost; the cost of In this section, the principles of ABC,
performing a utilization review, then, is as described by Chan (1993), a variant of
simply the sum of the expenses assigned to

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Health Care Quality: An International Perspective

the format suggested by Daigh (1991), a records is the responsibility of a clerk while
set of hypothetical data and an Excel the preparation of selected records is
spreadsheet are used to illustrate a model performed by a medical record technician.
that estimates the costs associated with
quality management. Consistent with As indicated in the exhibit, the magni-
Figure 1, appraisal costs are estimated first, tude of cost assigned to the review process
followed by the costs of prevention and depends on the number of discharges (i.e.
failure (Annexure). number of records available for review), the
selection rate, a factor that influences the
number of records selected for review, the
APPRAISAL COSTS average time, in hours, required to select,
prepare and review the record, the amount
As indicated, appraisal costs represent the of compensation per hour and related
resources that are consumed to ensure that supply expenses. In the illustration, it is
the delivery process satisfies the needs of assumed that 5,000 records are available
consumers, defined in terms of both for review and that the percentage of
providers and patients. When viewed from discharges grouped by medical specialties
the perspective of the patient, a primary represented by physicians A, B, C, D and E
focus of quality management is on an is 10, 20, 40, 15 and 15 respectively.
evaluation of the mix of care, contingent Further, the distribution of discharges and
on diagnosis and case severity. In most the decision to select a 20 per cent sample,
health service organizations, the function by specialty, produced the distribution
of assessing the quality of care is the described in the fourth column of Exhibit
responsibility of the utilization review 1.A. The results suggest that 1,000 records
committee. were selected for evaluation and that, for
example, physician A reviewed 100 records
A method of estimating the annual while physician B reviewed 200 records.
costs of performing utilization review is Grouped by category of employee, the
shown in Exhibit 1.A. To simplify the amount of time per record that was required
illustration, the review process has been to complete each activity is listed in the
reduced to essentially four activities: (1) the column identified by the heading "Time Per
selection of records;(2) the preparation of Record". In this case, the selection of the
records for review; (3) the assessment of typical record required 0.25 of an hour, or
records by members of the utilization review 15 minutes, while the preparation of the
committee, and (4) the preparation of a typical record required 0.5 of an hour or
final report describing the conclusions and 30 minutes. Note that the product of the
recommendations of the committee. time required to process the typical record
Further, the illustration assumes that the and the number selected, prepared or
committee consists of five physicians, each reviewed represents the labour hours
of whom represents a separate medical committed to the review process. Shown in
specialty, and that the selection of medical the column identified as the "Cost per Hour"

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 Cost of Improving the Quality of Healthcare

is the rate of compensation for each rate and the number of units received. In
category of employee. In this chapter, the the example, 500 units of item S1 were
hourly rate of pay is given by the ratio of selected for inspection prior to their use,
annual pay to the annual number of paid an outcome given by the number received,
hours, represented by the product of 40 10,000, and the selection rate of 5 per
hours per week and 52 weeks per year. The cent. The total costs of inspection, shown
product of the amount of time per record, in the last column of the exhibit, are
the number of records and the amount of obtained by the product of: (1) the number
compensation per hour yields the cost of of units inspected; (2) the time required to
the employees involved in the utilization inspect the typical unit, by category of
review. As shown in the column identified supply, and (3) the labour cost per hour.
by the heading "Labour Cost", the labour As indicated, the model estimates that the
costs of selecting and preparing records for total cost of evaluating supply items
review amounted to $8,000 while the time received by the laboratory amounted to
committed by physician A in the review of $3,290.
100 records cost approximately $721.
Further, when the assumed supply expense In addition to the dimensions described
of $125 is combined with labour costs of previously, the philosophical foundation of
$28,558.89, the results indicate that the TQM suggests that other providers in the
cost of the review process amounted to process of health care delivery are users of
$28,683. laboratory services and results. Accordingly,
prior to reporting results to other providers,
As presented in Exhibit 1.A, the focus the health service organization should
of the evaluation is on the patient and the adopt a policy of appraising the perfor-
mix of service provided during the episode mance of the laboratory and other similar
of care. However, as indicated previously, units. In Exhibit 1.C, it is assumed that the
the adoption of TQM requires the health laboratory is responsible for providing six
service organization to view the provider as services, represented by the set LAB1 , ...,
the user of both services and supplies. LAB6. Shown in the column identified by the
Shown in Exhibit 1.B is a spreadsheet that descriptor "Total Volume" are the number
calculates the costs of inspecting supplies of units of each service provided during the
received by the laboratory and ensuring that period while the values appearing in the
items received by the unit are without column identified as the "Selection Rate"
defects prior to their use. In this case, the indicate the proportion of each service that
focus of the appraisal is on the units was selected for evaluation. As before, the
received from Central Supply during the number of units inspected is simply the
period. As noted in the exhibit, the product of the number of units and the
illustration is limited to four supply items, selection rate. When combined with the
S1, S2 , S3, and S4 . Similar to the inspection time per unit, measured in hours,
discussion of Exhibit 1.A, the number of and the labour cost per hour, the number
units inspected is a product of the selection of units selected for evaluation form the

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Health Care Quality: An International Perspective

basis for estimating appraisal costs. In each step, it is likely that supplies and the
Focusing on laboratory service LAB1, the services of labour are consumed, resulting
calculations indicate that the annual in an additional set of appraisal costs.
inspection of 1,400 units required a total
of 72 staff hours. When combined with a
rate of compensation amounting to $18 PREVENTION COSTS
per hour, inspection costs of $2,100 were
incurred by the organization. As indicated in the discussion of Figure 1,
the costs of prevention are incurred prior
Also included in Exhibit 1.C is a
to the provision of service and result from
summary of the annual defective rate and
functions or activities designed to avoid
the number of defective services discovered
sub-optimal performance. Employee
during the evaluation process. As indicated,
training and the calibration of equipment
the summary suggests that, prior to
are among the most obvious of the
reporting results to other providers in the
preventive activities. Similar to the discus-
organization, the laboratory identified a
sion of the previous section, the costs of
total of 1,413 defective procedures.
preventive activities are related to the
Accordingly, the policy of correcting
intensity of their application and the
defective results prior to their use in
complexity of related tasks.
evaluating the patient's condition may
enable the health service organization to Presented in Exhibit 2.A is a method
avoid errors in diagnosis or the prescription of calculating the costs of employee
of the therapeutic course of treatment. training. In this case, it is assumed that the
employee is compensated for 52 weeks
In addition to the dimensions outlined
per year and 40 hours per week, resulting
in the exhibits, the health service organiza-
in a total of 2080 hours. The labour cost
tion should perform an internal evaluation
per hour is obtained by the ratio of the
of the complement of resources. As
employee's annual salary to the total
described by Duncan, Ginter and Swayne
number of paid hours. If the employee is
(1996), the internal environment of the
entitled to a paid vacation of two weeks
organization might be described in terms of
or 80 hours, a total of 2000 hours are
functions such as administration, finance,
scheduled for market activity. As noted in
clinical and marketing. The focus of the
the exhibit, labour costs are derived
evaluation should be on the adequacy of
separately for instructors and trainees. For
staff, the internal information flow, the
example, employee A devoted 8 per cent
technical capabilities of the organization,
of the scheduled 2,000 hours of market
and synergy. To simplify, the internal
activity (i.e. 160 hours) to the preparation
evaluation consists of several activities such
and delivery of instructional programmes.
as preparation of the survey instrument, the
The amount of cost assigned to employee
administration of the instrument, preparation
training is related to the frequency or
of data, analysis of results and evaluation.

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 Cost of Improving the Quality of Healthcare

complexity of instructional activities, as costs shown in the exhibit are obtained by

measured by the percentage of time the product of the supply expenses per
devoted by each employee to training, and adjustment and the annual number of
the hourly rate of compensation. When calibrations that were introduced initially in
combined with the employee's hourly rate Exhibit 2.B. Accordingly, an increased
of compensation, the results indicate that emphasis on prevention, as indicated by the
the costs of committing the individual to implementation of a policy to adjust
training others employed by the health equipment more frequently, results in higher
service organization amounted to related costs and is expected to lower failure
approximately $3,000. Further, as rates, a consideration that is evaluated in
indicated by the spreadsheet analysis, the the next section.
total cost of employee training (i.e
$19,183.65) is simply the sum of total
labour costs and related supply expenses. FAILURE COSTS
When viewed from the perspective of
TQM, the maintenance of equipment is a As indicated by the discussion of Figure 1,
prerequisite to improving quality and programmes that improve evaluation and
reducing failure rates. Shown in Exhibit 2.B prevention are expected to reduce the
are the basic data that are required to failure rate, the number of defective services
estimate the costs of calibrating the or procedures and thereby reduce failure
equipment used in the laboratory depart- costs. The costs of int ernal failures are
ment. As indicated, the illustration assumes directly related to the appraisal of services
prior to their use by other providers in the
that the laboratory uses eight items of
sequence of delivering health services. The
equipment that differ in terms of the number
discussion of Exhibit 1.C was based on the
of adjustments required annually and the
assumption that, prior to reporting the
amount of time needed on each occasion
results of laboratory procedures to other
the items are calibrated. Further, if the rate
providers, the process of inspecting a
of pay grows with the skills required of
sample of the procedures provided by the
maintenance personnel, variation in the
laboratory enabled the director of the unit
complexity of calibrating equipment is
to identify defective services or results.
reflected by differences in the amount of
Hence, the principles of TQM require the
labour cost per hour. As indicated, the
unit to correct errors prior to reporting
product of time per adjustment and the
results to the physician or other health
annual frequency of calibrating each item
professional, thereby avoiding external
yields the annual number of hours devoted
failures, additional production costs and,
to maintenance. The product of the labour
occasionally, the need to collect a second
cost per hour and the total number of hours
specimen from the patient. This section
devoted to calibration enables the health
examines a method of estimating the
service organization to estimate total labour
additional production costs; those related
costs, as shown in Exhibit 2.C. The supply

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Health Care Quality: An International Perspective

to the collection of a second specimen are for a TECH1 is 0.05 of an hour. The related
considered in the next. labour cost per service of $0.75 is the
product of 0.05 of an hour and $15 per
Recall from the discussion of Exhibit hour, the rate of compensation of the
1.C that a total of 1,413 defective services individual occupying this position. The
were detected by the internal evaluation labour cost per procedure, grouped by
performed by the laboratory. Prior to category of service, is obtained by summing
reporting laboratory results to the physician the set of costs per procedure classified by
or another provider, it is assumed that these occupational category. Hence, the labour
procedures were corrected, resulting in costs per unit of procedure LAB1 is the sum
additional labour and supply costs. The of the products appearing in the first row
basic data that are required to estimate the of Exhibit 3.B. Also included in the exhibit
additional production costs appear in are the set of supply costs per procedure,
Exhibit 3.A. The first set of data indicates grouped by type of service.
the mix of labour, measured in hours, that
is required on each occasion that one of The results produced in Exhibit 3.B are
the six laboratory procedures is provided. combined with the number of failures
The coefficients appearing in the first row identified by the internal evaluation to
indicate the complement of labour that is determine the additional labour and supply
required on each occasion that procedure expenses that are incurred to correct
LAB1 is provided while the values appearing defective procedures or results. As indicated
in the last row correspond to the hourly in Exhibit 3.C, the additional labour costs
rates of compensation of the four types of resulting from the need to reprocess 140
technicians. The values appearing in the units of LAB1 amount to $1,589. This
column identified by the heading "Number estimate is obtained by the product of the
of Defective Units" correspond to the number of defective units and the labour
procedures that were identified by the cost per unit. In a similar fashion, the
internal review of the laboratory and were additional supply expenses appearing in the
copied directly from Exhibit 1.C. exhibit were obtained by multiplying the
number of defective units of each procedure
As shown in Exhibit 3.B, the basic data by the corresponding supply cost per unit.
are then combined to determine the labour
and supply costs per unit of service by type In addition to the increment in produc-
of procedure. To determine the labour cost tion costs described above, the need to
per unit of each procedure, the set of evaluate the accuracy of those services that
coefficients depicting the labour require- were corrected may result in additional
ments per unit of service is multiplied by appraisal costs, which for the sake of
corresponding rate of pay. For example, the illustration, are included in Exhibit 3.C. As
data presented in Exhibit 3.A indicate that indicated in Exhibit 1.C, the inspection cost
on each occasion a unit of procedure LAB1 per unit, grouped by category of procedure,
is provided, the corresponding requirement is the product of the appraisal time per

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 Cost of Improving the Quality of Healthcare

service, measured in hours, and the hourly procedures that are returned for correction
rate of pay. If it is assumed that all corrected is given by the product of the proportions
procedures are evaluated, the additional that appear in the column identified by the
appraisal costs listed in Exhibit 3.C were heading "Return Rate" and the corres-
obtained by the product of the number of ponding volume of service that was
defective items, grouped by procedure, and introduced initially in Exhibit 1.C. Similar
the corresponding inspection costs per unit to other exhibits, the labour cost per
of service. The results of these calculations collection is simply the product of the time,
indicate that the additional production costs measured in hours, required to obtain the
resulting from identifying defective items specimen needed for a given laboratory
prior to reporting results to other providers procedure and the rate of compensation
consist of labour expenses, amounting to per hour. The additional collection costs for
$16,950, and supply costs of $4,812.45. a given procedure is simply the number of
In addition, the need to rectify previous occasions on which a specimen is collected
errors also resulted in additional appraisal and the cost per collection. Accordingly, the
costs of $1,575.30. increment to the collection costs for all
procedures is obtained by the sum of these
The second set of failure costs consist products. As shown in Exhibit 4.A, related
of expenses that are incurred after services, supply expenses are estimated by the
procedures or results have been provided product of the supply expense per collec-
to the patient or a health professional tion, grouped by procedure, and the
responsible for the diagnosis or treatment number of collections. The calculations
of the patient. With a focus on the obtained from the spreadsheet indicate that,
laboratory, the number of external failures, in the illustration, additional labour and
represented by the number of procedures supply expenses resulting from the need to
returned for additional processing, consists collect an additional specimen from
of at least two components. First, it may be involved patients was $13,740 and
necessary to collect an additional specimen approximately $4,662 respectively, resulting
from involved patients. Second, the in an addition to retrieval costs that
laboratory is required to perform additional amounted to approximately $18,402.
procedures, resulting in higher production
or processing costs. The method of estimating additional
production costs is summarized in Exhibit
A method of estimating the costs of 4.B. As can be determined easily, the labour
external failures is shown in Exhibit 4.A. In and supply costs per unit of each procedure
this case, the focus is on the mix of service were calculated initially in Exhibit 3.B. The
provided during the operating period and additional labour and supply expense
the return rate, defined as the portion of shown in Exhibit 4.B is simply the sum of
each procedure that requires additional products among the returned mix of services
processing and alluded to the internal and the corresponding labour and supply
evaluation. As indicated, the mix of cost per unit respectively. As noted, the

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Health Care Quality: An International Perspective

additional production costs resulting from suggested, an increased emphasis on

the need to correct returned procedures prevention is expected to lower the failure
amounted to approximately $33,348. rate and the number of defective proce-
dures that must be corrected. As the number
of defective procedures or processes
TOTAL COSTS decline, the discussion suggests that the
increment in related production costs and
The estimates of each component of the the need to inspect these services or
costs of quality might be summarized as processes also decrease. Hence, the
shown in Exhibit 5. The total expenses interface among the exhibits enables
associated with evaluation or appraisal and management to assess the financial
represented by quality review, the a priori implications of an increased emphasis on
inspection of supplies and the internal prevention and the resulting decline in
inspection of the services provided by the appraisal and failure costs.
laboratory were obtained from Exhibits 1.A,
1.B and 1.C. The costs of prevention,
represented by employee training and the THE DATA
calibration of equipment, were obtained
from the labour, supply and total costs As indicated in the previous section, the
calculated in Exhibits 2.A and 2.B. while approach presented in this chapter requires
the set of internal failure costs was obtained a set of coefficients that measure the mix
from Exhibit 3.C. Finally, the external failure of resources required to provide a service
costs were copied from Exhibits 4.A and or to complete a process. From a practical
4.B. As the summary indicates, the total perspective, it is usually necessary to limit
costs of quality management that were the number of services or resources for
estimated in the simplified illustration were which detailed production coefficients are
approximately $146,375, an amount that developed. For example, the laboratory is
was comprised of labour and supply capable of processing hundreds of proce-
expenses of approximately $123,940 and dures or tests, a feature that prevents a
$22,435 respectively. As such, the focus on the entire scope of services. Rather,
approach outlined in this chapter enables management might limit the detailed
management to estimate not only analysis to the 15 or 20 services that
appraisal, prevention and failure costs but comprise 80 per cent of the volume. Since
also the labour and supply component of the number of labour categories in each
each. unit or department is relatively small, it is
usually necessary to reduce only the range
In addition to the estimation of the costs of consumable supplies to a manageable
assigned to quality management, the number.
proposed model also enables management
to assess the interrelation among preven- Once the number of procedures,
tion, appraisal and failure costs. As processes and categories of resources have

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 Cost of Improving the Quality of Healthcare

been established, the amount of labour and tion of labour and supplies when providing
supplies, grouped by procedure or process, a service or completing a process. The
might be determined by relying on one of distribution of labour and supplies among
several methods. In most cases, the mix of the procedures or processes might be
consumable supplies used in the provision obtained from an application of functional
of a procedure or completion of a process accounting. As is well known, a functional
is dictated, in varying degrees of precision, accounting system is characterized by a set
by medical technology or the dictates of of subsidiary expense accounts in which the
medical practice. As a consequence, the costs of labour and supplies are assigned
health service organization might rely on to the services provided or processes
expert opinion, as described below, to completed during the period.
determine the supply expense per unit.
Alternatively, the distribution of labor
However, the mix of labour required to resources , by employee category and type
perform a procedure or complete a process of service or process, might be obtained
is less well specified and varies from by the logging method. For the logging
institution to institution. Rather than rely on approach, a responsible employee is
technological considerations, as in the case required to maintain a record of the mix of
of supplies, management should adopt one labour required to provide a service or
of several approaches to develop complete a process during a given period.
coefficients that measure the labour However, the information derived from the
requirements per procedure or process. In log may reflect existing inefficiency resulting
this regard, management might rely on from current practice.
expert opinion, historical averages, logging
or batching methods or time and motion When the batching procedure is used,
techniques to establish labour requirements. a known number of work units is assigned
to an individual and the amount of time to
When expert opinion is employed, the complete the service or process is recorded.
department head or supervisor is asked to Similar to the logging approach, the
list the amount of each type of labour that batching technique results in a distribution
is required to provide a service or complete of hours, by procedure or process and by
a process. Simplicity and ease of collection employee category. In turn, the resulting
are among the major advantages of the distribution forms the basis for calculating
approach. However, the results obtained the coefficients that measure the time
from relying on expert opinion usually are required for each labour category to
not verified by independent evaluation or provide a given service or complete a
statistical analysis. specific process, such as collecting a
specimen.
The resource requirements per service
or process might be estimated by relying Finally, management might rely on time
on historical data that depict the consump- and motion studies to derive a distribution
of labour hours, by occupational category

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Health Care Quality: An International Perspective

and type of service or process. In general, example, the additional costs of an

observed effort is transformed into "normal increased emphasis on prevention might
effort", a process that is accomplished by be estimated by increasing the percentage
an industrial engineer. Normal time refers of time committed to training activities or
to the amount of time required to complete increasing the frequency of calibrating
one cycle by an employee performing at equipment. Similarly, the model
the normal level of effort. To accommodate instantaneously calculates the increment in
fatigue resulting from repeated cycles, the cost that would be produced by an
need to take breaks and normal interrup- increased emphasis on appraisal, as
tions in the work process, normal time refers indicated by increasing the selection rates
to a standard of performance, measured appearing in Exhibits 1.A, 1.B or 1.C.
in hours, that might be satisfied by a Moreover, the model enables
properly trained employee during an management to assess the relation
extended period of time. Accordingly, the between the costs of control activities,
development of normal time forms the represented by appraisal or prevention,
foundation for an application of the and the cost of failures. For example,
approach described in this chapter to suppose that, prior to the period,
several problems confronting the typical management decides to increase the costs
health service organization, a consideration and related complement of resources
that is discussed in the final section. devoted to prevention and appraisal by 10
per cent. Holding other factors constant,
assume further that the increased emphasis
THE USES on control lowered the failure rate and
related costs by 15 per cent. Accordingly,
In addition to the obvious benefit of the results produced by the model enable
estimating the actual costs of quality the organization to assess the influence of
management, the proposed model TQM on fiscal performance and to
enables the health service organization to evaluate the relative benefits of policy
perform a sensitivity analysis that estimates options that might be implemented in the
the differential costs produced by changing future. As such, a careful evaluation of
one parameter and holding all others differences between failure and control
constant. For example, prior to the period, costs might enable the organization to
most organizations should develop and lower operating expenses, increase profit-
assess the desirability of adopting one of ability and improve the quality of care.
several possible options, each depicting Further, if adopted successfully by the
a different level of commitment to majority of health service organizations,
evaluation and prevention. The model TQM and CQI may contribute to resolving
proposed in this chapter simultaneously the difficulties of lowering systemic
estimates differences in cost that are likely spending on health services while
to result from committing more or less maintaining or improving the quality of
effort to evaluation or prevention. For care.

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 Cost of Improving the Quality of Healthcare

Annexure 1

Exhibit 1.A : Annual appraisal costs: utilization review

Total Time Per
Activity Selection Records Cost Per Labour Supply
Number Record Total
Resource Rate Selected Hour Cost Cost
Available (In Hours)
Selection
Preparation
Clerk 5000.00 0.20 1000.00 0.25 8.00 2000.00 2000.00
Technician 5000.00 0.20 1000.00 0.50 12.00 6000.00 6000.00
Physician
Review
A 1000.00 0.10 100.00 0.15 48.08 721.15 721.15
B 1000.00 0.20 200.00 0.20 60.10 2403.85 2403.85
C 1000.00 0.40 400.00 0.50 52.88 10576.92 10576.92
D 1000.00 0.15 150.00 0.25 64.90 2433.89 2433.89
E 1000.00 0.15 150.00 0.40 67.31 4038.46 4038.46
384.62 384.62
Final Report 125.00 125.00
Other
Total 28558.89 125.00 28683.89

Exhibit 1.B : Annual appraisal costs: Inspection of supplies

used by the laboratory department
Inspection Labor Total
Supply Units Selection Units
Time/Unit Cost/ Inspection
Item Received Rate Inspected
(In Hours) Hour Costs

S1 10000.00 0.05 500.00 0.10 14.00 700.00

S2 4000.00 0.01 40.00 0.15 14.00 84.00
S3 7000.00 0.10 700.00 0.05 14.00 490.00
S4 8000.00 0.15 1200.00 0.12 14.00 2016.00

Total 3290.00

Exhibit 1.C : Annual appraisal costs: Evaluation of

services provided by the laboratory
Number
Inspection Labour
Total Selection Units Labor of Defective
Service Time/Unit Cost Per
Volume Rate Inspected Cost Defective Rate
(In Hours) Hour
Services
LAB1 2000.00 0.70 1400.00 0.08 18.00 2100.00 140.00 0.07
LAB2 10000.00 0.50 5000.00 0.05 18.00 4500.00 750.00 0.08
LAB3 3000.00 0.40 1200.00 0.07 18.00 1512.00 60.00 0.02
LAB4 4000.00 0.80 3200.00 0.10 18.00 5760.00 256.00 0.06
LAB5 1500.00 0.90 1350.00 0.05 18.00 1215.00 27.00 0.02
LAB6 20000.00 0.30 6000.00 0.04 18.00 4320.00 180.00 0.01

Total 19407.00 1413.00

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Health Care Quality: An International Perspective

Exhibit 2.A : Prevention costs: employee training

% of Hours
Scheduled Labour Cost of
Resource Devoted to Annual Salary Salary Per Hour
Hours Training
Training
Instructors
A 2000.00 0.08 40000.00 19.23 3076.92
B 2000.00 0.05 35000.00 16.83 1682.69
C 2000.00 0.05 32000.00 15.38 1538.46
Trainees
E 2000.00 0.10 30000.00 14.42 2884.62
F 2000.00 0.10 30000.00 14.42 2884.62
G 2000.00 0.05 28500.00 13.70 1370.19
H 2000.00 0.05 28000.00 13.46 1346.15
Subtotal 14783.65
Supplies 4400.00

Total 19183.65

Exhibit 2.B : Prevention costs of calibrating laboratory equipment:

The basic data
Item of Time Per Adjustments Labor Cost Per Supply Cost/
Total Time
Equipment Adjustment Per Period Hour Adjustment
A 1.20 1.00 1.20 12.50 4.00
B 0.50 3.00 1.50 10.00 5.50
C 0.80 8.00 6.40 11.50 0.00
D 1.50 4.00 6.00 12.50 3.00
E 3.20 2.00 6.40 13.40 45.00
F 5.30 1.00 5.30 14.00 3.20
G 4.20 7.00 2.40 13.90 5.00
H 0.30 10.00 3.00 10.00 16.00

Total 17.00 36.00 32.20 97.80 81.70

Exhibit 2.C : Prevention costs: Calibration of laboratory equipment

Item of
Labor Cost Supply Cost Total Cost
Equipment
A 15.00 4.00 19.00
B 15.00 16.50 31.50
C 73.60 0.00 73.60
D 75.00 12.00 87.00
E 85.76 90.00 175.76
F 74.20 3.20 77.40
G 33.36 35.00 68.36
H 30.00 160.00 190.00

Total 401.92 320.70 722.62

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 Cost of Improving the Quality of Healthcare

Exhibit 3.A : Annual internal failure costs of the laboratory department:

The basic data Labour Hours Per Service
Number of
Tech 1 Tech 2 Tech 3 Tech 4
Defective Units
Service
Lab1 0.05 0.50 0.00 0.10 140.00
Lab2 0.00 0.20 0.80 0.00 750.00
Lab3 0.10 0.00 0.50 0.25 60.00
Lab4 0.00 0.00 0.35 0.40 256.00
Lab5 0.20 0.60 0.00 0.15 27.00
Lab6 0.20 0.00 0.50 0.00 180.00
Cost/Hour 15.00 18.00 12.00 16.00

Exhibit 3.B : Supply and labour cost per unit, by type of service

Type of Labour Labour

Supply Cost/Unit
Cost/Unit of
of Service
Tech 1 Tech 2 Tech 3 Tech 4 Service

Service
Lab1 0.75 9.00 0.00 1.60 11.35 1.44
Lab2 0.00 3.60 9.60 0.00 13.20 2.35
Lab3 1.50 0.00 6.00 4.00 11.50 3.60
Lab4 0.00 0.00 4.20 6.40 10.60 5.25
Lab5 3.00 10.80 0.00 2.40 16.20 2.45
Lab6 3.00 0.00 6.00 0.00 9.00 6.79

Exhibit 3.C : The Internal failure costs of the laboratory Unit

Additional Additional Additional
Production &
Labor Supply Appraisal
Appraisal Costs
Costs Costs Costs
Service
Lab1 1589.00 201.60 210.00 2000.60
Lab2 9900.00 1762.50 675.00 12337.50
Lab3 690.00 216.00 75.60 981.60
Lab4 2713.60 1344.00 460.80 4518.40
Lab5 437.40 66.15 24.30 527.85
Lab6 1620.00 1222.20 129.60 2971.80
Total 16950.00 4812.45 1575.30 23337.75

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Health Care Quality: An International Perspective

Exhibit 4.A : External failure costs of the laboratory:

The additional collection costs
Time Per Supply
Number Labor Additional
Return Speciman Cost/ Labor Supply
of Cost/ Speciman
Rate Collected Collected Cost Cost
Failures Hour Costs
(In Hours) Speciman
Service
LAB1 0.05 100.00 0.50 12.00 1.36 600.00 136.00 736.00
LAB2 0.08 800.00 0.70 12.00 2.34 6720.00 1872.00 8592.00
LAB3 0.10 300.00 0.30 12.00 1.23 1080.00 369.00 1449.00
LAB4 0.09 360.00 0.40 15.00 1.56 2160.00 561.60 2721.60
LAB5 0.11 165.00 0.80 15.00 1.55 1980.00 255.75 2235.75
LAB6 0.02 400.00 0.20 15.00 3.67 1200.00 1468.00 2668.00
Total 13740.00 4662.35 18402.35

Exhibit 4.B : The External Failure Costs of the Laboratory:

Additional Production Costs
Additional
Number of Labor Cost/ Supply Cost/
Labor Costs Supply Costs Production
Failures Unit Unit
Service Costs
LAB1 100.00 11.35 1.44 1135.00 144.00 1279.00
LAB2 800.00 13.20 2.35 10560.00 1880.00 12440.00
LAB3 300.00 11.50 3.60 3450.00 1080.00 4530.00
LAB4 360.00 10.60 5.25 3816.00 1890.00 5706.00
LAB5 165.00 16.20 2.45 2673.00 404.25 3077.25
LAB6 400.00 9.00 6.79 3600.00 2716.00 6316.00

Total 25234.00 8114.25 33348.25

Exhibit 5 : Summary of Cost Calculations

Component Labor Cost Supply Cost Total Cost
Utilization Review 28558.89 125.00 28683.89
Inspection of Supplies: Laboratory 3290.00 0.00 3290.00
Appraisal of Services: Laboratory 19407.00 0.00 19407.00
Appraisal of Services (Internal Failures of 1575.30 0.00 1575.30
Laboratory)
Employee Training 14783.65 4400.00 19183.65
Calibration of Equipment 401.92 320.70 722.62
Internal Failure Costs: Laboratory 16950.00 4812.45 21762.45
External Failure Costs: Collection by Laboratory 13740.00 4662.35 18402.35
External Failure Costs: Production by Laboratory 25234.00 8114.25 33348.25

Total 123940.77 22434.75 146375.52

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 Cost of Improving the Quality of Healthcare

References 8. Horngren CT and Foster G (1991). Cost

Accounting: A Managerial Emphasis. Prentice
Hall, Englewood Cliffs, NJ.
1. Arikian V (1991)."Total quality management:
Applications to nursing service". Journal of 9. McLaughlin CP and Kaluzny AD (1990). "Total
Nursing Administration 21(6) 46 quality management in health". Healthcare
Management Review 15(3) 2-14.
2. Chan, YC (1993). Improving hospital cost
accounting with activity-based costing" Health 10. Simpson JB and Muthler DL (1987). "Quality
Care Management Review 18(1) 71-83 costs: Facilitating the quality initiative". Journal
of Cost Management for the Manufacturing
3. Daigh RD (1991)."Financial implications of a Industry 1(1) 25-34.
quality improvement process" Topics in Health
Care Financing 17(3) 47-48 11. SleeV and Slee DDA (1991). Health Care Terms.
Tringa Press, St. Paul, Minn.
4. Duncan WJ Ginter, PM, and Swayne LE (1996).
Strategic Management of Health Care 12. Stiles RA and Mick SS (1997). "What is the cost
Organizations PWS Kent Publishing, Boston, MA. of controlling quality? Activity-based cost
accounting offers an answer" Journal of Hospital
5. Gillem T (1988). "Deming's 14 points and and Health Services Administration 42(2) 193-
hospital quality: Responding to the consumer's 204.
demand for the best value in health care" Nursing
Quality Assurance 2(3) 70. 13. Stiles RA and Mick SS (1997a). "Components of
the costs of controlling quality: A transaction cost
6. Hagan JT (1986). Principles of Quality Costs, economics approach". Journal of Hospital and
American Society for Quality Control, Milwaukee, Health Services Administration 42(2) 205-219.
Wisc.
14. Suver JD, Neumann BR and Boles KE (1992).
7. Harrington JH (1987). Poor-Quality Costs. "Accounting for the costs of quality", Healthcare
American Society for Quality Control, Milwaukee, Financial Management 46(9) 28-31.
Wisc.

Page 161
 10
10
Quality Assurance in Primary Health Care:
Saudi Arabia's Experience
Tawfik A. Khoja, MBBS, DPHC, FRCGP

INTRODUCTION AND OVERVIEW quently, the QA programme was proposed

and a Scientific Committee for QA in PHC

A
Quality Assurance (QA) programme (SCQA, PHC) was established. The
is now under way in the Kingdom of programme comprised five stages: manual
Saudi Arabia. The Kingdom has development, training of trainers, training
adopted and implemented the primary of health teams at HC level,
health care (PHC) programme since 1984, implementation, and evaluation.
shortly after the Alma-Ata Declaration. The The programme manual included
programme which is run by the Ministry of standards and indicators for activities in
Health (MOH) covers the whole country. eleven health centres. The Eastern
PHC is provided to the community through Mediterranean Regional Office (EMRO) of
more than 1,700 health centres (HC) WHO recognized the manual as the first
distributed equally in both urban and rural of its kind in the field of QA. All PHC
areas. An in-depth review of the PHC supervisors, about 250 in all, were exposed
programme in the Kingdom was conducted to training workshops for a period of six
by a joint committee representing the World days each.
Health Organization (WHO), Saudi
Universities and the MOH. The review The strategies developed therein clearly
revealed a sufficiently high coverage of the reflect the need for adhering to the "highest
population (98%) by the eight elements of possible level of quality" to meet the
PHC in all the regions of the Kingdom. expressed expectations of the Saudi
community. Today, every health centre is
The need to assure the quality of PHC providing PHC services to all, especially the
services was justified, especially after the needy, by defining vulnerable groups, by
interregional meeting organized by WHO providing target-based services and through
in Shanghai in October 1990. Conse- organized outreach services for disease

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Health Care Quality: An International Perspective

control and prevention as well as health 3. Recommendation to establish

promotion activities. Accordingly, the under- Standards and Uniform Guidance
served and at-risk groups of the community of PHC activities.
are recognized, registered and followed
(C) In 1992 (for MCH training programme):
through an established system.
1. Increased awareness of the
As these activities represent an ongoing
importance of MCH.
process, innovative changes are to be
introduced in the health delivery system to 2. Improvement in the knowledge,
accommodate the changing health needs. skills and attitude towards MCH
activities.
An in-depth review of primary health
care in the Kingdom of Saudi Arabia by 3. Improvement in data management
legitimate bodies (WHO/UNICEF/ and handling.
Universities/medical schools and MOH) (D) Since 1984 till now there has been an
brought out the following facts: internal review of the technical quality
of the PHC practice through:
(A) In 1987:
1. PHC policy is soundly based in the 1. Periodic structure, process and
Kingdom. outcome review by central and
2. PHC infrastructure is rapidly regional levels.
completed. 2. Development of standard review
3. Stress on the importance of quality. protocols and rating scale.

(B) In 1989: 3. Periodic review of administrative

processes by the planning
1. Acceptance of PHC by citizens department through the available
(friends of health committee). records.
2. Increase in: 4. Annual review of clinical processes,
• Team spirit e.g. cost of drugs / investigations
• Training of health care staff by respective departments.
• High coverage of EPI 5. Outcome reviews and review of
• Implementation of referral community acceptance through
system planned studies.

• Community participation 6. Implementation of the built-in

programme of supervision,
• Monitoring of chronic illnesses
monitoring and evaluation within
• Improvement of MOH services the QA programmes called
• Decrease in the incidence of Programme of Supportive
communicable diseases. Supervision (POSS).

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 Quality Assurance in Primary Health Care: Saudi Arabia's Experience

STATUS OF QUALITY ASSURANCE 2. Defining targets for PHC services.

3. Scheduling outreach services.
IN SAUDI ARABIA
4. System for defaulter tracing and
(A) The concept and practice of quality contact.
assurance (QA) is not new to Saudi 5. Access to secondary care through
Arabia. a system of referral and feedback.
(B) With the implementation of the PHC (E) Setting standards for PHC services, viz.
concept, "a desirable level of quality"
1. Development of protocols for
in every stage of PHC development was
target-oriented PHC services
experienced.
(medical examination, MCH,
(C) Setting standards for resources, immunization, etc.).
responsibility and information, viz. 2. Development of policies for
1. Assurance of minimal infrastructure. diarrhoeal disease control and
2. Limiting the health centres' national protocol for acute
responsibility by demarcating the respiratory infections (ARI).
geographical area to be served. 3. Development of national protocols
3. Planned baseline data collection and guidelines for bronchial
leading to the formation of action asthma as well as mental health
plan. care at primary health care centres.
4. Development of a system for 4. Standardization of referral protocol
periodic demographic data and procedures.
updating. 5. Introduction of essential drug list.
5. Standardization of statistical
6. Defining needed technologies for
returns, preforms, frequency and
PHC services (clinical lab,
time.
environmental disease control,
6. Standardization of monitoring health education, etc.).
indicators.
(F) Promotion of PHC professionalism
7. Introduction of PHC code for
through:
common diseases in line with ICD.
8. Assurance of cold chain, system for 1. Basic, category and selective
procurement, storage and training of all PHC workers.
distribution of drugs and vaccines. 2. Publication of PHC manual.
(D) Development of a system for ensuring 3. Development of training standards
equity, viz and protocols through publication
of appropriate manuals, evaluation
1. Registration of beneficiaries
of training programmes and
through family files.
feedback.

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Health Care Quality: An International Perspective

4. Scheduled PHC symposia and – The Ministry of Health, in its endeavour

workshops, working together with to put the Quality Assurance
other health/health-related sectors. Programme in a practical perspective,
decided to handle this task, and formed
(G) Setting standards for PHC
the "Scientific Committee of Quality
management:
Assurance" in Shawal 1411 H (May
1. Standardization of supervisory 1991). The Director-General of Health
checklist. Centres was appointed as Chairman of
2 Training of PHC managers. the committee that included a group
3. Development of trainee manual of consultants and resource persons
and protocol. from the MOH, Health Services of the
National Guard, General Presidency of
Women's Education and Armed Forces,
in addition to King Saud University
CONCEPTUALIZATION AND College of Medicine. The staff from
CONSOLIDATION OF QUALITY MOH were concerned with PHC
planning, supervision and follow-up.
ASSURANCE IN MOH The scientific backgrounds as well as
the experiences of the committee
– Taking into consideration all that has
members are diverse and therefore
been described before, this necessitated
enriching to its responsibilities.
the need to look for quality in services
offered to the community by these – Selection of PHC activities that will be
facilities. As some of the hospitals in the covered by the QA programme.
Kingdom had begun their programme – Preparation of standards, checklists,
of QA earlier, the Ministry decided to rating scales and indicators for the
launch a similar programme for PHC. selected PHC activities.
– The idea took shape after the – Coordination with WHO and the United
contribution made by the Saudi Ministry Nations Children's Fund (UNICEF), who
of Health, represented by its Director- supported the programme.
General of Health Centres, at the
Interregional Meeting on Assurance of – The first workshop on QA programme
Quality in Primary Health Care, was held in Riyadh, 2-3 Rabi II 1412H
Shanghai, China, 8-12 October 1990, (9-10 October 1991).
which was organized by the World
– The scientific papers prepared by the
Health Organization.
committee members, as well as the
– A proposal was prepared by the General results of the first workshop, have been
Directorate of Health Centres on: circulated to PHC experts in different
"Quality Assurance Programme in PHC", regions of the Kingdom, Jumadah I
Ramadan 1411 H (March 1991). 1412 H (November 1991), seeking

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 Quality Assurance in Primary Health Care: Saudi Arabia's Experience

their critical review and practical Specific objectives of QA in

comments.
PHC
– The second workshop on QA
programme was held in Makkah, 9th 1) To set standards for the delivery of
Shaban 1412 H (12 February 1992), quality PHC activities (services) that
for the same purpose as in the item include the eight PHC components and
above. other components as deemed
necessary.
– A national symposium on QA in PHC
was organized in Riyadh on 18th 2) To set standards for better performance
Ramadan 1412 H (2 March 1992). of PHC workers.
– Thereafter, training of trainers was 3) To define sensitive instruments to assess
started in the regions for 250 the performance of PHC workers - the
candidates. process of delivery of PHC activities.

4) To select sensitive and valid indicators

General objectives of QA in to continuously monitor and evaluate,
PHC as well as to supervise the progress and
outcome of PHC services and their
1) To improve and upgrade the impact on the health of the community.
performance of PHC workers.
5) To include all of the above in the
2) To promote the delivery of quality
processes of overall health planning,
services that satisfies the aspirations as
programming (and re-programming
well as the expectations of the
when necessary), monitoring and
community and the PHC workers
evaluating PHC activities.
themselves.
3) To reduce the overloading of the
secondary and tertiary health care
facilities with minor ailments that can
PROGRESS OF QA TRAINING
be dealt with at PHC centres. PROGRAMMES
4) To reduce the cost of health care being
The number of supervisors (participants)
received now by community members
trained in the eight workshops was around
who seek health care in the private
250 (i.e. an average of 30 supervisors per
sector by providing quality and cost-
workshop). The questions of the pre- and
effective services by the government
post-test were the same. There were 25
based on equity and social justice.
questions dealing with subjects related to
5) To reduce morbidity and mortality rates quality assurance concept. Comparisons of
and promote the health status of the the results of the pre- and post-tests showed
Saudi people. an overall increase of 12.8% in the total

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Health Care Quality: An International Perspective

marks (68% and 80.8% in the pre- and pre-testing prior to the commencement of
post-tests, respectively). This increase a workshop should be encouraged, as it
represents "good" improvement in the forms the basis on which one can build up
knowledge of the participants when further conclusions at the end of the
compared to similar situations and workshop.
assuming the originality of the subject. The
highest such increase (18.8%, from 69.2% There were many problems which the
to 88%) was observed in the first two committee faced in its work from the
workshops, as well as the 8th. Moderate beginning, some of which were:
increase was observed in the 4th, 5th and • Inadequate resources
6th workshops, whereas the lowest increase
• Different structures between urban
was noted in the 3rd and 7th workshops.
and rural areas
This fluctuation may be due to many
factors: • Different categories of manpower
in PHC
• Different scientific backgrounds of
participants; • Language dilemma

• Different levels of enthusiasm • Comprehensive manual versus

among participants; manual by category

• Variable attitudes towards training • Different disciplines of education/

in general and the subject of QA training of the members of the
in particular; and scientific committee.

• The prevailing circumstances and

settings in each workshop.
It is highly desirable, and
DEVELOPMENT OF QA MANUAL
recommended, to orient the participants
The development of the manual for quality
about the subject, objectives and
assurance in PHC passed through a
methodology of a workshop sufficiently in
number of stages, which are:
advance. This suggestion also applies to
making available training materials and Step 1 - One or more members of
other documentation. In Saudi Arabia, the SCQA developed draft standards for
participants, despite the fact that they were specific PHC activities emphasizing their
doctors and spoke both Arabic and English, scientific validity, clinical relevance and
showed special preference for the Arabic comprehensiveness.
language during the workshops.
Step 2 - The proposed draft standards
In adult education and training, the were then discussed in a workshop held in
recommended method of training is two- Riyadh in October 1991. It was attended
way (dual) communication rather than one- by selected groups of PHC supervisors,
way lecturing, for example. Performance of

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 Quality Assurance in Primary Health Care: Saudi Arabia's Experience

PHC managers and health centre staff from manual of its kind receiving WHO
the 18 regions of the Kingdom. approval.

Step 3 - The scientific papers proposed

by the committee, as well as the result of
the first workshop, were circulated in THE NEXT STAGE
November 1991 to the PHC departments
in the Directorate of Health Affairs in all Training of trainees
the regions of the Kingdom.
• This stage has commenced in the
Step 4 - During December 1991, the beginning of 1414 H,
responses of different regions were received corresponding to mid-1993.
and analysed. The responses were divided • Training of all health centres'
into two groups: one who were in personnel all over the Kingdom;
agreement with the draft standards, and the doctors, nurses, health inspectors,
other who suggested additions, omissions pharmacists and assistant pharma-
or modifications. cists, technicians (laboratory and X-
ray), social workers, and managers
Step 5 - The second workshop on
quality assurance was held in Makkah in Trainers included members of the
February 1992 for further discussion on the SCQA and about 250 trainers who were
opinions expressed by different regions with specifically prepared for this task in the
the objective of further modifications of the second stage of the programme (1413 H
standards. / 1991-93).

Step 6 - After the Makkah workshop,

the modified draft standards were reviewed
by two WHO consultants in Riyadh, who
TIME PERIOD
interviewed all members of the SCQA
To achieve this ambitious objective the
individually and in small groups.
country's regions were divided into three
Step 7 - The draft manual containing categories according to the number of
the revised standards and indicators was health centres in each region: small regions
sent to the WHO Regional Office in (less than 50 HCs) where training of
Alexandria (EMRO) for final revision by trainees should be accomplished within one
concerned regional advisers. year; intermediate regions (50 to less than
100 HCs) where 1-1/2 years were given
Step 8 - As a final step in the to accomplish the training objective; and
development of the QA manual, WHO's large regions (100 HCs and over) where
approval was conveyed to the SCQA, with two years were thought to be adequate to
the recognition that this was the first QA achieve the objective.

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Table 1. Targets for Training tionally in order to avoid the potential of

by Category failure attached to it.
Target Number
Category Training
Trainees
Courses
MONITORING AND EVALUATION
Doctors 3187 219
OF TRAINING AT REGIONAL LEVEL
Nurses 7176 412 Three methods were employed for the
Health monitoring and evaluation of trainees'
1397 86 training in the regions. The first training
Inspectors
course was attended by the National
Pharmacists &
1296 87 Coordinator of the programme and one or
Assistants
two members of the Scientific Committee
Managers & in all regions. No region was allowed to
4081 163
Others start its first training course unsupervised.
Total 17,137 967 The technique of SWOT analysis was
employed to point out the strengths,
weaknesses, opportunities and threats.
However, shortly after the commence- These areas of analysis were discussed with
ment of this stage, it was realized that this the concerned health authorities and
time frame was too ambitious. The QA technical staff. A comprehensive report was
training faced many difficulties, which prepared - at the end of this analysis - and
included: presented to the higher authorities in the
Ministry.
• Shortage of human resources. This
affected the trainers as well as the A quarterly report (pre-designed
trainees because of inadequate format) was required from all regions to be
staff to cover those that moved to presented to the General Directorate of
the training halls. PHC. Each report was further revised and
• Shortage of material resources critically evaluated for the purpose of
necessary for training purposes. providing feedback for improvement to the
regions.
All regions were also committed to
other training programmes (e.g. maternal A points system was implemented for
and child health training and PHC essential comparing the regions according to leader's
training for the newly-appointed staff). Thus, support, performance of trainers and
their training schedules were already trainees, training facilities, and skills . The
stuffed. Therefore, for these reasons, the following is the First Training Course, QA
time frame was slightly stretched inten- Training of Trainees, Saudi Arabia 1994:

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 Quality Assurance in Primary Health Care: Saudi Arabia's Experience

Table 2: First training course, QA training of trainees, 1994

Training
Trainers’ Trainees’
Leader's situation Training Total
Region perfor- Perfor-
Support and skills points
mance mance
facilities
Riyadh 3 3 3 3 3 15
Jeddah 3 3 3 3 3 15
Makkah 3 3 3 3 3 15
Taif 2 2 2 2 2 10
Baha 3 3 3 3 3 15
Madinah 3 3 3 3 3 15
Tabouk 3 3 3 3 3 15
Sharkia 2 2 2 2 3 11
Hasa 2 3 3 3 2 12
Hafr Al Batin 3 3 3 3 3 15
Asir 3 3 3 3 3 15
Najran 3 3 3 3 3 15
Jizan 2 2 3 1 1 9
Qaseem 3 3 3 3 3 15
Alhodod Ash. 3 2 3 3 3 14
Al-Gouf 3 2 3 3 3 14
Al Koriat 3 2 3 2 3 13
Hail 3 3 2 1 3 12
Besha 3 3 3 3 3 15

Key: 3 = Good, 2 = Average, 1 = Below average, 0 = None

The quarterly report was characterized numerator (achievements) which

by the following: was cumulative.
• Standardized format so as to allow • The report was also flexible in the
comparison between regions. sense that it allowed regions to
comment on their training
• Text in the report was kept to the
problems and obstacles, as well as
minimum (emphasis on numerical
to suggest realistic solutions to
data).
these problems.
• The main sections of the report
needed absolute numerical data. Field visits were made to the sites of
The first part of the data training in the regions. The training sites
represented the denominator which included not only the central training places
was approximately constant in all (in the regions' capital) but also other
reports (the target), whereas the peripheral training centres (in the regions'
second part represented the sectors). These visits aimed also at:

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Health Care Quality: An International Perspective

Table 3. Format of quarterly report for monitoring quality assurance

Pharmacists
Health
Indicator Doctors Nurses & Assistant Managers Others Total
Inspector
Pharmacists

Total target
Total
executed
(Cumulative)

Obstacles
& barriers

• Assuring the quality of training; The aim of POSS was to assure the
• Supporting the training activities at quality of primary health care activities
regional PHC level; and at the health centre level in the 20 regions
of the Kingdom through supportive
• On-the-spot identification of supervisory field visits. The target areas
training problems and managerial
of POSS were primary health care
bottlenecks and finding possible
activities in the regions where the health
solutions.
centres were considered to be the primary
At the beginning of 1415 H (mid- sampling units. POSS was also directed
1994), the Kingdom's Deputy Minister for towards regional PHC supervisors. POSS'
Executive Affairs, based on the recommen- activities were coordinated by an
dations of the Directorate of Health executive board which was composed of
Centres, required that all health centres in members of its technical committee (all
the 20 regions adhere to the standards of whom were highly qualified physi-
included in the Saudi Quality Assurance cians), chaired by the Director-General
Manual. This decision triggered a new of Health Centres.
process of monitoring, POSS (Programme
of Supportive Supervision).
OBJECTIVES OF POSS
PROGRAMME OF SUPPORTIVE • Strengthening relations between the
central level (MOH) and the
SUPERVISION (POSS) intermediate and peripheral levels.

This programme was started in 1995 to • Field training of regional PHC

strengthen the implementation of QA supervisors on the implementation
activities in PHC centres. of the "Quality Evaluation Form".

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 Quality Assurance in Primary Health Care: Saudi Arabia's Experience

• Monitoring and evaluation of PHC Furthermore, the technical committee

activities at the beginning of the of POSS is divided into three teams. Each
implementation of the QA team consists of three persons and is
programme. required to monitor and visit about six
regions on a regular basis. Specifically, one
• Promoting and strengthening the region is to be visited per week, i.e. four
concept of supervision as a tool for regions per month. All regions are to be
improving health services. visited at least twice a year. During each
supervisory visit the following is to be
• Monitor training activities in
included:
different programmes of primary
health care networks. • Short meeting with the region's top
management (Director General/
• Use of systematic follow-up of Director and his Assistant for PHC)
training and continued education to explain the aims and objectives
of supervisors and workers. of POSS.
• Assess the practical implemen- • Meeting the PHC supervisors of the
tation of different programmes at region. This meeting includes
health centres by using QA defining three health centres (two
indicators. urban and one rural) that will be
visited by POSS team and the
• Identify potential areas needing regions' supervisors.
improvement by problem-solving
and solution development. • One "Quality Evaluation Form" to
be completed for each health
• Evaluate the outcome of those centre in collaboration with and
programmes. with full participation of the region's
supervisors.
• Identify areas of strengths and
weaknesses. • Final meeting with the Assistant
Director for PHC and the regions'
• Exchange lessons learned between supervisors to analyse the results of
different directorates through field visits and to formulate
mutual field visits. appropriate recommendations.

• Supply the health authorities in the The POSS team then submits a report
regions with appropriate feedback to the POSS Chairman (Director-General
following each visit. The feedback of Health Centres), who sends it, with
is summarized in the form of appropriate comments and recommen-
points of strengths and weak- dations, to higher authorities in the Ministry.
nesses, supported by relevant In addition, the visited region is supplied
recommendations. with a feedback report.

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Health Care Quality: An International Perspective

IMPLEMENTATION OF POSS IN SPECIFIC OBJECTIVES OF CDD

NATIONAL HEALTH POSS PROGRAMME
PROGRAMMES: • To measure the extent of
implementation of monitoring by
Control of diarrhoeal indicators in the regions.
diseases programme (CDD) • To measure variance to the
planned target achievement.
Preliminary arrangements are made every • To provide regions a feedback
time a visit is made to a region. In this including weak and strong points
example a visit was prepared for before of performance.
the actual visit was made. This process • To provide a basis to standardize
included a study of the background of the all procedures in health centres in
region for the CDD programme, contact- relation to assessment, treatment
ing the authorities in the regional health and reporting.
affairs, and giving them adequate time
before the actual visit. At this point the
Table 4. The impact of POSS on the
objectives of the visit are communicated
pattern of infant feeding
to the authorities of the regional health in Quriat region
affairs and an agreement is reached with
the authorities on the programme of the Before After
Feeding by Age
POSS POSS
visit and its timing.
Breast-feeding 0.5697 0.5749
(<6 months)
During each regional visit, 3-4 health
Breast-feeding 0.3393 0.4549
centres are included, both rural and urban, (7-12 months)
along with regional authorities and
Supplementary 0.8893 0.99
supervisors. Evaluation is performed using
feeding
'quality indicators' (feeding, ORS-use, I.V.-
use, drug-use, hospital admission, type and
duration of diarrhoea). The indicators are Table 5 : The impact of POSS on the
measured by using monthly annual case type and duration of diarrhoea
management reports and family files, in in Quriat region
addition to the actual observations. Type of diarrhoea
Before After
Feedback is then provided to the health POSS POSS
care staff on both the positive and negative Diarrhoea 0.0125 0.0056
findings. These findings are entered in the (> 14 days)
supervisory record as reference points for Bloody diarrhoea 0.0118 0.0102
future visits.
Severe dehydration 0.0033 0.0021

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 Quality Assurance in Primary Health Care: Saudi Arabia's Experience

Table 6. The Impact of POSS on • Integrate hospital and health centre

the treatment of diarrhoea services.
in Quriat region
• Energize supportive supervision
Treatment of Before After through QA.
diarrhoea POSS POSS
• Procure training materials.
ORS-use 0.987 0.9914 • Train more trainers as necessary.
I.V.-use 0.0114 0.0074 • Revise and update manuals.
Antibiotic-use 0.1048 0.0847
• Improve referrals and feedback
Anti-diarrhoeal 1.25 0.0022 systems.
measures
• Improve the health information
Hospital admission 0.0419 0.0361
system (HIS).
• Consider redistribution of health
manpower.
POSITIVE ASPECTS OF POSS IN • Incorporate the programme in the
health plan.
CDD PROGRAMME
• Evaluate the impact of the
• Aroused interest and interaction programme on the health and well-
• Improved communication and being of mothers and children.
coordination Based on the above, and as a first step,
• Provided an assessment of structure a training programme was developed on
and training needs the use of Indicators for Monitoring and
Evaluation back in 1996. The programme
• Emphasized the role of supervisors objectives included:
• Emphasized the use of manuals • Emphasis on the concept of indica-
• Identified weaknesses of tors as a tool for monitoring and
information system evaluation.
• Enhanced collaboration between • Field training of PHC supervisors
MOH central departments with on indicators' utilization.
peripheral regions. • Orientation of PHC supervisors on
the common methods of data
organization, analysis and
RECOMMENDATIONS interpretation.

• Organize continuing medical • Enhancing the morale of

education (CME) with involvement supervisors in promoting self-
of educational institutions. satisfaction.

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Health Care Quality: An International Perspective

Technical staff of the General Directorate References

of Health Centres provided the training. The
programme was provided to all assistant 1. Khoja TA, Farag MK. Synopsis of indicators:
monitoring, evaluation and supervision of health
directors of PHC and to all PHC supervisors care quality, 1997. Ministry of Health, Saudi
in the 20 regions (about 250). Additionally, Arabia.
the programme included a total of eight 2. Al-Mazrou YY et al. Quality assurance in primary
workshops with 25-30 trainees in each, health care manual, 1994.
while the training material included synopsis 3. WHO. Implementation of the global strategy for
of indicators, manual on quality assurance health for all by the year 2000. Eighth report on
the world health situation, 2nd Ed. WHO/ EMRO,
in primary health care, quality indicators
1996: Vol 6.
form, and health centres' registers and files.
4. Al-Mazrou Y, Khoja TA and Rao M. Health care
worldwide: health services in Saudi Arabia. Proc
R Coll Physicians Edinb., 1995; 25: 263-6.
FUTURE ACTIONS 5. Khoja TA, Basulaiman M. The 3rd yearly report
of the programme of supportive supervision June,
1997.
A book titled "Synopsis of Indicators" was
6. Annual health report, 1995. Ministry of Health,
distributed nationwide. The book will be Saudi Arabia.
utilized for supervision and training 7. Sebai ZA. Health in Saudi Arabia. Tihama Pub,
purposes. It will also serve as a directive Riyadh, Saudi Arabia, 1st Ed 1985: Vol 1.
manual for monitoring and evaluation. The 8. Al-Farsy F. Saudi Arabia: a case study in
book contains chapters on: monitoring and development, 1986. KPI Ltd.
evaluation of the quality of care; develop- 9. Ministry of Planning. General objectives and
ment and use of indicators; health policy strategic bases of the sixth development plan
1995-2000. General Secretariat of the Council
and socioeconomic indicators; coverage of Ministers, Saudi Arabia.
and health status indicators; treasurer of 10. WHO. Third monitoring of progress. Implemen-
Islamic teaching; and the programme of tation of strategies for health for all by the year
supportive supervision "POSS". The Quality 2000. WHO/HST/GSP/93.3, 1993.
Indicators form has been included as an 11. Ministry of Planning. Achievements of the
annex. development plans 1970-1992. Saudi Arabia.
12. Al-Mazrou YY et al. Principles and practice of
primary health care, 1990.

Page 176
 11
11
QA Project in Al-Hussein Hospital,
Salt, Jordan
Dr Osama Samawi

O HOW DID IT BEGIN?

ne of the definitions of quality
assurance is (QA) is that
"Quality is never an accident, it The Jordanian Ministry of Health (MOH) felt
is always the result of high intention and strongly about the need to improve the
skillful execution; it represents the wise efficiency and quality of the health services
choice of many alternatives." in the country given that Jordan spent more
than 9% of its budget on health services.
We found this definition to be quite The MOH called upon the Quality
accurate and true during the implemen- assurance project of the US Agency for
tation of the QA project in Al-Hussein International Development (USAID) for
Hospital, Salt, Jordan. technical assistance .

When we began to implement this In June 1992 a two-day Quality

project in February 1994, we thought that assurance Awareness workshop was
improving the quality of work was a conducted in Amman, in which 30 senior
spontaneous, self-moving process which MOH officials representing the central
will proceed by a simple administrative MOH directorates, peripheral hospitals and
decision. But we soon realized that good other directorates of health participated.
intention, good planning, continuity,
sincere efforts, central support, commit- At the end of the workshop, the
ment, motivation and clear vision were all participants came up with the following
so crucial for the success of the quality vision statement for the future QA
programme. programme in Jordan:

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Health Care Quality: An International Perspective

VISION STATEMENT
"In five years there will be a nationwide quality assurance system having clear policies
supported by the organizational structure of the MOH, with authorized and participatory
leadership. It will be practical and realistic. There will be a widespread awareness in the
community of the need for quality in health services and all health personnel will be
aware of, and feel the need for, quality assurance as reflected in their attitude and
behaviour."

In order to find out from where to were used to continuously improve the
begin, an assessment study was conducted, quality and efficiency of care.
which included staff interviews and observa-
tion of the quality of the health services Strategy 2: Assist the MOH in designing,
being provided. A special QA programme implementing and evaluating a pilot QA
was designed which would be applicable programme in the Salt health directorate
in Jordan. This QA programme became a and hospital.
major part of the Family Health Services
Strategy 3: Assist the MOH to expand and
project (FHS), which had two main
integrate quality birth spacing services into
objectives:
ongoing family health services.
1. To expand and improve the
accessibility and quality of those Strategy 4: Carry out studies to assist the
family health services that most MOH in its strategic planning, to document
directly impacted on maternal and unit costs, and to evaluate the changes in
child health and fertility; and efficiency resulting from QA activities.
2. To assist the Government of Jordan
to design, develop and implement Strategy 5: Assist the MOH in expanding
a comprehensive and integrated FHS improvements and the QA programme
quality assurance programme at all to other regions of the country.
levels and, ultimately, in all facilities.
Within less than a year, the MOH
In order to achieve these objectives five created the Directorate of Monitoring and
strategies were put into action: Quality Control Directorate (MandQC),
which became responsible for planning,
Strategy 1: Assist the MOH in developing coordination and supervision of all activities
the capacity of a central QA unit to ensure related to quality improvement and
that the health care resources in Jordan management throughout Jordan. More-
over, Al-Hussein Hospital, Salt and the

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 QA Project in Al-Hussein Hospital, Salt, Jordan

Directorate of Health, Balqa, were chosen in Jordan, and it should be sustained by

as the pilot area where the project would keeping abreast with the latest scientific and
be implemented and demonstrated. technological changes that are taking place
in the world. Moreover, the private sector
is a strong competitor with the public sector
Al-Hussein Hospital, Salt in Jordan. The public sector serves more
than 65% of the population (41% in
It is worth mentioning a few words about
government hospitals and 25% in Royal
the Al-Hussein Hospital in Salt city. The
Medical Military Services).
hospital provides care to 283,000 citizens
of the Balqaa Governorate. It is a 140-bed Improving hospital services using only
facility with an area of about 7000 m2 (50 existing resources was found to balance
m2/ bed) with an occupancy rate of 73%, only some of the shortcomings occurring
considered to be one of the highest in due to shortages in supplies. Cost contain-
Jordan, and an average length of stay of ment was another important reason for
3.78 days. implementing QA in Jordan.
During 1995, 13, 230 patients were Nevertheless, the project faced
admitted to this general hospital, of which considerable resistance in the early months
3073 were for general surgical operations, of its implementation due to some
3948 for normal deliveries and 1044 for unexplainable fear of change. Some of this
minor operations in the emergency room. resistance was attributed to the fear of the
The number of outpatient visits was 77,298 unknown. A majority of the staff did not
in addition to 47,829 ER visits. Also, during have any idea about the QA concept, and
the same year, 33,809 X-ray films and it took a few months for the hospital
264,993 laboratory tests were completed. management and the QA project staff to
explain it to them to overcome their
These services were provided by 602
resistance and eventually to get them
employees, of which 134 were physicians
actively involved in the project.
representing 15 different specialities as well
as 236 nurses. The hospital serves more
than 283,000 people, which is the
population of Balqa Governorate . THE FIRST QA MEETING
The first QA meeting was held in the
hospital on February 18, 1994. Three
DID WE NEED THE PROJECT? important issues were discussed in that
meeting:
Implementing the project was not due to
marketing efforts, but due to a real 1. The QA structure: A comprehensive QA
understanding of the ideas and needs for organizational chart was developed
QA. Medicine has reached reputable levels

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Health Care Quality: An International Perspective

connecting the hospital with different 3. Problems list: A question was asked
administrative and QA structures. from the hospital QA council members:
"What are the most important problems
A. QA Steering Committee, which
you feel that the hospital is facing?"
was the highest QA organ in Balqa
Governorate responsible for plan- A brainstorming session was conducted and
ning, prioritizing, implementing the attendees came up with the following
and monitoring QA activities in the list:
Governorate. This steering
committee, headed by the General 1. Medical records
Director for Health, had the follow- 2. Admission process of emergency
ing members: the hospital's patients
director, the health director, director
3. Consultations
of planning, director of MandQC
directorate and the general coordi- 4. Inadequate space for neonates
nator of the QA project in the unit.
MOH. 5. Paging system
B. The QA council of the hospital, 6. CPR group
headed by the hospital's director
and with the membership of the 7. X-ray department maintenance
following heads of department: 8. Lack of computers
surgery, gynaecology, paediatrics,
9. Scientific activities
internal medicine, nursing,
engineering and pharmacy. The 10 wards reorganization
membership was a subject for 11. I.C.U. reorganization
further studies, discussion and
changes over a period of time. 12. Visitors and guarding
13. Monitoring internal problems
2. QA committees: Six permanent QA
committees were formed: 14. Dispensing medication

– Medical records review committee 15. Uniforms

16. Discharge card
– Medication utilization committee
17. Deficiencies in supply
– Infection control committee
18. Outpatients' files
– Mortality and morbidity committee
19. Logistics
– Blood utilization committee
20. Nursing re-staffing
– Scientific committee.
21. Employees' transfer

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 QA Project in Al-Hussein Hospital, Salt, Jordan

22. Simplification of discharge 1. The Medical Records Committee had

procedures several meetings with the physicians,
23. Small area for pharmacy nurses and administrative staff during
which the committee ascertained their
24. Patieznts' length of stay needs and added a few new forms to
25. Laboratory test monitoring the patients' files. These new forms were
submitted to the central directorates in
26. Referrals from PHC to hospital
the MOH to get their approvals for the
27. Referral system. dissemination of these files all over the
country. As a routine, 15 randomly-
During the following two years, the
selected files were reviewed during
hospital's QA council was able to resolve
each of the Committee's meetings. This
more than half of the issues listed above.
review included physicians, nursing
The other half was out of the hospital's
notes and follow-up, and the
control, e.g. salaries, equipment
administrative part of the file. For this
acquisition, hiring, etc.
purpose some check sheets were
created for unified chart content
evaluation. The results of the review
ACCOMPLISHMENTS OF THE were periodically reported to the
QA COUNCIL director of the hospital, who sent the
files back to the head of the department
Upon the request of the council, the project with the list of "deficiencies in the file"
offered the following equipment to the and an official letter requesting him to
hospital: ask the responsible party to correct
these deficiencies. Improvements were
– A package of recently published
noticed in a short period of time soon
issued nursing, QA, and medical
after the committee began its activities.
books
– An overhead projector A Terminal Digit System ( TDS ) was
– A slide projector introduced. Each medical record was
– A camera given a number that corresponded to
– A personal computer the year it was created and a unique
– Paging system family and individual number for each
patient. Medical records were also
– Furnishing the lecture room and the
colour coded to expedite proper
hospital QA unit
storage and retrieval. Once this system
– Needles disposal containers.
was implemented and on proper staff
As soon as the QA committees were training was completed, this system
formed they began to carry out their allowed retrieval of a medical records
responsibilities. file in less than 8 seconds.

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Health Care Quality: An International Perspective

2. The Medication Utilization Committee standardization of the use of cultures

began its activities by studying the in the laboratory.
current pattern of antibiotic use in the
hospital. It found that these were over- 4. The Mortality and Morbidity Committee
used. Physicians were required to included only the heads of the four
document the rationale of each major departments in the hospital,
expensive antibiotic prescribed. A namely, surgery, gynaecology, paedia-
substantial drop in the use of expensive trics and internal medicine. They met
antibiotic was noticed almost monthly to discuss patients' complaints,
immediately. deaths, complications, hospital
incidents and compliance between
The committee also prepared a booklet
discharge diagnosis and pathology
containing the generic and trade names
reports or postmortem diagnosis.
of the most commonly used medicines,
indicating their doses and contra- 5. The Blood Utilization Committee began
indications. The committee also its activities by studying and observing
initiated the study of the use of Lidocain the current situation by using a
gel, which was used by the staff as a flowchart to understand all the steps in
lubricant when applying the EKG leads the blood transfusion process. The
to the chest. The study showed that committee recognized that no
there were no significant changes in the standards were available for the entire
EKG reading when Lidocain was process of blood donation until
replaced with plain water. Therefore, transfusion. Therefore, in collaboration
the practice was changed to use water with the clinical instructors, standards
instead of Lidocain for EKG measure- were developed for blood ordering,
ments. Saving in this practice alone was drawing, storage, use and transfusion.
to the extent of 3,800 Jordanian dollars They arranged with the scientific
(=US$5,000). committee to make presentations and
impart training on the use of these
3. The Infection Control Committee made standards to all concerned hospital
a study on recording the incidence of personnel. Once the standards had
nosocomial infection and post-opera- been communicated, the committee
tive wound infection. Standards for the started the process of monitoring their
prevention and control of infection were compliance. It is believed that this
set and used. This included proper practice will result in reducing the
isolation, scrubbing, and routine incidence of reactions and contami-
cleaning of operation room and lab nation from blood transfusion. The
equipment. Considerable amount of committee also discussed the most
money was saved through the effective ways to increase the number

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 QA Project in Al-Hussein Hospital, Salt, Jordan

of blood donors through media the hospital and other institutions

campaigns. participated. The first few workshops were
conducted by international consultants, but
6. The Scientific Committee which was once a cadre of local professionals had
also responsible for Continuing been trained, they became responsible for
Medical Education, participated conducting the rest of the workshops. The
actively in the conduct of training number of the professionals trained by early
courses for doctors and nurses in 'hot 1997 is shown in the following table:
subjects' such as cardio-pulmonary
resuscitation and EKG-readings inter- Out of the 602 hospital employees,
pretation as well as education on a 325 (54%) attended at least one workshop.
number of clinical practice guidelines. Unfortunately, in spite of such a large
number of persons receiving training, only
three had the opportunity to attend all the
Table basic workshops in order to be nominated
Number
as master trainers.
Number of
Subject of of profes-
workshops
Workshop sionals
held
trained
STANDARDS AND GUIDELINES
Q A awareness 14 151
Team building During the first QA exploration visit it was
4 39
and basic skills obvious that no standards were existing in
Intermediate skills 1 7 the Salt Governorate, so the process of
Customers` setting up and communicating standards in
8 101
service the hospital and primary health centers
Standard setting 2 16 begun. In the hospital alone, 26 standards
Training of and guidelines were set. The following is
1 3
trainers the list of these standards:
Current leadership
issues
1 8 • C.P.R.

Total 31 325
• Blood collection
• Blood storage
• Blood donation
WORKSHOPS • Blood administration
• Intravenous administration
Within less than one year of the start of the
project, seven workshops were conducted • Sterile dressing
in the hospital's training auditorium in which • Procedure review
a large number of health professionals from

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Health Care Quality: An International Perspective

• Patient record documentation - • Diabetes

nursing • Hypertension
• Blood culture collection • Epilepsy
• Pre-operative nursing procedure • Diet list for diabetic patients
• Post-operative nursing procedure • Brucellosis
• Medical record tdcs • C.P.R.
• File design • Nocturia
• Lumbar puncture • Child nutrition
• Naso-gastric feeding • Diarrhoea
• Supra-pubic aspiration • Rehydration
• Intra-osseous infusion • Breast-feeding

• Gastric lavage • Vaccinations

• Nursing procedure for lumbar • Breast cancer

puncture • Care of ears
• Nursing role in admission • Bilharziasis.
• Blood transfusion in thalassaemia Furthermore, different QA committees
major wished to prepare special forms to record
• Newborn care - nursing and evaluate data. Their efforts resulted in
the creation of several evaluation and
• Chest tube application reporting forms, of which the most
• Nursing procedure important were: forms for reporting of
• Disposal of medical wastes. death, unintended accidents, surgical
operations cancellations and medical
These standards and clinical guidelines procedures evaluation. With support from
were followed in the hospital and were the Scientific Committee, the hospital issued
submitted to the Ministry of Health in order a quarterly newsletter which highlighted the
to be disseminated to other hospitals for hospital's accomplishments and other
adoption. scientific issues.
In addition, another 17 educational
materials were prepared and distributed to
the general public and patients when they CLINICAL INSTRUCTORS
visited the clinics. The topics covered
included: Together with the QA project, another
Italian project to train clinical nursing
• A child with hypothermia instructors was under way in the hospital.
• A child with convulsion Five clinical instructors trained in well-

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 QA Project in Al-Hussein Hospital, Salt, Jordan

equipped nursing units studied the weak- down to the actual purchases and salaries.
nesses and deficiencies in the actual nursing The results were extremely beneficial in
performance in the hospital. Accordingly, establishing a baseline for comparison
they designed special teaching workshops whenever similar studies are undertaken in
and educational materials, to enhance and other hospitals.
improve the nursing standards. Seven work-
shops were designed, four of which were The hospital Director, a paediatrician,
repeated several times in order to allow and a respiratory physician were part of the
more nurses to participate. In the end a total team of experts who supervised and ran a
of 445 nurses attended these workshops study entitled "The effect of cement dust on
which covered subjects such as nursing the respiratory system of the population of
documentation, infection control, I.V. Fuheis city", a city where the main cement
nutrition, E.K.G. principles, care of diabetic factory is located. The study, which was
patients, C.P.R., and communication with sponsored by the Higher Council of Science
patients and doctors. and Technology, was a cross-sectional
comprehensive study comparing the
population of Fuheis city with another city
STUDIES which is identical in all respects, except in
the exposure to cement dust. This unique
Several studies were conducted in the and original study yielded results which
hospital, some of which were organized in were comparable to the outcomes
collaboration with other organizations. documented by other similar international
Some of these studies were the following: studies.

A number of epidemiological studies

The cost of bed utilization in were conducted all over the country on
topics that included morbidity, mortality and
Al-Hussein Hospital
maternal and infant deaths. The hospital
The first of its kind in a government hospital, was selected as one of the sites for these
this study was prepared by a distinguished studies.
study panel consisting of a government
In order to examine patients' satis-
auditing agency, General Director for
faction and comfort during their stay in the
Preventive Services (MOH), General
hospital, a study was prepared by a hospital
Director of Administration (MOH), and the
team. The patients were requested to fill out
hospital's Director, with the assistance of the
a questionnaire and drop it in a centrally-
international consultants of the QA project.
located box specifically used for this
The study took into consideration every purpose. The results were collected and
cent spent in the hospital during the fiscal analysed periodically, showing a high
year beginning with the hospital's share of acceptance level of the services provided
the central MOH administrative spending by the hospital in three major areas:

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Health Care Quality: An International Perspective

administrative, nursing and physician – Contracted with a private company

services. The results indicated that 88%, for security, cleaning and catering.
80% and 86% of the patients, respectively,
were satisfied. Notably, the satisfaction level – Adding new ambulances and a
was higher among the inpatients than the truck to the existing vehicles pool.
outpatient attendees. – Equipped the paediatric depart-
ment with four ventilators and two
Another study was aimed at studying
phototherapy units.
the bronchial asthma, its frequency, mis-
diagnosis, as well as variation in physicians' – Increased the number of kidney
diagnosis and treatment. More than dialysis units to four.
14,000 inpatient and 20,000 outpatient
files were screened during 1995 alone, of – Automated the financial, personnel
which 459 patients were found to be having and medical records departments.
bronchial asthma. The team alsostudied – Introduced the bar coding system
whether the treatment plan varied form into the hospital's pharmacy
patient to patient and from one physician system.
to another. The results of this study, the first
of its kind in Jordan which may also serve – Trained 40 hospital employees in
as a baseline for other studies, concluded computers.
that there was a need for clear guidelines
for the treatment of bronchial asthma. – Furnished a new lecturing and
Accomplishments training room.

– Expansion and improvement of the

The Al-Hussein Hospital organized all
kitchen.
its activities towards improving the health
status of the patients through its doctors, – Initiated training programmes for
nurses and Administrative services. In the intern physicians and residents.
process the following developments and
activities took place: – Initiated training programmes for
undergraduate students, nurses,
– Created an examination room in medical school, other private
each of the hospital's departments colleges and universities.
to assure patients' privacy.
– Participated in "free medical days"
– Created the patients' information conducted in remote areas that
desk in the hospital lobby. lacked medical services.
– Expanded the neonatology depart- – Trained 20 employees of the
ment from 6 to 16 neonate hospital about fire and safety
incubators. guidelines by the civil defence staff.

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 QA Project in Al-Hussein Hospital, Salt, Jordan

– Conducted four workshops on LESSONS LEARNED

EKG interpretation for general
practitioners in primary health – Be patient.
centres.
– Study, adapt and use others'
– Published the quarterly hospital experiences.
newsletter.
– Begin strong, with funding, resources
– Organized a number of lectures for and support.
the public on such topics as
– Motivate people.
diarrhoea, breast-feeding, vacci-
nation, child nutrition, and – Link the employees' progress and
diabetes. performance with incentives.
– Devoted, full-time people are really
needed in specialized units.
CHALLENGES – Planning without proper documentation
will create bad image and inaccuracy.
Throughout the long QI journey, there were
frequent shifts in the commitment of top – Participate actively in international QA
level staff that delayed the activities and at meetings/seminars.
times even made some of them to withdraw
– Subscribe to and review relevant
from active participation in the programme.
periodicals and bulletins.
People, however, slowly came around to
accept the idea and culture of QI, although – Document every step of the process
they resisted it in the beginning as they and every activity, however small.
thought it would reduce their privileges or – Gain and maintain top-level
go against their interests or keep a watchful commitment.
eye on them. The opposition gradually
crumbled as people started to understand – Have an economist and a statistician
the real concepts of QI. in your main teams in order to measure
the progress and cost improvements.
Although QI is "everybody's job", some
– Begin with small "showy" projects and
people should be wholly dedicated to it on
then proceed to bigger, long-term, cost-
a full-time basis. This was not realized until
saving projects.
two years later when we felt that there was
a real need for a QI office in the hospital – Successes, however small, do
that will collect, summarize, analyse and contribute to the overall improvement
disseminate the data and will plant the of the system and the organization, for
seeds to make the idea of QI grow. the huge building is built of small
stones. Keep the momentum going!

Page 187
 1212
Quality Assurance in Malaysia
Dr Abu Bakar Suleiman
Dr Maimunah Abdul Hamid
Dr Rusnah Hussein, Dr Ding Lay Ming
Dr M.A. Kadar Marikar

INTRODUCTION AND managed by paramedical personnel and

the health clinics and polyclinics by
BACKGROUND professionals and paramedics. At the
secondary level, there are small (non-
Provision of health care in specialist) and large (basic speciality)
Malaysia hospitals in districts which are closely linked
to the state and regional specialist hospitals.

T
he Ministry of Health (MOH) is the At the tertiary level, there are university
main provider of health care in the hospitals and the National Referral Centre
public sector, with the rest of care or Kuala Lumpur Hospital.
being provided by the ministries of
Currently, 96% of the population in
Education, Defence, and Home Affairs,
Malaysia have access to primary health
statutory bodies and local authorities. The
care services provided by the MOH
health care services are complemented by
(Ministry of Health, Malaysia, 1994). In
the private medical sector and some
1994, the ratio of health clinic to popula-
nongovernmental organizations.
tion was 1:15,753. The doctor-population
The MOH has established hierarchical ratio was 1:2,207 and that of the nurse was
levels of health care with a network of 1: 1,474. The development of the health
service delivery points throughout Malaysia. care delivery system over the past few
Each level has a prescribed scope of decades has established an effective
functions with an established referral network of health infrastructure in the
system. At the primary care level, there is a country. This has brought the basic elements
two-tier system. The rural dispensaries are of essential primary care within the reach

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Health Care Quality: An International Perspective

of the vast majority of the population in the

country, where about 74% live within 3 km
HEALTH STATUS
of a health facility and about 95% live within A marked improvement in the health status
5 km of it.
of the Malaysian population is indicated by
Currently, all services provided at rural the steadily decreasing mortality rates,
clinics and health centres are free of charge. longer life expectancies, considerable
Minimal user charges are levied for hospital success in controlling communicable
services to all users except the medically diseases and increasing efforts to address
indigent. All other expenditures, both capital and combat new diseases. Over the last
and recurrent, for all government facilities decade, infant mortality has fallen from
are borne by the government, where capital 19.7 per 1,000 live births in 1986 to 10.4
investment is from loans and recurrent in 1995, and reduction in maternal
expenditures are from revenues. mortality has been by more than half, to
20 per 100,000 live births in 1995
The private medical sector has grown
(Department of Statistics, Malaysia,
tremendously in recent years, thriving well
1996a). Epidemiologically, the country's
in the country's free market economy.
disease pattern is in a transitional phase,
There were 197 private hospitals with a
from a domination of infectious diseases
total bed complement of over 7,192 in
and malnutrition associated with under-
1995 (Department of Statistics, Malaysia,
development to one of a predominantly
1996b). This constituted 21% of the total
noncommunicable nature, reflective of
hospital beds in the country. General
socioeconomic and lifestyle changes. The
practitioner clinics number just over 3,000
life expectancy at birth for males was 69
throughout the country (Planning and
years and that of females 74 years in 1996
Development Division, 1997). The majo-
(Department of Statistics, Malaysia,
rity of private sector facilities are urban-
1996b).
based, concentrating mainly on high return
curative care with some preventive
activities such as immunization against
childhood diseases. HEALTH EXPENDITURE
In Malaysia, traditional healers
continue to play a significant role in the Much of the performance as reflected in
health care system. They include the the health indicators is a result of public
Chinese, Indian Ayuverdic and a large sector expenditure. Over the past years,
number of Malay traditional practitioners. health expenditure has increased signifi-
The nongovernmental organizations such cantly from [Malaysian Ringgit (RM)] RM
as associations, societies and others play 2,487.8 million in 1992 to RM 2,771.9
a central and major role in the care of million in 1995, representing an average
independent groups such as the elderly, incremental rate of 11.4% (Department of
mentally ill, and mentally and physically Statistics, Malaysia, 1996b). At the same
disabled, through care in the community. time the share of health expenditure of the

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 Quality Assurance in Malaysia

Federal Government's recurrent expenditure in the development policy and plans of

has been steady at 5%. As a percentage of many countries, including Malaysia.
GNP, health expenditure constituted only
3%, compared with 5% - 9% spent by Malaysia's development policy has the
developed countries (World Development objectives of improving the capability and
Report, 1993). Not much is known about productivity of all sectors so as to enable
the expenditure of the private health care them to play an important role in accelera-
sector in Malaysia. ting the nation's economic growth and
development; ensuring that the nation's
There is no national financing mecha- resources are used efficiently and effectively,
nism for health care in Malaysia at the and improving the quantity and quality of
present time. The public sector is largely services to the public (INTAN, 1994).
financed through taxation but private sector Quality initiatives are part of the Federal
services are on a fee-for-service payment Government's ongoing strategic plan to
scheme or by third party payment with develop and consolidate the competitive
private medical insurance. edge in the global market (Ahmad Sarji,
1993). This strategic plan is translated in
the health sector as well, where the
COMMITMENT TO QUALITY importance of quality has been integrated
into the development of the health system
The concern for quality is inherent to any in Malaysia.
professional endeavour (Blumenthal, 1996;
Up to the beginning of 1980s, the main
Donabedian, 1996; Krczal, 1996; Taylor,
goal of the Ministry of Health was to provide
1996). In health care, several initiatives and
adequate coverage. Having then achieved
approaches have been used during the past
a fairly extensive coverage of its health
hundred years, and these were the fore-
services, the MOH next focused on
bears of modern day quality assurance.
improving the quality, efficiency and
Quality, thus, has always been an integral
effectiveness in the delivery of health
part of health care. Of late, the rise of
services. This was also in response to the
consumerism, the philosophy of account-
increased awareness and expectation of the
ability with authority, rapid advancements
public of the quality of care provided. The
in costly medical technology coupled with
review of the Fourth Malaysia Plan1 (1981-
rising medical costs and the perceived need
1985) called for emphasis on quality and
to contain these costs place the concern for
coordination of quality-related activities
quality beyond the hand of the health care
(Ministry of Health, Malaysia, 1983). In
provider (Bassett, 1993; Ferguson et al,
1985, the MOH pioneered the way for
1994; Williamson, 1994). These concerns
quality assurance and launched the Quality
have placed quality as an important agenda

1
Malaysia Plan is a five-year rolling plan for socio-economic development with the social sector, including
health, as an integral part of the planning process.

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Health Care Quality: An International Perspective

Assurance Programme (QAP) as a strategy The Government of Malaysia has also

to evaluate the quality of services provided embarked on quality initiatives as part of
by the MOH in a planned and systematic the Federal Government's ongoing strategic
manner (Medical Services Division, 1991). plan to improve productivity and quality of
The Fifth Malaysia Plan (1986 - 1990) work. In 1991, the Government launched
marked the era of quality management. The the "Quality of the Public Service" initiative,
Plan identified the need to strengthen the giving emphasis to the implementation of
evaluation process in the health services to quality services in various areas, outlined
enable continuous upgrading and through a series of government circulars
improvement of services. called the Civil Service Development
Administration Circular (Prime Minister's
In February 1991, the Prime Minister Department, Malaysia, 1993). In 1992, the
announced Vision 2020 which stated that, Government introduced Total Quality
"By the year 2020, Malaysia is to be a united Management (TQM) as part of its efforts
nation, with a confident Malaysian society, to raise the quality of the country's public
infused by strong moral and ethical values, services (Ahmad Sarji, 1996). Recently,
living in a society that is democratic, liberal attaining MS ISO 9000 certification was
and tolerant, caring, economically just and endorsed by the Government as targets to
equitable, progressive and prosperous, and be achieved by all government depart-
in full possession of an economy that is ments. A quality awards system was
competitive, dynamic, robust and resilient." introduced in which several national awards
(Ahmad Sarji, 1993). This Vision laid down were bestowed yearly to organizations and
the path for Malaysians to take. As for the departments with outstanding quality work.
MOH, the Vision has been translated as the Quality assurance is one of the criteria
aspiration of a nation of healthy individuals, included in the assessment for these
families and communities. This desirable awards. Quality is given added prominence
state is to be brought about by a health care by being the main focus of the Seventh
system that is equitable, affordable, efficient Malaysia Plan (1996-2000).
and technologically appropriate, consumer-
friendly and environmentally adaptable. This
system will also emphasize quality and
innovation, respect for human dignity and
DEVELOPMENT OF QUALITY
health promotion. It will promote individual ASSURANCE PROGRAMME IN
responsibility and community participation
towards an enhanced quality of life (Ministry MALAYSIA
of Health, Malaysia, 1996b). The emphasis
on improving the quality, effectiveness and The concept of quality is not new in
efficiency in the delivery of health services Malaysia. Formal quality protection
was spelt out in the Sixth Malaysia Plan methods which include registration of
(1991-1995) (Ministry of Health, Malaysia, doctors, nurses and pharmacists, licensing
1993). of hospitals and pharmacies, code of

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 Quality Assurance in Malaysia

conduct and code of ethics were already shortfalls in quality in a planned manner
in place decades ago. Various quality- and to investigate systematically the cause
related activities such as mortality reviews, of such shortfalls and institute appropriate
drug audit committees, quality control, corrective measures so as to improve
quality control circle, medical audit, nursing quality (Pathmanathan, 1990). The specific
audit, peer review, utilization review, clinical objectives of the Quality Assurance
pathology conferences and others have Programme are:
long been practised. However, these
• To develop in all health personnel,
activities were often uncoordinated and
including health managers, a
implemented in an ad hoc manner and
favourable attitude, acceptance
many of them to a large extent were
and commitment towards
dependent on the interest and concern of
continuous quality improvement;
individuals (Lim et al., 1991).
• To provide health personnel with
The effort to coordinate these activities skills to carry out Quality Assurance
was initiated by the Ministry of Health in activities;
January 1985 with the launching of the • To develop an appropriate,
National Quality Assurance Programme acceptable and sensitive system for
(QAP). The QAP was intended to improve monitoring quality of care where
the quality, efficiency and effectiveness of information on shortfalls in quality
the delivery of health services and to is available in a timely manner; and
facilitate the evaluation of quality of services
(Medical Services Division, 1989). • To develop an effective system for
evaluating the programme.
Quality in health care is defined as the
Essentially, Quality Assurance is
optimum achievable result for each patient,
intended as a management tool to assist
avoidance of iatrogenic complications, and
managers and health care professionals to
attention to patient and family needs in a
develop a system to identify problems at
manner that is cost-effective and reasonably
work and promptly respond to the problems
documented, within the constraints of
by taking appropriate action.
available resources (Ministry of Health,
Malaysia, 1996a). The goal of the The QAP was implemented in a phased
Malaysian Quality Assurance Programme manner to cover ultimately all the service
is to ensure that, within the constraints of divisions in the MOH. It began with the
the Health Ministry's available resources, the Medical Services Division (for patient care)
patient, the family and the community in 1985, followed by Health Services
obtained the optimum achievable benefit Division for promotive and preventive care
from its services. (1990), Pharmaceutical Services Division
(1990), Engineering Services Division
The QAP aims at establishing a (1992), Dental Services Division (1990),
mechanism to monitor the quality of the Laboratory Services (1992), and lately in the
various services delivered so as to detect Training and Manpower Division (1996).

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Health Care Quality: An International Perspective

The development of QA in Malaysia QAP in the Health Ministry, determines

has been well recognized and quoted as priorities for development and implementa-
one of the first countries in the Western tion of QAP among the various service
Pacific Region of WHO to use quality as divisions as well as coordinates and
an indicator of the performance of monitors QAP for MOH. Currently, the
programme delivery (WHO, 1994). committee meets at least twice a year.
Malaysia has also been described as having
interesting developments in standards and The Coordinating Committee for staff
evaluation, which may eventually lead to training, chaired by Under-Secretary of the
accreditation as a result of government Manpower and Training Division, is
policy (Heidemann, 1993). responsible for planning, coordination and
monitoring of training activities for QAP.

Each service division then has its own

ORGANIZATIONAL STRUCTURE TO QAP committee chaired by the respective
SUPPORT QAP IN MOH director which develops strategies for
implementation and monitors the develop-
Recognizing the need for a continuous ment and implementation of QA of its
monitoring process in quality assurance programme(s). One or more technical sub-
activities, the QA activities were institu- committees, such as research and develop-
tionalized into the current activities of health ment, and implementation and training, are
personnel. The QAP was thus initiated formed to support the main committee.
without additional human resources.
Several QA committees were formed at
At state level
national, state, district and institutional
levels to facilitate the coordination of There is a QAP committee for every state,
activities (see Figure 1). Members of these chaired by the state Director of Health. This
committees are existing personnel within the committee plans, coordinates and monitors
MOH and the committees are represented QAP in health facilities, plans and imple-
by multiple disciplines. ments relevant programmes, provides
assistance to hospital QA committees and
provides feedback to the Health Ministry
At national level
headquarters. The state QA committee is
A National Steering Committee for the also supported by local technical sub-
Quality Assurance Programme was set up committees at the state level.
at the national level in January 1985, under
the chairmanship of the Director-General
At hospital level
of Health. The membership included the
Deputy Directors-General of Health and the The Hospital QA Committee plans,
various Programme (Division) Directors. implements and monitors QA activities at
This committee establishes policies for the hospital level and provides feedback to the

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 Quality Assurance in Malaysia

Figure 1 : Organizational structure of the Quality Assurance Programmeme

(QAP) in the Ministry of Health, Malaysia

QAP Steering Committee

Ministry of Health

QAP Coordinating QA Secretariat

Committee for Staff Training

QAP QAP QAP QAP QAP QAP

QAP Committee
Committee Committee Committee Committee Committee Committee
Pharmaceutical
Patient Care Health Laboratory Engineering Dental Training &
Services
Services Services Services Services Services Manpower

QAP
Committee
State Health
Services

QAP QAP QAP QA Committee, other institutions

Committee Committee Technical Sub- (as per MOH Organizational Structure
Hospital Health District Committee

State QA Committee. The committee is tators' or 'QA coordinators' were formalized.

represented by multiple disciplines and is They are the "prime movers" of QA,
chaired by the Hospital QA Coordinator, consisting of motivated individuals who
who is currently a clinician, on a two-year proactively support the programmes at
rotation. The Hospital Director is the local level. For the patient care programme
secretary of this committee. at hospital level, clinicians were identified
to play this role on a two-year rotation
basis. They provide leadership and support
Quality coordinators for the implementation of QA activities at
To facilitate the implementation of activities local level, which is in addition to their
at state and hospital levels, quality normal clinical work. They were given
coordinators termed either as 'QA facili- priority to be trained and to have further

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Health Care Quality: An International Perspective

exposure in QA, either locally or abroad, effectiveness of the corrective actions is

to enable them to perform their role more determined through continued monitoring
effectively. of the indicators.

Throughout the problem-solving

The approach process, the participation and involvement
of health personnel from various disciplines
The concept of "ABNA" - Achievable is facilitated by working in a multi-
Benefit Not Achieved - as described by disciplinary team. This is to enhance the
Williamson in his health-accounting relevance of the issue being monitored, the
approach is the backbone of the ownership and acceptance of the activity.
Malaysian QAP (Williamson et al., 1982).
ABNA represents lost opportunity or In the beginning, the concern was that
potential not realized. The QAP, in quality care was not being carried out
principle, aims to reduce ABNA through uniformly across hospitals, and the primary
maximum utilization of resources at all aim of QAP was to develop and institute
levels. This principle is applied to the a standardized monitoring system through
problem-solving indicator approach, the National Indicator Approach (NIA),
which is the main thrust of the QAP in also known as "top-down" approach. The
Malaysia. The emphasis of QAP is on "ground-up" approach, termed as the
continuous improvement and learning Hospital Specific Approach or District
from experience. Specific Approach (HSA/DSA), was
intended to be implemented concurrently
Through the problem-solving process,
to complement each other. However, the
group consensus is used to identify and
HSA/DSA could only set off five years after
prioritize quality problems to be
the implementation of NIA as more time
monitored. This is followed by identifying
was required to train health care personnel
quality indicators which are to be used as
at local level. While the NIA gives a broad
a 'flag' or as early warning devices to
indication of the performance of various
indicate some potential problem(s) in the
hospitals or institutions, the HSA is
quality area being monitored. The indi-
cators are monitored over time against intended to encourage more initiatives to
pre-set standards, which provide the improve services at local level, thus
yardstick of acceptable performance or complementing each other. In addition,
otherwise. The unacceptable performance there are many areas in which nation-wide
is termed as "outlier" and the institution or monitoring or standardization may not be
the relevant discipline is required to feasible and is best done at local level.
investigate to confirm the "outlier" status, Experience and expertise in the NIA
and determine where the shortfalls were. methodology enhance the capability to
The findings of the investigation would conduct HSA/DSA projects at local level.
lead to the formulation of remedial This combined approach has evolved
measures to initiate corrective actions. The slowly and steadily from there on.

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(i) The National Indicator The findings and recommended

Approach (NIA) remedial action are sent to the local QA
committee for implementation. In situations
In NIA, a standardized monitor-and- where there are limited resources to
feedback system was formalized through implement the recommendations at local
nationally identified indicators to monitor level, the issue is brought up to the State
quality in common areas of interest. Group QA Committee or, at times, to the QA
consensus through participation of repre- Programme Committee. Remedial mea-
sentatives from relevant clinical disciplines sures requiring policy change are referred
at national and institutional levels, was the to the National Steering Committee for
strategy used to assist in identifying Quality Assurance.
common quality problems which may be
monitored nationwide; and developing The effectiveness of remedial measures
indicators, standards and criteria. The local is monitored through the follow-up cycle
health personnel at institutional or district of data collection, which could be six
level are made aware of their role in monthly or yearly. An improvement or
gathering and using the information. otherwise may not be apparent in the
Collated data is submitted to the national immediate cycle, for some remedial
level, commonly through the existing Health measures require time to effect change. In
Management Information System. Investi- such a situation, the institution need not
gation protocols were also developed for carry out investigation if found to be an
each NIA indicator to guide and assist local "outlier" again in the follow-up cycle.
staff to verify their "outlier" status, and if
confirmed to be so, to determine where the Implicit in the NIA approach is the
shortfalls were by using the model of good concept of "benchmarking" or comparison
care. The model of good care is the best of performance with other similar institu-
available practice for managing the tions. This is intended to stimulate hospitals
identified health problem. The model and institutions to compare their
facilitates the identification of critical points performance between and within institu-
in the process of care where there are tions or hospitals. Local hospitals or
potential shortfalls in quality. The investi- institutions are expected to study the
gatory protocols provide guidelines on problems and initiate remedial actions
sampling, variables to be collected, method even before they are informed of their
of data collection and method of analysis. performance by the national quality
assurance secretariat. This is possible for
The analysis of the investigation would most of the NIA indicators, as individual
provide information on where the shortfalls hospitals or institutions would know their
were and the factors contributing to them. status in terms of the performance of the
This information provides input to make indicator prior to submitting data to
recommendations for remedial action to be national level.
taken.

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The NIA was used as the initial to the development of QA projects. The
approach in the QAP in Malaysia because information is used directly by local
it allowed a standardized mechanism to managers and summary reports of activities
monitor quality and provide common are submitted to the national level.
feedback. This is facilitated by the existence
of an organizational structure within the
MOH which can support the hierarchical
Selection of NIA indicators to
needs of monitoring and feedback required measure quality
in NIA. The health information system is
Through the problem-solving process,
already established to support collation and
several quality indicators have been
compilation of data for monitoring
developed to monitor quality in common
purposes. In addition, NIA was also found
areas of concern. The focus was on the
to be relatively easy to implement and QA
areas which addressed issues of patient
could rapidly and extensively be introduced
care, utilization of resources and patient
at all levels within the MOH.
satisfaction. Outcome measures are the
The NIA, however, has its weaknesses. main thrust for quality monitoring at
The top-down approach gives an impres- national level and process measures are
sion of the "big brother" looking over your commonly employed at the institutional or
shoulder, searching for the "bad apple". This local level.
is unavoidable as correctly stated by Don
Several factors can result in an organi-
Berwick: "Practically no system of measure-
zation becoming an "outlier". These include
ment - at least none that measures people's
case-mix, pre-admission case-severity and
performance - is robust enough to survive
condition of patient, a true quality problem
the fear of those who are measured."
within the organization, influences outside
(Berwick, 1989). Inevitably, as the
the MOH or a chance occurrence. Because
programme was implemented several
of this, the outcome indicators which were
misconceptions arose. Details of these
chosen could not be regarded as direct
misconceptions are described further at the
measures of quality. Instead, they were to
end of this paper.
be "flags", indicating that potential problems
existed in the specific areas of concern
(ii) The Hospital/District Specific (Pathmanathan, 1990). The indicators are
Approach (HSA/DSA) also used to serve as proxy indicators of
care for a group of similar conditions or
In HSA/DSA, the emphasis is on "local situations rather than for individual
people solving local problems". Local QA diseases. For example, "death due to
committees are given the responsibility to typhoid" is a proxy indicator of the quality
identify and monitor the quality of care at of management of pyrexia of unknown
their level. The problem-solving approach origin and "percentage of visual defects
is also applied in the QA process leading detected in primary school entrants" is

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regarded as a proxy for the detection rate SETTING THE STANDARDS

of other abnormalities through the school
health screening programme. The functions A standard has been defined by
of these indicators are described as the Donabedian as a quantitative statement of
rationale for selecting them. the "desired achievable (rather than
The indicators chosen were mainly observed) performance or value with regard
sentinel events or rate-based. The following to a given parameter" (Donabedian, 1982).
were the criteria used for the initial selection It is necessary to set standards in QA (Irvin,
of NIA indicators (Pathmanathan, 1990): 1990), although it is known that standards
are not devoid of problems (O'Dowd,
1. The indicators should measure 1991). The science of standard-setting is
outcomes of care, rather than well developed. Its effectiveness in
structure or process of care. The improving practice has been demonstrated
rationale was that while outcomes when standard is set by, or is made
are being monitored, the process acceptable to, those whose performance is
and structure components would to be reviewed (North of England Study of
be looked at when investigating the Standard and Performance in General
shortfalls. Practice, 1992). But setting standards is
2. The indicators should be generic in time-consuming, and clearly a trade off is
nature; in other words, these needed between "ownership" and
should not necessarily be disease- "practicality". In NIA, explicit standards have
or discipline-specific and should been developed by clinical, managerial and
focus on particular outcomes of multi-disciplinary group members. In setting
concern to the patients and the standards for the measurement of quality,
community, rather than be of a the approach adopted is to identify
singular interest to clinicians. yardsticks which are reasonable and
attainable, with the intention of further
3. The indicators should allow early
refinement as the programme progresses.
comparison between similar units
Stringency in the cut-off points is avoided
or between hospitals so that
except for indicators which are classified as
national or regional profiles may
sentinel events, such as "death due to
be constructed.
haemorrhage in pregnancy", "incidence of
4. The indicators should be based as tetanus neonatorum", and "number of
far as possible on data available wrongly dispensed items (drugs)" where all
in the existing information system. or none is the rule.
Examples of NIA indicators for various The common methods and sources of
service division QAP in the MOH are listed information used in setting these standards
in Appendix A. are listed below. It is customary that more

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than one method is used in the formulation Review of national and

of the standards. international references
Literature search from published
Review of available data
international references is also used
This is a common method employed in wherever available. In a few indicators, the
the Malaysian QA Programme. The main international standards are directly applied
source of the data is the health and to the Malaysian setting. An example is the
management information, which is use of the External Quality Assessment
routinely collected and compiled from Scheme (EQAS) standards for the
measurement of "performance in analysis
health care facilities. The summary
of core biochemistry" in clinical pathology
statistics of this information such as the
laboratories (Whitehead et al, 1981;
mean, median, highest and lowest values
Institute for Medical Research, 1993). In
are employed as the reference values for
other instances, available international
consideration of standards. Commonly,
standards are presented to local expert
these statistics are presented to groups of
groups for discussion, where modification
experts who would deliberate and come
to suit the local environment is made.
to a consensus for their adoption or
modification. As an example, this method
has been applied in deciding on the use Use of safety regulations
of the "morbidity index" in monitoring the
incidence of typhoid fever as an indicator Safety regulations as stated in legal
for monitoring the surveillance of documents have also been used as the
communicable diseases, in which the source for standard- setting. An example is
median number of cases in the previous in the indicator of "proportion of wards
five years is used as the reference point inspected for drug-keeping to the total
(Health Services Division, 1994). Other number of wards in the hospital" for which
examples include the use of the "highest a 100% coverage, within a three-month
and/or lowest" reported values during the cycle, is made compulsory (Federation of
monitoring cycle for the "hospital gross Malaya, 1952; Pharmaceutical Services
fatality rate", "bed occupancy rate", and Division, 1990)
"average length of stay" indicators for the
assessment of the utilization of resources Expert opinion and consensus
in hospitals. The "moving average of the
best annual national average" was used Group consensus among clinical experts
as the standard in monitoring the and administrators is another method
violation rate of specific quality commonly employed in setting standards
parameters for measuring the quality of for the Malaysian QAP. The experience of
drinking water. these experts formed the baseline for

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determining arbitrary standards. This is the health care services in the country since
more common method used by the HSA/ almost 55% of the doctor population and
DSA quality assurance projects, where the about 15% of the total hospital beds in the
quality-related problems monitored are less country are in the private medical practices
complex than in the NIA. Furthermore, at (Ministry of Health, Malaysia, 1994). While
the hospital or district level, comprehensive acknowledging the advantage of an
literature references are not easily available optimal mix of private and public delivery
to support the use of a more scientific of medical care, the Ministry of Health also
approach. recognizes the potential risks of commer-
cialization of medicine in the private sector.
Research As is happening in other countries, the
unprecedented growth of the private sector,
For more complex indicators, special principally in curative care, has contributed
studies on sampled cases or pilot projects considerably to the increasing cost of health
are conducted to obtain the statistics. An care. The Government has a moral
example was in the development of responsibility to ensure that access to health
standards for monitoring the management care and, more importantly, the quality of
of patients with different levels of severity care given are not compromised or
for myocardial infarction, head injury, and jeopardized in this situation. It is with this
acute respiratory infection in children concern that the MOH has been encoura-
(Maimunah et al, 1988). In other situations, ging the private medical sector to undertake
pilot studies were conducted over a period also quality assurance activities. The Private
of time. The results of the pilot studies were Hospital Act defines mainly the require-
used to formulate standards. This method ments for physical structure and manpower
has been applied to the indicators for (Laws of Malaysia, 1971) and there is no
"laboratory specimen rejection rate", provision to monitor the quality of services
"percentage of urgent laboratory tests", provided under the Act. Presently, quality
"waiting time at out-patient services", and assurance activities in the private medical
"percentage of X-ray films rejected". sector are on a voluntary basis. Some
medical audit activities are being carried
out on individual motivation and a few of
QUALITY ASSURANCE IN THE the private practitioners have participated
in the National Maternal Mortality Review,
PRIVATE MEDICAL SECTOR initiated by the MOH. The involvement of
private hospitals in quality activities will
The private medical sector has registered soon be made compulsory with the
tremendous growth in recent years, introduction of a system of accreditation of
providing care to those who can afford it. hospitals in which quality activities will be
The private medical sector is playing an one of the key requirements. The
increasingly important role in shaping the Association of Private Hospitals, Malaysia,

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Health Care Quality: An International Perspective

took the initiative along with the MOH to on the methodologies and approaches
draft the standards for accreditation of adopted for QA. Specifically, the training
hospitals. Some private hospitals too are covered the problem-solving process, the
moving towards attaining the certification concept and methodologies of QA, the
for MS ISO 9000 for certain departments monitoring process, the feedback
in the hospitals. Currently, the relevant laws mechanism, the investigatory procedure,
and regulations are being reviewed with the the development of remedial measures and
intention of including quality activities, such action plan (Vuori et al, 1990). Small group
as audit and credentialling. management was also included to enable
effective teamwork to be established among
QA group members. In addition,
TRAINING ACTIVITIES FOR THE educational technology was introduced to
enable learning to be propagated at local
QUALITY ASSURANCE PROGRAMME level through echo training. The thrust of
the training in capacity-building was
Recognizing that QA is a new concept for
"learning by doing", where groups of
all health personnel, multiple training
participants were brought through the
approaches were adopted in an effort to
process by designing specific QA projects
promote and institutionalize QA in health
(Public Health Institute and Medical Services
care activities. In the early phase of
Division, 1991). This training usually took
development of QAP, consensus-building
a longer period, between 2-7 days,
was the emphasis of training. Training
depending on the curriculum.
activities during this period concentrated on
promoting the concept and values of QA. The aim of the training programme in
One- or two-day seminars were organized QA is to develop a critical mass of health
for all levels of health care personnel, personnel knowledgeable in QA who are
including the top managerial group. These able to provide technical support at local
consensus-meetings were found to be level. The training strategy adopted is to
useful in sensitizing the health personnel to build on what has been introduced in other
QA, making them feel less threatened and related training programmes. For example,
more open to the new concept. These the methodology of problem-solving has
meetings enabled the MOH to gauge the long been introduced in the courses
readiness and degree of apprehension at designed for strengthening management
all levels. Presently, consensus building
skills and Health Systems Research
continues to be carried out to promote QA
methodology. This same methodology is
to newcomers in the MOH.
also adopted for QA. The training also
The awareness created through emphasizes on the development of teams
consensus-building was quickly followed by from state, district or institutions, where
capacity- building, with the aim of providing members come from different disciplines,
knowledge and skills to health personnel including paramedical staff and non-clinical

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disciplines. This enhances multi-disciplinary RESEARCH IN QUALITY ASSURANCE

teamwork and local support.

Training in QA is imparted at two Research in quality assurance is rather

levels - national and local. The national rudimentary in Malaysia. Patient satisfaction
level training concentrates on the surveys are carried out on a small scale,
development of a critical mass of health independently in institutions or hospitals.
personnel who can provide leadership and There is very little health outcome research
technical support to the local level. Priority work carried out in Malaysia. One such
is given to quality coordinators and study is currently being conducted in the
directors of hospitals to participate in these discipline of nephrology, looking at the
training programmes. Training modules outcome of care among patients under-
were developed and participants were going renal dialysis and renal transplant
given ample reference materials on QA. (Department of Nephrology, 1997).
Besides the specific skills of QA, national- There are, however, many HSA/DSA
level training is also conducted in other projects which adopt the Health Systems
related areas, such as research Research methodology being carried out at
methodology including data analysis, institutions or hospitals. In 1995, a total of
management skills, teamwork and use of 62 HSA/DSA projects were reported on.
computers. These training activities are Some examples of these studies are listed
organized by the Public Health Institute, in Appendix B.
which is the focal point for the training
activity in QA. The participants who
attended this training were given materials
to enable them to conduct echo training
DISSEMINATION AND
at their level, with or without the support DOCUMENTATION OF QUALITY
of the national group. Every organization
and hospital sets its own targets for QA ASSURANCE ACTIVITIES
training activities.
In general, the documentation and dissemi-
On-the-job training is continued by nation of QA activities in Malaysia is not
getting individuals to work closely with the commensurate with the amount of activities
national or hospital groups to work on undertaken and the effort devoted to QA.
specific tasks, such as the development of A major concern now is that much useful
protocols for investigation, evaluating effort and work in QA cannot be shared
indicators, or developing new ones. A widely because of inadequate documen-
number of selected individuals were given tation. An attempt to impart some of this
the opportunity to be attached to overseas information through quality conferences,
institutions to acquire new perspectives scientific meetings and quality bulletin has
and methods in QA. been initiated, but more effort is needed to

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disseminate widely the information and awareness of the usefulness of quality

findings from QA projects and activities. assurance among health care providers is
also noted. Problems which were hitherto
unrecognized or unattended to are being
ACHIEVEMENTS IN QUALITY realized. The simple examples of these
include the need for improved rapport
ASSURANCE between clinical departments, importance
of accurate returns, importance of correct
Although there is much more to be done documentation, and need for continuing
for QA in Malaysia, thus far, there have medical education and refresher courses.
been considerable achievements. QA was
received with varying degrees of apprehen- On a more serious note, it is often
sion in the mid-1980s and early 1990s. quoted that QA needs to be integrated into
With continued support and leadership in routine practices if it is to have a significant
quality, QA has moved from apprehension impact on the quality of care (Pedro, 1995;
to acceptance. Health care professionals Harvey, 1996). Malaysia has attempted to
are now more receptive to QA. Awareness do this in several ways. Many of the QA
of QA is widespread and there is no indicators have been used as performance
obvious cynical attitude towards it. The QAP indicators or expenditure targets in
has succeeded in bringing about improve- monitoring spending and expenditure in the
ments in hospitals and institutions which Modified Budgeting System2. On several
accepted QA as a tool to upgrade their occasions, the findings of QA have been
quality of services. used in the justification of budget and
acquisition of resources. For example, the
The direct impact of quality assurance findings on monitoring the "percentage of
in health care may not be easily measured pressure sores among bed-ridden patients"
or observed within a short period of time. in a hospital had helped the management
However, some observable improvements to convince the higher financial authority
have been noted in the process as well as of the need to approve acquisition of
the outcome of care. Some examples of additional ripple beds for the hospital.
these include: better deployment of
resources, development of guidelines for QAP was initially introduced in
managing certain conditions, improvement Malaysia without additional human or
in the management of some clinical financial resources. The national secretariat
conditions and improvement in record was assisted by personnel who contributed
keeping (Lim et al., 1991). The growing part of their time to support the QA activities

2
The Modified Budgeting System (MBS) is a budgeting system which has been pilot-studied since 1990 in three
government agencies, including the Ministry of Health. The main objectives of MBS are: to encourage
decentralisation of authority in budget management in line with the principle "let managers manage"; to
encourage involvement of top management in budget management; and to improve the level of accountability
in budget performance. To achieve these objectives, several important elements have been introduced. They
include the use of expenditure targets, preparation of programmeme

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while performing their own job functions. CHALLENGES ENCOUNTERED

It was only in 1993 that a secretariat with
three staff members was approved and The achievements attained so far did not
started functioning full time for QA come easily. Many defects were observed
activities. With the proven achievements and barriers encountered. Most of the
and hard work, more staff positions were challenges encountered were issues related
recently approved to support QA activities to perception, motivation and implemen-
at the national level. A proposal is currently tation of QA, in particular the NIA
being submitted to support secretarial needs approach. The impression of "big brother"
for QA at state and hospital levels. looking over your shoulder, searching for
QA has also succeeded in strengthen- the "bad apples" as described by Don
ing other quality improvement activities. For Berwick (Berwick, 1989) was one of the
biggest hurdles to overcome.
example, the maternal mortality audits which
were undertaken at state and district levels There were several obvious misconcep-
were formalized through the establishment tions noted during the course of the
of the Maternal Mortality Review in 1991. implementation of the QAP. There was a
This is now linked to the National QA general perception that the emphasis was
Programme. This linkage allows matters on the process of collection and submission
which require inter-disciplinary and inter- of data on indicators for it to be analysed
sectoral actions to be more effectively at the Health Ministry headquarters. The
coordinated and acted upon. Similarly, the passive role adopted by hospitals and
Pre-operative Mortality Review, which districts was to be mere data providers
originally began as a HSA project to examine rather than analysing the data against set
the quality of anaesthetic services, is now a standards and taking necessary action.
national programme which examines into all Hence, investigations were done more to
post-operative deaths in 20 public hospitals comply with the requirements rather than
(Inbasegaran et al, 1996). wish a genuine desire to identify the causes
of possible shortfalls and to correct them.
QA in Malaysia is also supported by
Since investigations were time-consuming,
other quality improvement activities which
have a common goal towards providing the increased workload without any
quality care. These include total quality perceived benefits had even resulted in the
manipulation of data so as to avoid the
management, medical audit, quality control
"outlier" status. The guidelines developed
circle, quality control, nosocomial infection
to assist in the investigation of shortfalls for
control and others. An evaluation is being
each of the NIA indicators were perceived
carried out currently to assess and recom-
mend how these efforts may be maximized to be too rigid which constrained the scope
and coordinated in a more efficient and of investigations, although they were clearly
stated as general guidance only. As a result,
effective manner towards achieving a
feedback on disagreement or recommen-
common goal (Maimunah, 1997).

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dations for the improvement of these beyond the pre-set standards was hardly
guidelines were not forthcoming. This led attempted.
to the investigations being carried out
unsatisfactorily. At the same time, several technical
weaknesses were noted. A number of
Many hospitals and states had also indicators were being used as proxies to
misconstrued all the indicators as direct detect shortfalls in a much broader area of
measures of quality rather than as a 'flag' concern. The validity of such an assumption
to examine an issue. Thus, when hospitals had not been scientifically established, nor
were not within standards for certain substantiated by studies or research. Some
indicators, it led to the impression that these of the indicators were found to be insuffi-
hospitals were providing sub-standard ciently sensitive to detect shortfalls in quality,
service. These hospitals went on the defen- nor were they sufficiently specific to measure
sive and produced reports to justify why they factors which were influenced by health care
were not "outliers". This defeated the providers or unreliable because accurate
purpose of the QAP which was to identify data were not available. Indicators had
the causes of possible shortfalls and to therefore to be reviewed with input from care
correct them. providers who were involved in QA activities.

In many instances, the staff of the There were also errors in coding and
hospitals failed to see the significance or transcription so that some hospitals were
the clinical relevance of the indicators by wrongly identified as "outliers" (Nafisah et
which they were being judged. The lack of al, 1991). Incomplete documentation in
understanding of the rationale behind an case notes also posed challenges to
indicator and its use led to confusion, investigators when attempting to identify
resentment and resistance. This situation causes of shortfalls. As a result of
persisted even after a carefully selected inadequate investigations, issues were not
representation of various clinical experts correctly identified, and in some instances
had spent long hours in discussion to revise these issues were not based on the
these indicators through an interactive and investigation findings but on perceptions.
rational process. This demonstrated that not Similarly, options for remedial actions were
all indicators which appear excellent on neither seriously considered nor explored
paper may be used effectively in practice. fully and did not match the issues identified.
They were simplistic in nature with no
Yet another misconception was that the specific plans or details on how they might
QAP was a punitive measure to find fault be implemented and evaluated. When
with the hospitals. In contrast, a sense of several issues were identified, these were
complacency was observed among not prioritized based on importance,
hospitals or districts which were not urgency and frequency of occurrence.
identified as "outliers", so that improvement When the remedial actions were identified

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 Quality Assurance in Malaysia

they, too, were not prioritized in terms of programmes where initiatives originate from
importance and feasibility of implemen- them and where ownership can rest with
tation. The time frame for implementation them. Nonetheless, In order to ensure
was in some instances too short and sustainability in the future, an evaluation of
unrealistic. It would appear that the entire quality improvement activities, including
exercise was not geared towards finding a QA is, being conducted and it should be
solution to overcome the shortfall, but to able to provide new directions for QA
write a report and comply with procedure. activities.
This led to frustration, both at the national
and ground levels.

A number of challenges were LESSONS LEARNED

encountered in the implementation of HSA
and DSA. These were related mainly to the The one lesson learnt from the process of
time-consuming nature of the studies, the developing and implementing QAP in
difficulty of initiating remedial action, in Malaysia may be summarized in the
maintaining staff initiative and interest in proverb, "Where there is a will, there is a
repeated evaluations and cyclical way". The shortcomings were turned into
monitoring as well as the technical inability opportunities to move forward. The strong
of local staff to conduct HSA/DSA projects. leadership provided by the pioneers of QA
The sustenance of HSA and DSA at local in Malaysia succeeded in guiding and
levels seemed to be person-dependent, and motivating others through the difficult
this was closely associated with the period. The strong commitment shown by
proactiveness of local QA coordinators. the top management continues to uphold
the morale of others to strive harder. The
Introducing and implementing QAP is successes achieved were celebrated, and
an important step forward for the MOH in most important of all, QA activities have
its quest for quality. The path has been been carried out in good team spirit,
difficult, and it will be no less so in the future involving various levels of health care
in order to sustain the enthusiasm, personnel in the Ministry of Health.
commitment and innovative actions of the
care-providers and managers. It is an Over the years we had received very
added workload over and above their useful feedback from clinical doctors, and
normal duties. The process to ensure a recurrent theme had been a request for
sustainability is a pressing challenge. We greater involvement by the new members
have been very fortunate in being able to of the clinical departments. This was most
obtain leadership and full support of clinical encouraging and emphasized the need for
doctors and the management. Other allied continuous training programmes in quality
health professionals in our organization activities to be conducted at state and
have been actively involved in QA activities institutional levels, as has been the practice
and are showing interest in developing for some years now. It is equally important

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for the organizational structure for quality a necessity. Quality must be included
activities to be dynamic and to be reviewed explicitly in the strategic planning process
to ensure that it supports the needs of and quality must be managed. Strong
management as well as those who directly leadership in quality has to come from all
provide the care. levels and must be transparent. Senior
managers must foster staff commitment and
These challenges and opportunities involvement in quality improvement by
have helped the MOH to improve the advocating and participating in the process.
mechanics and approaches to achieve The management must show support by
quality care. While some of these problems providing the necessary resources to carry
had been anticipated, others were the result out QA activities and they must be
of inadequate understanding of the concept adequately prepared for their role as the
of QA, the objective of the programme, the "movers" of QA.
rationale for the approach adopted and the
use of the indicators. Measures were taken QA can only succeed if it is accepted
to resolve these shortcomings such as as an integral part of daily practice and
strengthening the training programme and management and not perceived as an
the feedback mechanism from national and additional burden. QA will be meaningful
state to lower levels, and modification of and effective when it becomes the daily and
the monitoring and reporting process in the personal, goal of everyone in the organi-
QAP. A shift of the emphasis of QAP from zation – clinicians, administrators, and
NIA to HSA/DSA was carried out in which clerical and support staff. However, these
personnel were given more freedom and personal goals for optimal care cannot be
flexibility to monitor and manage their QA realized unless it is the culture where all
activities. members of the organization accept
individual responsibility for producing
quality improvements in their own particular
THE CHALLENGES AHEAD service. It is with this realization that the
MOH launched its "corporate culture" as a
There are many more challenges ahead for strategy to instil greater commitment in the
QAP in Malaysia. First, the concept of members of the organization in quality
quality needs to be considered in a different activities through the promotion of shared
light where the view point of the patient and values of quality, teamwork, accountability
the community must be taken more and professionalism.
seriously. Quality goals should be moving
targets, reset continually at higher and There is a need to achieve even greater
higher levels and continuous improvement integration of quality into the clinical and
must be the objective. To realize these management systems. A good start has been
challenges, an organization-wide commit- made by integrating some of the quality,
ment to quality and internalizing quality budget and annual performance targets. The
ethics at all levels of the Health Ministry is leaders of the quality "programmes" and

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 Quality Assurance in Malaysia

activities have been advised to develop their monitoring and enhancement of quality. An
own vision, mission, objectives and targets accreditation system is currently being
which should be in line with those developed developed to facilitate this activity and a
by the Ministry of Health. These need to be national society of quality in health is being
fully implemented. In addition, there is a planned to be established to support these
need to develop strategic goals with definite aspirations. Thus, there is every reason to
objectives of providing high quality health believe that the MOH will continue with its
care, or achieving customer satisfaction. effort to make QA a success in Malaysia
These should be specific actionable goals, and with it, the achievement of care
such as ensuring that all medical reports are provision of the best possible quality.
available within a week upon request, or to
reduce by 10% the cost of high volume
specifically-identified interventions. ACKNOWLEDGMENT
There is also a need for us to know that
The authors wish to thank Dr Peter Low
initiatives taken do result in improvement.
Chock Seng for editing this manuscript.
The need to develop careful, objective
definitions of what is to be measured is
critically important and requires strengthen-
ing in our quality activities. This, of course,
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Appendix A

Examples of national quality assurance indicators

Service
Programme Indicator
Patient care Death due to typhoid
Death due to elective cholecystectomy
Death due to haemorrhage in pregnancy
Death due to eclampsia
Hospital gross fatality rate
Post-operative infection of clean wound
Pressure sores among bed-ridden patients
Plaster of Paris cast complications of limbs
Bed occupancy rate (overall and by clinical disciplines)
Average length of stay (overall and by clinical disciplines)
Death due to gastroenteritis among children
Myocardial infarction case fatality rate
Acute respiratory infection case fatality rate among children
Head injury case fatality rate
Percentage of outpatients undergoing X-ray examinations
Percentage of inpatients undergoing X-ray examinations
Percentage of X-ray films rejected

Health Incidence rate of eclampsia

Incidence rate of puerperal sepsis among home deliveries
Incidence rate of severe neonatal jaundice
Percentage of children below 1 year who had completed third dose of DPT/DT
immunization
Incidence of tetanus neonatorum
Percentage of visual defect detected among Standard 1 school children
Average notification time index for typhoid
Morbidity index for typhoid
Detection rate of samples contravening microbiological standards
Detection rate of samples contravening non-microbiological standards
Malarial deaths
Dengue notification index
Dengue outbreak control index

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 Quality Assurance in Malaysia

Service
Programme Indicator
Pharmacy Proportion of production batches failed to batches tested for intravenous fluids
Proportion of batches failed to batches produced for intravenous fluids
Proportion of batches tested to batches produced for intravenous fluids
Annual turnover rate of stocks
Proportion of value of stocks written off annually to value of stocks held annually
Proportion of ward inspections requiring corrective action to total number of
ward inspections
Proportion of prescriptions queried to total number of prescriptions received
Number of wrongly dispensed drugs

Dental Percentage of repeat fillings to total fillings done on anterior and posterior
permanent teeth
Percentage of schoolchildren covered
Percentage of schoolchildren maintaining dentally fit status
Rate of post-extraction complications
Percentage of patients issued full dentures
Percentage of violation of optimum fluoride level at reticulation points
Percentage of 12 and 16-year-old children free from gingivitis
Percentage of 16-year-old children with complete dentition
Percentage of 12-year-old children with DMFX < 3
Percentage of 6 and 12-year-old children with caries-free mouth

Engineering Residual chlorine (RC) violation

Fecal Coliform (FC) violation
RC + FC violation
Downtime for autoclave
Downtime for X-ray equipment
Downtime for standby generator

Laboratory Percentage of urgent laboratory tests

Laboratory specimen rejection rate
Performance indicator in chemical pathology
Performance in bacterial identification and antibiotic sensitivity testing
Performance in HB, TWDC and interpretative morphology
Performance in coagulation
Performance in blood banking
Performance in histopathology
Timeliness in urgent tests in clinical biochemistry
Timeliness in CSF results
Timeliness in histopathology

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Health Care Quality: An International Perspective

Service
Programme Indicator
Training Student-teacher contact hours
Student-teacher ratio
Completion of log book
Completion of lesson plan
Passing rate of examinations

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 Quality Assurance in Malaysia

Appendix B

Examples of hospital specific approach and

district-specific approach projects

1. Documentation of in-patient medical records

2. Wound management in health centres

3. An audit of the prescription of thrombolytic treatment in patients with myocardial Infarctions

4. Waiting time for emergency surgery on compound fractures

5. Postponement rate for elective surgery

6. Shortage of drug supplies in in-patient pharmacy

7. Appropriateness of admissions to the intensive care ward

8. Effectiveness of the appointment system in Kuala Krai Hospital

9. Compliance to treatment of patients with Hansen's disease

10. Delay in scrambling time to answer ambulance calls

11. An audit on blood ordering policy for elective surgical procedures

12. Audit on quality of case summaries in paediatric follow-up clinic

13. Reducing ante-natal admissions through day-care obstetrics

14. Delay in diagnosis and treatment of patients with pulmonary tuberculosis

15. Audit in anaesthesia: A one year report.

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 CHAPTER 13
HEALTH CARE QUALITY: EXPERIENCES IN
INDONESIA
IGP WIADNYANA
NAMITA PRADHAN
PHILIP STOKOE

INTRODUCTION

The congenial economic environment coupled with the spread of education, improved
standards of living, political stability and an increase in the people’s social status have
made the community and organizations, including the health care profession, in Indonesia
look more closely at the 'quality of care'. Important questions have emerged from this new
accountability attitude such as: Is quality care being delivered in the holistic way of
promotional, preventive, curative and rehabilitative health care delivery? Is quality being
applied to health care delivery organizations? Is the level of quality being monitored and
measured? Are there differences between geographical areas only or between different
socioeconomic strata within the community? Are there accompanying structured
organizations to accommodate quality of care issues? Is there a management information
system to collect, compile, analyse and disseminate issues concerning the quality of care?
Has quality of care suffered due to cost-awareness and cost-containment? Can quality be
maintained in the face of medical/technological advancements and spiraling treatment
costs? What is the association between the health care structure, process and outcome
with the monitoring of the quality of care? What are the quality assurance roles of the
government, community, health care institutions, medical care providers, reimbursement
organizations, employers and the clients?

The paramount concern in Indonesia is whether the medical profession can assess
the quality of care. Until very recently it was neither heard of nor even thought of to
question the quality of care. Historically, medical professionals have considered
themselves representatives of the 'divine healer' and almost beyond the law of
accountability. Comments such as "medicine is an art form and not an exact science" are
still a commonplace statement. Trying to quantify 'quality of care' was beyond the
wildest imagination till the recent past. In a special communication Donabedian is quoted
as follows: the quality of care was considered as being something of a mystery: real,
capable of being perceived and appreciated, but not subject to measurement”. The authors
would like to add to this statement: And not even conceptualized as being used as a
yardstick to assess the practices of health practitioners.

To guarantee quality one has to measure the latter, and thus, before measuring the
quality of care, one has to consider the following: Are we going by the historical route by
measuring practitioner performance? Should the health care amenities be included in the
measurement? Should the accessibility and availability of health care be included in the
measurement? Should patient/customer satisfaction be included in the evaluation of

223
quality of health care? Should we try to measure the quality of care in relationship to
patients behavioral attitudes?

Indonesia has adopted strong policies addressing quality and health care
institutions and is currently implementing these policies through acceptable strategies at
various levels. Figure l outlines the conceptualized central and peripheral policies and
strategies, which are currently being implemented through various donor projects.
However, we need to first look at the basic health structure as it exists in Indonesia.

Figure 1

NATIONAL POLICIES AND IMPLEMENTATION STRATEGIES

FOR QUALITY OF HEALTH CARE IN INDONESIA

PERIPHERAL STRATEGIES

Fitting quality into the organization

and administrative infrastructure

CENTRAL POLICIES
Feedback Preconditionin
1. Quality g and training
- Definition of essential
- Philosophy staff
- Statement
- Framework
Globalization 2. Standard and guideline
setting:
(Clinical/non-clinical)
Development
- Structure
of hospital/
- Process
health centre
- Outcome
Modify - Sponsorship
- Quality
Expand - Quality
Sustain 3. Specific quality issues: statement
Institutionalize - Medical records - Philosophy/
- Accreditation culture
- Licensing - Plan
- Privileging
- Credentialling
4. Technology
- Assessment
Implementation
Information - Import
Model
transfer 5. Information transfer
- Quality Assurance
6. Medical curriculum re-
• Assessment
definition
• Management
7. Continuing quality
• Improvement
Monitoring/ medical education
- Standards
Evaluation 8. Risk management
implementation
9. Quality issues and the
- Accreditation
health law
- Technology
assessment
- System analysis
224
225
Health care system in Indonesia
The Republic of Indonesia is the largest archipelago in the world, consisting of more than
17,000 islands, of which about 931 islands are inhabited. The size of the islands ranges
from a few acres to 534,460 sq.km as in the case of Kalimantan, which is the biggest
island, followed by Sumatra, Irian Jaya, Sulawesi, and Java. Indonesia's population,
according to the 1990 Population Census, was 179,321,641, with an average annual rate
of increase of 1.98% between 1981 - 1990. Indonesia is the fourth most populated country
in the world. In 1997, the population was estimated to be about 200 million, of which
65% lived on the island of Java alone which accounts for only about 7% of the total area
of the country. Seventy-eight per cent of the people live in rural areas. The literacy rate
is 88.3% for males and 75.3% for females. The per capita income, according to the
World Bank, was about US$ 670 per annum in 1992. In the last about five years
Indonesia’s economic growth was at an average rate of 3 – 4% annually, which was
contributed greatly to accelerating the country’s development programmeme, including
health.

Indonesia is divided administratively into 27 provinces. The provinces are divided

into kabupaten/kotamadya (districts/municipalities). At the district level there is a regency
health office under the district autonomous government, which is responsible for the
execution and implementation of health programmemes. In each sub-district there is a
health centre (HC) that provides accessible, comprehensive and integrated health care to
the community in its area of responsibility, which is a sub-district or part of a sub-district.

Health infrastructure

Hospitals: There are four types of hospitals in Indonesia. These are classified as Class A,
B, C and D, depending on their size and the manpower available. At the national level
(Jakarta, Surabaya, Medan and Ujung Pandang) there are public hospitals with 1000-
1500 beds (class A hospital), which are the national top referral hospitals. In each
province there are public hospitals, class B with 400-1000 beds which are provincial-level
top referral hospitals. These class B hospitals could also provide all kinds of medical
specialist services but do not have many super-specialist services. In each district there
are class C or D hospitals serving as referral units for health centres when specialized
services are required such as surgery, ob-gyn, Pediatrics and internal medicine, with
capacity ranging from 50 to 400 beds. The D class hospitals are gradually being upgraded
so that each district would have at least a C Class hospital.

Health centres: In each sub-district there is at least one health Centre run by the
government. Each of the HCs is headed by a medical doctor and has about 8-20
paramedical personnel. Under each HC, there are 2-5 sub-centres consisting of 1 or 2
paramedical personnel (usually a nurse or midwife), to provide limited services to the
community in 1 or 2 villages within the HC’s geographical area of responsibility. One
midwife is posted in each of the villages which are beyond the catchment areas of the
health centre and sub-centre. Each HC serves about 20,000 - 50,000 population. At
present, there are 6,950 health centres, of which 1,459 centres have an inpatient ward with
an average of 10 beds each as the intermediate referral centre. The health centres are

226
supported by 6,024 mobile health centres (which are equipped with four-wheel vehicles
or motor boats depending on the geographical location). There are 19,977 sub-centres and
36,000 midwives posted at the village level. Traditional birth attendants (TBAs) are still
conducting almost 70% of the deliveries in the country. The health centres in Indonesia
provide comprehensive integrated health services including preventive, promotional and
curative services; they are also responsible for health development in their catchment
areas through community participation activities and the application of innovative
approaches. Health centres provide a broad range of basic services. Depending on the
availability of personnel and facilities, the basic services provided would include maternal
and child health; family planning; nutrition; environmental sanitation; prevention and
control of communicable diseases; curative services including treatment of casualties due
to accidents; health education; school health; sports health; community health nursing;
occupational health; dental and oral health; mental health; eye health; and simple
laboratory examinations.

Health centres operate under the administrative authority of the second level of
regional government, i.e. the regency or district-level administration. They are
administratively and technically responsible to the head of district health office. Health
centres are headed by a physician who directs, coordinates and supervises its activities,
though a number health centres lack a physician, especially in the outer islands. The
administrative support services, personnel, finance, logistics, information, etc., are
provided by an administrative section. The core operating budget for health centres is
provided through the district-level routine budget, which is mainly financed indirectly
from the central level through salary expenditure grants to regional government, other
subsidies and fee revenues. The core budget tends to be sufficient to ensure the presence
of the staff and minimal logistical support; funding for virtually all other activities is
provided from other, mostly central budgetary sources (e.g. drug subsidies, salary
supplements, etc.).

The role of the health centre is extended through several subordinate units, i.e.
health sub-centres; trained midwives posted at village level and community-based
integrated service posts ("Posyandu"). Health sub-centres are relatively simple health
service units designed to support health centre activities in a smaller catchment area,
usually two to three villages. The sub-centres, operating under the direction and guidance
of the health centre doctor are usually headed by a nurse or midwife with a total staff of
fewer than three persons; the sub-centre tends to provide curative care and maternal and
child health services. Generally, each health centre has three to four sub-centres.
Midwives posted at the village level are newly-graduated midwives who are in
compulsory government service for three years and are posted at the village level in rural
areas. They live with the community and provide MCH services to the community
through the posyandus, beside attending the deliveries at home or at the community-based
village maternity hut ("polindes"). At the periphery of the system is the community-
based integrated services post (posyandu) at the village level. Posyandus are not
permanently staffed facilities, but take the form of monthly "clinics" held by resident
village health volunteers at borrowed premises. The Posyandu focuses on providing
priority MCH services: immunization, nutrition, diarrheal disease control, antenatal care
and family planning. A visiting team from the health centre or midwives at the village
level provide supervision and technical support which is beyond the competence of the
resident village health volunteers, viz., immunization, IUD insertion, ANC, etc.

227
Development Of Concept Of Quality Of Health Care
As mentioned earlier, there has been a growing concern in Indonesia to improve the
access to and quality of health care. Given the steady economic development of the
country there is an increasing demand for good quality health care. The health scenario in
the country has been dynamic, continuously improving over the last two decades. One of
the changes that have occurred over the last few years has been the change in the situation
of the availability of manpower in the health sector. During the first few decades
following independence, shortage of medical practitioners led the government to follow a
policy whereby all medical graduates were required to join public service. However,
supply slowly outstripped the demand, leading to a situation whereby the government
revised its policy and currently appoints all fresh medical graduates for a period of three
years on a contract, to serve in health centres, after which they are free to either join the
public or the private sector.

As a result, there has been a steady increase in the availability of health personnel
in private medical care. In the face of this competition, the need for better quality public
health care has been strengthened. Introducing quality assurance programmemes, both in
the areas of primary health care, and hospital care is one of the major priorities of the
government's initiative in health care. Through the five-year Development Plans, the
emphasis has been on increasing the accessibility of health care to the people of
Indonesia, including those living in remote and difficult areas. Using the primary health
care approach, the National Health System has established a network of sub-centres,
health centres and hospitals in all districts of the country so as to ensure access to health
care. All the 3500 sub-districts of the country have at least one health centre. In some
areas these health centres are equipped with 10 beds and can provide basic in-patient care.
Sub-centres provide immunization, basic health care and health education.

It has been felt that physical expansion is not enough to ensure that the goal of
providing health for all is achieved. The development of health services in this vast
country has, at times, not been uniform throughout the country, especially in the difficult
and remote areas. The utilization of the health infrastructure remains patchy and low.
While much progress has been made in reducing the infant mortality rate, from 145 per
1000 live births in 1969-70 to 58 in 1993-94, the maternal mortality rate continues to be
higher than other countries with similar economies, causing great concern to health
administrators and policy-makers in the country. The main causes of maternal deaths are
the "classical triad" which are hemorrhage (40%-50%), infections and sepsis (20%-30%),
and toxemia in pregnancy (20%-30%). Based on the study conducted in 12 hospitals, the
above-mentioned main causes of death covered 94% of the total maternal mortality,
which was mainly due to late referrals or neglected emergency cases. Similarly, while
remarkable progress has been made in controlling vitamin A deficiency, Iodine deficiency
is still a major problem. Lack of resources, improper management and inappropriate
application of technology sometimes make the situation worse. The main outline of the
State Policy in1988 as well as in 1993 emphasized the need to enhance the quality of
health services besides ensuring equity. Having extended health services coverage to
remote and under-served areas (urban and rural), the Government of Indonesia, in the 6th
Five-Year Development Plan (1994-1999), has emphasized policies directed towards

228
improving the quality of care, particularly those that may affect a reduction in the
maternal mortality rate. Efforts to improve the quality of care began when a classification
of hospitals was attempted through the issue of a decree of the Minister of Health No.
033/Birhup/1072. However, it was soon realized that classification as a tool for improving
quality had its limitations, and that it was still too early to set out goals for a quality
programmeme. By 1981, the Army Hospital Gartot Subroto had already begun to
implement a quality assurance programmeme based on complaints received from the
clients. This programmeme was adopted by the Husada General Hospital three years later
and gradually began extending to other hospitals.

One of the earliest instances of improving the quality of health care was tried out
in the Dr Sutomo Hospital in Surabaya, East Java. As far back as 1985 a Nosocomial
Infection Control Programmeme was launched in the hospital. The goal of the
programmeme was to have clean surgical wounds at the clinical level. This activity was
chosen as it was felt that it would not need additional resources and would be easy to
monitor. A three-tier system was established - a committee of infection control at the
management level, a team at the department level, and an infection control nurse
stationed in many wards. A baseline survey showed that the Clean Surgical Wound
Infection (CSWI) was at 3.74% in 1985 at the start of the programmeme. By 1988, this
had been reduced to 1.02%. Moreover, with the reduction of CSWI there was a reduction
of 344 days of hospitalization, thus leading to substantial reduction in costs.

In 1990, an ad hoc committee on quality was formed in the Directorate General

of Medical Care, and one of its tasks was to define quality. A workshop on quality
assurance was held in 1991. This workshop formulated an operational definition of
quality assurance: Quality assurance is a systematic and continued process of measuring
the level of services to compare with the standards and make corrections so as to reach an
optimal health services delivery process with accepted outcomes. (Optimal service
delivery = minimal acceptable level of service delivery based on available resources.)The
following were to be the strategies to achieve this process.

The indicator used should be related to process and outcome, which is essential to
determine quality, and not impact indicators; QA which is dynamic and flexible should be
developed at various levels of services, at the contact point with the community, based on
the specific problems of each programmeme area; increasing the motivation of the service
implementers such that the climate and conditions are favourable; the process is focused
on the quality aspect and not on quantity; measurement of QA is stressed at the contact
points between the provider and the consumer(interface); it was to be achieved using the
existing technology and within available resources and should appropriately fit within
stipulations of the government, professional bodies, sponsors and peer groups.

The perception of quality of services depended on the expectations; different

interest groups have different perceptions about the quality of health services. These were
identified as:

1) The perception of the consumers is that the health services should be well
organized, the place of delivery be neat, clean and not over-crowded, there
should be reduction in the waiting period, and that service providers should be

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 sympathetic and approachable. The patients universally expect good,
appropriate and affordable curative treatment;

2) The professionals’ and service providers’ view is that the services should be
technically sound, their advice respected and they should be provided with the
technology necessary for the provision of quality services;

3) The funding agencies expect that efficient and effective use is made of their
financial resources; and

4) The owner of the service institution expects that a substantial income should
accrue from the facility providing quality health care and that there should be
no complaints, and that they should be able to survive in a competitive market
environment.

During quality assessment, at times, the problems identified may not be solved
locally, because the cause of the problem may relate to the total organization and the
health care delivery system. Therefore, the solution of the problems would involve the
total management system which would consist of the following: emphasis on
continuous improvement and not just achievement of a standard; quality assurance as the
responsibility of all health workers and not only of a person or unit who is in charge of
monitoring of standards; understanding the objective of health care from the point of view
of clients; the need to improve the organization, management financing and operation of
the health system to correct deficiencies from the standards; total health system
improvement not just of individual programmemes; provision of qualified essential staff
to implement and supervise QA programmemes; a short-term orientation (in the context
of long-term goals); and multi-level information transfer and rapid feedback from higher
levels . Figure 2 gives a simulated national paradigm for a total quality management
process.

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 Figure 2

A SIMULATED NATIONAL PARADIGM FOR THE TOTAL

QUALITY MANAGEMENT PROCESS

1. CORPORATE AND SENIOR LEVEL SPONSORSHIP

2. ORGANIZATION/ADMINISTRATION BACK-UP
TQM PROCESS 3. TRAINED PERSONNEL
NEEDS: 4. ACCEPTED STANDARDS/ CONTINUOUS
IMPROVEMENT
5. CATERED TO CUSTOMER/PROFESSIONAL/PAYEE NEEDS

MANAGE/ SUSTAIN

MODIFY & IMPROVE HEALTH CARE CONCEPTUALIZE

PRIMARY

TOTAL
SECONDARY
QUALITY
MANAGEMENT
FEEDBACK &
TERTIARY IMPROVEMENT

SPECIALIZED

REGULATE IMPLEMENT

MONITOR

PS/VIII/199

The Quality Movement in Indonesian Hospitals

The major push for quality improvement in hospitals started in Repelita V and was further
emphasized in Repelita VI. The Ministry of Health with the help of professional bodies,
donor NGOs and universities (i.e. University Indonesia, University Gajah Madah,

231
University Air Langga) forged a strong hospital quality programme for hospitals,
following a Hospital Diagnosis Study in 1989, which concluded that quality in hospitals
needed to be improved. The first step was to precondition hospitals in quality and
develop a quality culture supported by strong policies and appropriate strategies. Quality
programmes were implemented in five Unit Swadana hospitals (i.e. government
hospitals that are allowed to retain and use their revenues for operational and other
purposes) and these addressed both the clinical and non-clinical aspects of health care
delivery. A central QA committee was established with various departments or unit
committees reporting the results of QA activities for coordination, integration and
information transfer. Departments and units of hospitals were encouraged to start clinical
and non-clinical QA activities on a small scale usually prioritizing problem areas. Certain
departments selected time-sequence studies to identify and solve persistent problems
which led to a delay in health care delivery. QA teams were schooled in various QA
methodologies that they modified to suit their operational feasibility (i.e. cause and effect
analysis, plan-do-act-monitor-modify-sustain, and Pareto priority analysis) and soon
became proficient in their application. Clinical departments and units applied total
quality assessment methodologies which included the following; clinical profile and
system analysis, structure-process-outcome analysis, utilization review, standard and
clinical guidelines setting, health professionals review, rational drug use, peer review,
technology assessment, risk management, blood transfusion review and other pertinent
issues.

Hospitals that had mastered the QA activities implemented total quality

management (TQM) as their next step in quality improvement. TQM included the
following activities: strategic QA planning, resource identification and mobilization to
support QA activities, user-clientele-needs research, quality as part of the medical and
continuing medical education curriculum, information transfer of quality results,
quantitative and qualitative analysis for quality data, monitoring and evaluation of QA
activities, management of personnel involved in QA, continuos process involvement,
clinical and non-clinical outcome orientation, and the continuous multi-level and multi-
focal training of quality methodologies.

Currently the Indonesian hospital quality programme has undergone many

changes that have benefited the patient and the provider. Improved quality has led to a
better perception of hospital services in the eyes of the patient which, in turn, has led to
increased utilization resulting in better revenues for the hospital. The Indonesian hospital
quality model has progressed from an autocratic, top-down, focus-oriented QA
programme to a holistic type practical paradigm which is a decentralized, participative
management type model that is continuously improving the structure, process and
outcome of hospital health care delivery. Hospital quality programmes have passed from
the police-action, finger-pointing and fault-finding type of activity, and have been
transformed into programmes of risk management, utilization review, knowledge transfer,
customer-payee-sponsor-professional satisfaction, outcome-orientated and total health
care improvement of the health care delivery process. Quality of care is changing from a
single team handling quality assurance to department-units being responsible for their
own operational quality standards formulation, implementation and management. The
future paradigm calls for corporate sponsorship, managerial and administrative patronage,
increased middle- and floor-level supervisor involvement as facilitators, participation by

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all types and levels of hospital professionals, and the involvement of the community in
the hospital QA programme.

Hospital accreditation programme:

One of the early quality programmes initiated by the Ministry of Health was the
Hospital Accreditation Programme. The National Health System (NHS), 1982, stated that
"the means for the accreditation of hospitals need to be established in the near future, used
in developing policies to strengthen or improve the quality of hospitals." Accordingly, an
accreditation section was set up in the Ministry of Health. The idea was to establish a
mechanism that will assess hospitals against standards to ensure attainment of these
standards. It envisages setting up of an accreditation organization with members from the
government as well as the private sector. The method includes a pre-accreditation survey,
followed by an accreditation survey done by designated surveyors. All hospitals are
sought to be accredited but in a phased manner and in stages, starting with five basic
services of administration and management, medical services, emergency services,
nursing services and medical record services, followed by seven supporting services
including operating, radiology, laboratory, high-risk perinatal care, hospital infection
control, central sterilization, safety, fire and disaster plans. This programme has been
successfully implemented in many hospitals nationwide.

Quality Improvement Activities in Family Planning

The first formal family planning quality improvement activities were initiated by AVSC
(Access to Voluntary and Safe Contraception) with PKMI( Perkumpulan Kontrasepsi
Mantap Indonesia) in 1983, focusing only on voluntary sterlization (VS) as a "quality
assurance" approach. The system consisted of standards for service delivery, supervision
visit to VS clinics each quarter, and the use of check-lists. This quality assurance system
was seen as a way to monitor the provision of services in all these newly-upgraded
clinical sites as well as get a handle on the increasing incidence of morbidity and
mortality. Around this time, as part of a bilateral project with BKKBN (National Family
Planning Coordinating Board), PKMI organized a three-day national meeting on quality
assurance. General QA concepts were discussed which included various QA activities in
Indonesia. In 1988, PKMI prepared several documents for the VS, QA system, including
special reporting forms and an internal quality improvement component. It was
recommended that all hospitals that were part of this system should hold monthly
meetings to discuss quality problems and to decide on solutions.

Starting in 1988, BKKBN expanded its QA system to cover all the 27 provinces.
In 1990 the Private Sector Family Planning (PSFP) project was initiated with a quality
assurance component. One of the thrusts of this project was to strengthen professional
organizations, including the Indonesia Midwife Association (IBI), in quality. In 1990-
1993 BKKBN conducted a Quality Indicators study. The BKKBN and the Population
Council jointly sponsored an international meeting on Quality of Care in Bandung in
1992, which was attended by 10 countries from the Asia and the Middle East. In
preparation for this international meeting, BKKBN held a national meeting in December
1991 to gain a consensus on what quality of care (QC) meant in Indonesia. A wide
variety of organizations and people attended this national meeting, which produced lively
discussion of the theory and practice of the quality of care in Indonesia's family planning

233
programmes. Around this time (1991-1993), as part of a government-wide campaign,
BKKBN undertook its own "Quality Circle" (Gugus Mandala Mutu or GMM) programme
for its staff. In 1993, a Quality of Care Project was started and this project helped in: (1)
making accessible a good deal of QC material in the Indonesian language; (2) starting
and maintaining a dialogue between BKKBN, Depkes and various NGOs concerning QC,
and (3) funding two research studies that dealt with basic non-clinical quality of care
issues. This project helped several BKKBN bureaus (Contraceptive Services Bureau, Bio
Medical Research Bureau) to start developing their own QA concepts, papers and models.

In 1994, there was a major breakthrough in QA, with the formation by the
BKKBN of a national steering committee for family planning quality improvement
(Panitia Peningkatan Mutu Nasional). Members of this national steering committee
included the Deputy Minister for Manpower and Programme Development (Training and
Research) as chairman, personnel from BKKBN, several members from Depkes (MOH),
professional associations and the Consortium for Health Sciences. The BKKBN has
progressed rapidly in the field of quality assurance and is currently under the auspices of
donor projects conducting new operations research into quality issues and implementing
quality strategies that are applicable nationwide.

Field experience in QA in PHC from three study areas.

The quality assurance programme (QAP) as it evolved in Indonesia became more
concerned with promoting and supporting workers to improve the many processes in their
work and not only adhere to fixed standards (though development of uniform standards is
an important component of the QAP in Indonesia.). It meant helping personnel to set
performance standards that are realistic in the local setting and to monitor their progress.
In practical terms, the Indonesian QA is a problem-identification and problem-solving
approach, linking improvement in quality to continuous assessment of performance. It
begins with a multi-disciplinary team identifying a problem or problems. Using various
methods of analysis, the team identifies the causes of the problem and formulates
measures to improve the situation; at the same time it monitors the implementation to
achieve the standard and finally lays down new performance standards based on current
information, technology and the demand of the clients. This process is repeated to
identify the problems, find the causes of the problems, implement the remedial measures
and finally again to monitor results, thus achieving continuous total quality improvement.

A: Experience from Sukaresmi Health Centre at Cianjur district, West Java

The health centre covers an area of approximately 6,000 sq.km., providing services to
five villages with a combined population of approximately 40,173. The manpower
available within the working area of the health centre was as follows: 1 medical doctor, 1
dentist, 2 midwives, (one of them posted in the village), 1 assistant midwife, 1 female
nurse, 1 vaccinator, 1 assistant nutritionist, 1 sanitarian, 2 male nurses, 2 drug dispensers,
and several other non-paramedical personnel. One four-wheel vehicle was available to
be used as mobile health centre. Funds for this project were provided by WHO.

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 The health centre provided 13 of the 18 HC services: maternal and child health,
family planning, nutrition, environmental health, communicable disease control activities,
dispensary (pharmacy) services, school health, community health nursing, community
health education, dental and oral health, mental health, simple laboratory examinations
and report and record-keeping. The health centre supported two sub-centres, four village
clinics/dispensaries and 70 integrated service posts (posyandu). There was only one
midwife posted at village level in the area covered by the health centre.

Though various measures of health centre performance indicated that the

Sukaresmi Health Centre was fulfilling its role within the district health system, there
remained operational and managerial support problems that adversely affected the quality
of care provided, thus limiting the health centre's ability to effectively influence a
reduction in the maternal mortality rate. The project was conducted in four stages:

Stage I: Identifications of problems

The health centre staff and relevant district-level personnel, working in close
collaboration with members of the community, and assisted by the investigators,
identified and prioritized problems relating to the quality of maternal care provided by the
health centre. They introduced a modified check-list for ante-natal care developed by the
Aga Khan Foundation to observe the ante-natal care provided by the midwife at the health
centre and interviewed pregnant mothers after ante-natal care. The observation and
interviews were conducted by the investigators. The number of pregnant mothers
observed and interviewed was 18. Based on this, the possible causes of the problems
were identified and guidelines for focus group discussions were formulated by the team
of investigators. Towards that end, a separate series of focus group discussions were held
between the groups of health centre staff and district-level personnel on one hand and
among members of the community on the other. The use of a dual-track approach, using a
series of focal group discussions for health centre staff/district-level personnel, and a
second series of focal group discussions for the community, was seen as a means of
maximizing the input and contribution of community members, especially of those
persons who might be intimidated or hesitant to enter into a full and frank discussion in
the presence of government officials. The results from the two groups were integrated
into a single list of priority problems and their possible causes, which reflected both the
provider and community perspectives.

Stage II: Suggesting solutions

In the second stage a potential course of action (solution) was identified for addressing
the "root causes" of the priority problem mentioned above. The dual-track approach
which elicited both the provider and community perspective was employed under the
guiding principle that each of the two groups was asked to address those aspects that
reflect the group's relative competencies. The specific courses of action (suggested
solutions) with their related time-frames, resource requirements, name(s) of individuals
within the "implementing units" - the community, health centre, sub-centre, district health
office - that had immediate responsibility for the implementation of specific planned
activities, as well as a list of indicators for monitoring and evaluating the desired change

235
and a framework to guide the final evaluation, was integrated into a formal
"implementation plan". The "implementation plan" was developed by health centre staff,
relevant district level personnel and members of the community as warranted (i.e. for
specific courses of action that involved the participation/collaboration of the community),
which was used in Stages III and IV of the project. Support and assistance of the
investigators was provided for the development of the "implementation plan".

Stage III - Implementing the solutions to the problems

Based on the "implementation plan" developed in Stage II, health centre staff, with
support from the district-level health team and in collaboration with the community,
began to undertake the specific sets of activities required to address the operational
function /managerial support problems identified as adversely influencing the quality of
care. As an initial phase in the implementation process, health centre staff and the
relevant district-level personnel, with assistance from the investigators, collected the
requisite baseline data for periodic monitoring and to allow for an effective final
evaluation of the impact of the project. As part of the monitoring function, they also
assessed the progress at regular intervals and made adjustments as required in the
project's implementation plan.

Stage IV - Evaluating the solutions

At the completion of the implementation stage, an evaluation was undertaken based on

the evaluation framework developed in Stage II, i.e. Suggesting Solutions. In assessing
the impact of the solutions, attention was focused on analysing why solutions were
successful or unsuccessful in achieving a real change, and developing a series of the
"lessons learned" that could be applied to other areas within Indonesia as well as in other
countries.

B. The Lampung study

A study was carried out for quality assurance in maternal health and neonatal care in the
Lampung Tengah district of Lampung province. This project aimed at building a
consensus on quality assurance, capacity-building, training and trying to incorporate
quality assurance in the daily routine of every staff member. It also aimed at developing
indicators for the quality of services. The processes used included technical meetings,
development of an instrument for data collection, data collection, conceptual framework
and plan of action for implementing QA, and a workshop to disseminate the concept and
evaluate the results. Interviews were carried out with the service-providers. The
following are some of the conclusions of the interviews:

Interviews with the health centre doctors

On the provision of Fe (iron) tablets to pregnant mothers, the responses were not
consistent. It appeared that there were no standard guidelines for the provision of Fe
tablets to pregnant mothers; the same inconsistent response was also found for the Hb
(Haemoglobin) test for pregnant mothers. Most of the blood pressure instruments at the

236
health centres, sub-centres and those of the midwives posted in the villages were not
working; most of the doctors did not quite understand fully the objectives of post-natal
care; the records for postnatal care were not uniform; most of the doctors did not receive
any feed-back whenever they referred patients to the district hospital; the cause of
maternal or neonatal deaths was not investigated to prevent more deaths by the same
cause; non-utilization by health centres of the standard operational procedures for ante-
natal, post-natal and neonatal care (e.g. at places they were kept on the shelf but not used;
sometimes they did not reach the health centre at all). The training needs identified by
the health centre doctors were: detection of high-risk pregnancy; management of high-
risk cases and timing of referrals; management of obstetrics emergency cases; refresher
courses for health centre doctors and health centre midwives; and management of MCH
programme and its application in the field.

Interviews with midwives at village level:

The midwives at the village level needed additional practical training, especially in the
field of administration and management, and also in the field of technical skills such as
ante-natal care and recording and reporting. Coordination among the district health
officer, the CDC section chief and the vaccinators was needed for the provision of tetanus
toxoid to pregnant mothers by midwives at the village level; and training to midwives on
how to record and report the delivery of essential services.

Interview at the district hospital:

The Central Lampung district hospital had 11 specialists. The Standard Operation
Procedure (SOP) in the hospital was considered important for the general practitioners,
nurses and midwives for handling emergency cases. Apparently nothing had been done
to improve the quality of service in the hospital; discussion of the referral cases between
the specialist and the health centre doctors had never been conducted; and medical audit
had never been implemented.

Interview with district health officer

No noticeable concerted effort was made to improve the quality of service; discussion of
referral cases between the specialists and the health centre doctors not carried out.

These results were discussed by a multi-level team and a mutually agreed upon
programme was drawn up to be implemented in selected health centres in the district.

C. Experiences from the study in East Java and West Nusa Tenggara

Ten health centres participated in this study - five in East Java and five in Nusa Tenggara
Barat (NTB). The centres in East Java were typically larger than those in NTB and were
headed by more senior physicians. A baseline survey, or systems analysis, of the quality
of care in three basic health services (ante-natal care, management of acute respiratory
infections (ARI), and immunization) was conducted in May - June 1994. The results of
the systems analysis were given to the senior staff of the health centres and they were
asked to prepare plans of actions to address the deviations from standards. The ten HCs
were then divided into three groups; each group was given a different set of initial inputs

237
in an effort to determine the separate effects of these inputs. Two HCs were initially
provided with more guidance than the results of the systemsanalysis; these were dubbed
as the “data feedback" centres. In the second "treatment", district supervisors were
trained to use check-lists to observe service quality. The check-lists were drawn from the
systems analysis and were detailed standards for the three basic services plus diarrhoea
management and malaria care. Four health centres were intensively supervised using
these check-lists; this was the essence of the "supervision-based" approach to improving
quality. The senior staff of the last four health centres received 12 hours of training in
basic problem-solving and team management approaches; this became the "team-based"
approach. The distinction between these three types of “treatment” became blurred as
additional inputs were provided in an effort to achieve an impact on service quality.
During the four months of the experiment, the health centres were monitored by an
individual called "a circuit rider". They had to remind the Health Centre staff of the
existence of the experiment; they had to provide timely inputs of informal training and
advice; and keep a careful account of what was occurring in the clinics and add their own
inputs regarding the implementation in each clinic.

The results were positive, with every clinic achieving substantial improvements in
compliance with quality standards. Prior to the experiment the service quality in the three
health services was low: maternal risks were not assessed; ARI patients seemed to be
treated in an almost random fashion; and vaccinations were plagued by non-sterile
techniques. At the conclusion of the experiment these problems had been virtually
eliminated. Further, several clinics had gone beyond compliance with the standards to
address more complex problems with service quality; these included areas as diverse as
patient waiting time, service quality in other health services, patient education and cure
effectiveness. The baseline study, which included the systems analysis, was composed of
three elements: First, there was direct observation of health workers. Detailed standards
that had been adapted from international sources and field-tested extensively in Indonesia
were the bases of the observations. In each health centre, the researchers observed 25
cases for each standard (ANC, ARI and vaccination). Health workers were then tested for
their knowledge in each area. Finally, existing patients were asked questions about their
knowledge of the service they had received. The results showed that despite the national
emphasis on reducing maternal mortality, assessment of maternal risk was rare. It was
found that only a few of the patients seen for respiratory complaints were assessed for
chest retraction or rate of respiration, and the treatment of the ARI patients seemed to
follow no consistent or empirical basis. Vaccination techniques were generally sound but
there were many instances of non-sterile techniques used. Counselling was found to be
weak in all areas of implementation.

Initially there were three types of interventions. In the first case, the health centres
received only the results of the system analysis as well as three hours’ assistance in
preparing a plan of action. In the second intervention, the health centres were supervised
three times a month by district supervisors using check-lists based on performance
standards. These same supervisors later visited the other clinics in the experiment to
communicate the standards and distribute check-lists for internal use by health centre
staff. The last intervention consisted of 12 hours of training in problem-solving and team
processes. All the health centres were then visited periodically by the researchers. The
‘circuit rider’ visited each facility approximately every ten days. An international research
consultant and two national researchers made additional periodic visits. During the three

238
month life of the experiment, one facility received a dozen or more of these visits.
Within all these health centres, the health centre chief, a doctor, discussed the plan of
action with other staff and a QA team was usually formed to address activities aimed at
improving quality and adherence to standards. Some of these teams functioned as true
teams; in other instances, their role was limited. The doctor then conducted informal
training on the standards, which was followed-up by monitoring the health workers,
usually with the same checklists used by the supervisors. In most instances, health
workers were also provided with new job aids to provide visual reminders of the
standards. In almost all health centres there were problems of resistance from one or more
health workers. This resistance was overcome through reconditioning, persistent
monitoring and direct supervision.

A second survey of clinical service quality was conducted in November 1994. The
sample sizes were reduced to 12 observations for each service; the minimum sample size
consistent with the LQAS (Lot Quality Assurance Sampling) methodology. In most areas
compliance with standards reached or approached 100 per cent and there was a definite
improvement in quality operations. However, the quality programmes are extended
beyond simple adherence to standards, with several of the health centres tackling the
more difficult problems. Some examples of quality improvement were: a) Chloroquine-
resistant malaria was a growing problem in some areas of NTB. Prior to the experiment, a
clinic in an endemic area had treated nearly all malaria patients based on clinical signs
since the patients were unwilling to wait 90 minutes for the blood analysis to be
completed; consequently, nearly all patients were treated with chloroquine. The clinic
staff initiated a programme of aggressive counselling of patients to await the results of the
slide examination. At the end of three months over 70 pre cent of malaria patients now
waited for the slide results. Fears that the increased wait might reduce utilization were
unfounded as the visit rate increased slightly. This change contributed to a clear health
impact as the incidence of Plasmodium falciparum malaria found in the health centre was
reduced to about 50 per cent in one month, and these patients now received effective
treatment. The nurse in another health centre, sensitized to issues of quality by the
implementation of standards, realized that non-sterile procedure was being used for
injections, with needles and syringes often re-used five times without sterilization. The
simple corrective action was to sterilize these needles and syringes was implemented,
which contributed to improved quality. As more complete examinations were performed,
the waiting time for patients increased. In some health centres the staff responded to this
problem by providing improved seating facilities, in others by keeping the waiting
patients occupied with taped health education messages, or by redistributing tasks among
health workers to handle the greater demand, and in yet others by dividing the
examination tasks to speed patient flow. These examples prove that simple corrective
actions can and do improve the quality of clinical and non-clinical health activities.

Lessons learned from QA Experiences

Every text on quality reminds us that without top-level support, quality improvement
efforts are doomed to failure. Strong political sponsorship and well-defined policies are
the first essentials, with senior-level support and multi-level coordination being vital. All
three studies showed that some health centre chiefs moved quickly in quality

239
improvement efforts; however, others showed little or no inclination to get started.
However, the presence from time to time of senior officials in these facilities to inquire
about the progress of the QA programme had a galvanizing effect.

Appropriate clinical and non-clinical standards should be available. The health

centre staff need little external support to improve compliance with standards. They also
find the presence of clear standards reassuring. The standards tell them exactly what is
good care and they know that they are fulfilling their professional duty when they follow
those standards.

Patients, when given adequate explanations about delays experienced while

seeking care, recognize and appreciate quality service. They come to expect the higher
standard of care. In the third study, no health centre reported a decline in utilization; some
even registered slight increases.

Staffs are quick to understand technical quality. The common perception of

untrained staff is that quality problems arise from a lack of resources. Their answer to
quality problems is for their organization to give them more supplies, better facilities and
advanced training. But after training in QA, and knowing the results of the systems
analysis, health workers realized that the solution to most of the quality problems was in
their hands. Health delivery institutions have to develop and define their own quality
culture.

Quality can be improved. The dramatic quality improvements achieved in a short

period of time was the most encouraging lesson to come out of this research. Three
dimensions of quality emerged – first, who defines the problems; second, certain
problems deal with simple compliance with process and effect outcomes; and third,
complexity of analyses is required as the programme progresses. The availability of
facilitators to help facilitate the process is important, as is the implementation of an
ongoing monitoring and evaluation system to sustain the quality initiative.

There has been evidence of the effectiveness of the programme, which was
manifest in the increase in the number of safe deliveries and improvement in the case
management of malaria and ARI. At the central level it resulted in taking a closer look at
the standards and to remove inconsistencies. However, the availability of standard
resources and standard operational procedures is not an assurance that the quality of
service would be improved. In one health centre, the staff had mastered the standard
operational procedure for the ANC, though they were not performing according to the
standard because of lack of technical supervision. Training and motivation of the
implementing staff members are needed. The climate and conditions of the working
environment need to be made favorable for supporting the staff in order to improve the
quality of service. Some system of incentives or rewards may be needed.

Good quality of service needs to be combined with good coverage of the service
to make an impact on the community at large. To achieve both quality and coverage, a
better management of the service is required. Feedback to the health centre and district-
level staff on the results of the observation and focus group discussion enabled the health
centre to realize their shortcomings and try to take corrective measures to solve the simple
as well as complex problems assisted by staff at the district level. They have been able to

240
produce a sound plan for the solution of the service quality problems. The supervision
conducted by district level staff is not only limited in time but also covers only the
administrative aspects of the programme. Supervision on the technical aspects of the
programme should be enhanced. Although decentralization of execution and budget
planning for health care delivery have been implemented at the district level, yet
continuous facilitation and guidance from the provincial and central evels is still required.
The ownership of the quality programme should be decentralized to facilitate
sustainability and institutionalization. Team work, participation, integration and
coordination need to be reiterated. It is also essential to involve the community, peers,
professional bodies, donors as well as the private sector in the quality programme.
Quality has to be a team effort that requires cooperation among teaching institutions,
professional bodies, peers and other sectors to ensure its long-term sustainability. Finally,
it is equally important that quality activities do not increase operational cos5ts and thus
prove a barrier to the provision of care to the poor and the needy.

ROADBLOCKS EXPERIENCED IN THE INDONESIAN QUALITY

MOVEMENT

Roadblocks experienced worldwide are very similar to the ones experienced in Indonesia.
These are: inadequate definition of policy, statement, philosophy, sponsorship and
objectives; insufficient preparation of the health delivery environment; rapid deployment
of central policies without careful systematic planning; lack of essential personnel;
resistance from medical doctors and other health care professionals; inadequate
monitoring and evaluation; poor institutionalization of the quality process; lack of follow
through; and lack of strategic long-range central/peripheral sustainability plans.

Conclusion
Quality assurance in Indonesia is here to stay. It forms an important strategy in the
delivery of primary health care services to the people. The health centre staff can be
motivated by continuous stimulation and encouragement provided the top-level managers
are motivated and enthusiastic to improve the quality of services. The Indonesian
Ministry of Health has stressed health care quality as one of its national priorities. It has
outlined the philosophy that embraces health care delivery, which is: appropriate,
acceptable, accessible, affordable, sustainable and conforming to national professional
standards. Health care delivery should be available to all members of the user-
community irrespective of their economic, social, geographical or religious stratification.
Indonesia is participating in the global trend of total quality improvement, and is setting
down policies and operational strategies that are being implemented nationwide. The
focus of the national policy is to include quality which is holistic and incorporates the
principles of promotional, preventive, curative and rehabilitative care. The policy
includes all members of the medical fraternity, including medical doctors, nurses and
paramedical, medical and non-medical support staff. The national policy is also aimed at
professional and payee satisfaction without forgetting that the client or the patient always
comes first.

241
 The Ministry of Health has embarked on its new policy of converting general
hospitals from purely social units to financially self-sufficient units, and this has made
policy-makers and national strategists to perceive quality as a priority. Policy-makers
feel that health care institutions at all levels of the system can increase their utilization by
improving the health care quality, thus improving revenue to the institutions, which can,
in turn, reduce government subsidies to hospitals. It is recognized that national policies
will fall short without the corporate will, ownership and sponsorship. It calls for the
cooperation of the medical fraternity, especially medical doctors, to take upon themselves
the yoke of quality as a willing partner and thus promote the effort as a nationwide
endeavour.

Other policies and implementation strategies that accompany the blueprint of

national health care quality include: a statement of philosophy and mission; specific
aims and objectives; an acceptable nomenclature for its national quality programme;
administrative and operational definitions; preconditioning of individuals and
institutions; national training at all levels; setting-up of professional standards;
development of an operational and administrative timetable; appointment of monitoring
and evaluation committees; institutionalization of policies; nationwide expansion; area-
specific approach to quality; sustainability and global participation in health care quality
information-sharing.

In conclusion, no change in any medical system can take place without the
national will, sponsorship and backing which has contributed to health care reform in the
quality sector in Indonesia. It is hoped that the models presented in this chapter might be
of help to other developing countries while they struggle in their quest for expansion of
quality in their respective health care systems. It is good to remember that Rome was not
built in a day and, thus, the Indonesian Ministry of Health looks forward to the process of
QA, TQM and continuous quality improvement to provide its population with continuous,
appropriate and acceptable care in the new millennium.

Acknowledgements
The authors would like to acknowledge the following people and institutions for their
leadership in the Indonesian quality movement: Dr H. Soejoga, Dr N. Kumara Rai, Dr
Brotowasisto, Dr Adji Muslihuddin, Dr Bagus Mulyadi, Dr Soemarja Aniroen, Dr Budi
Hartono, Prof Dr Rukmono, Dr Karyadi, Dr Samsi Jacobalis and other Unit Swadana
Hospitals, Indonesian universities and various health centres. Space does not allow the
authors to mention everybody else by name and they do duly apologize for the same.

References
Philip Stokoe and Prof.Rukmono: “Medical Services Quality in Hospitals”. Presented at
the Indonesian Doctors’ Association National Seminar, Jakarta, 11-12 Nov.1992.

Ministry of Health, Republic of Indonesia. "Primary Health Care in Indonesia". Samsi

Jacobalis. Efforts to Apply TQM in Hospitals in Indonesia. Presented at the ASEAN

242
Worshop Seminar on Quality Management of Health Services, Jakarta, 23-27 January
1995.

Wiadnyana, IGP. "Country Report" The ASEAN Workshop on Quality Management of

Health Services, Jakarta, 1995. MOH document.

Karjadi W. Djoko Rushadi, Nasrun Abdullah, and Irma Prasetio. " Nosocomial Infection
Control as an Action Programme for Quality Assurance and Cost Reduction". Dr
Soetomo Hospital, Airlangga School of Medicine, Surabaya, Indonesia.

Kartonon Mohammad. “Practice Parameters on Professional Standards, and the role of

the Indonesian Medical Association in Quality Assurance”. Presented at the ASEAN
Seminar, Jakarta 23-27 January 1995.

Achmad Harjadi. “How to assess the quality of health services at the hospital level”.
Presented at the ASEAN seminar, Jakarta, 1995.

Koesno Martoatmojo. “Promotion of Capabilities of Human Resources in the Effort to

Promote the Quality of Hospital Service”. Presented at the ASEAN Workshop Seminar
on Quality Management of Health Services, Jakarta, January 23-27 1995.

Harry Feirman, Philip Stokoe, Robert Kim-Farley. “The Role of Foreign Assistance in
Quality Assurance Improvement”. Presented at Seminar Workshop on Quality
Assurance and Improvement of Health Care, Jakarta, March 28-29th, 1994.

Vinod K. Sahney, Gail L. Warden, Brent C. James, Donald M. Berwick and G. Rodney
Wolford: The Process of Total Quality Management in Health Care. Frontiers Of Health
Services Management. 7(4), 1991.

Brotowasisto, Boedihartono, Soemarja Aniroen, Soedibjo Sardadi and Philip Stokoe: “A

Review of Lembaga Swadana”. Hospital Management Internationa, (A IHF
Publication), 82-82,1992.

Bagus Mulyadi, H. "Hospital Accreditation Programme in Indonesia". MOH

documnet,1995. Wiadnyana IGP, Ambar Wahjuningsih and Surjadi Hadiprodjo. " Total
Quality Management- Experiences at Primary Health Care Level" MOH document, 1995

Daniel Longo, Kathleen Ciccone and Jonathan Lord: “Integrated Quality Assessment. A
model for Concurrent Review. American Hospital Publishing Inc., 1989.

Michael Bernhart. "Progress Report from East Java and West Nusa Tenggara Study on
Improving the Quality of Basic Health Services" MOH document, 1994.

243
 14
14
Hospital Accreditation in Developing Countries
Humberto M. Novaes, M.D., Dr. PH1

INTRODUCTION may be minimal, defining a foundation or

base, or more elaborate and demanding,
The recession of the 1980s in Latin America defining different levels of satisfaction.
resulted in the deterioration of the social Accreditation implies confidence in a
sector and, therefore, hospitals. To remedy hospital by the population. It might be said
this situation and strive for an acceptable that a health care facility 'is accredited' when
level of quality, hospital accreditation the availability and organization of its
processes have begun to be implemented resources and activities conform to a
in most countries in the region during the process whose final result is a satisfactory
1990s, supported by the Pan American quality medical care. In almost all cases this
Health Organization Regional Office for can be achieved without major investments
Americas of the World Health in infrastructure. With most of developing
Organization. Hospital accreditation in countries carrying high foreign and internal
Latin America consists of a process of debts it is highly unlikely that resources are
continuously evaluating institutional health available for massive investments in
resources, periodically and confidentially, physical or functional areas.
with a view to assuring the quality of care,
through previously accepted standards, to In 1951, the American College of
progressively improve some 16,000 Surgeons, the American College of
facilities (47% of which are private) with Physicians, the American Hospital
beds, physically and functionally. Standards Association, and the American Medical
1
Consultant to the Hospital Accreditation Project, Brazilian Ministry of Health. Former permanent consultant of
the Pan American Health Organization/World Health Organization for Latin America and the Caribbean
(Washington, D.C.) Coordinator of the Latin American Accreditation Project. President of the Institute for Technical
Cooperation in Health - INTECH, Inc. Currently also supporting a WHO initiative to implement hospital
accreditation in 10 South-East Asian countries and coordinating a pilot project in Brazil and Colombia on the
Accreditation of Health Service Networks, for the W. K. Kellogg Foundation. For further information write to or
call INTECH, Inc., at 12 Pasture Brook Ct., Potomac, MD 20854, USA. Tel. (301) 610-9620, Fax (301)
610-9621or E-Mail: [email protected]

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Health Care Quality: An International Perspective

Association cooperated to form the Joint 1997, to have 60 hospitals accredited(1).

Commission on Accreditation of Hospitals, At the end of 1995, PAHO/WHO, head-
also as a result of the need to improve the quartered in Washington, D.C.(2), sponsored
quality of care in the US. Today it is the the III Conference on Accreditation in Latin
primary instrument, used by the U.S. Health America, where all the advances achieved
Care Financing Administration, to transfer in this region's countries were presented and
funds to hospitals. Only hospitals that have future goals discussed (see Annex).
passed an accreditation process are
contracted. Other regions of the world have In all successful cases, it was possible
also employed this method, such as to identify a leader in the process.
Australia, Canada, the province of Sometimes this leadership initiative came
Catalunia in Spain, and England, that has from the private sector, as in Guatemala,
a 'self-evaluation' programme. In Asian or from the public sector, as in Peru. Some
countries, the accreditation process is also approaches were paired where the public
beginning to be implemented in Thailand, sector was represented by health ministries,
Indonesia, Republic of Korea, and Taiwan. and the private sector represented by private
In Thailand, standards are currently being hospital associations, as in the case in
tested in 35 pilot hospitals, and in Indonesia Brazil. In spite of recommendations that the
standards for five hospital services or areas National Accreditation Commission be
in more than 100 hospitals, have already multi-institutional, and should represent
been developed and implemented. In both the public and private sectors,
Taiwan, 547 hospitals have met accredi- including broad representation by private
tation requirements, and the Republic of institutions, the presence of the Ministry of
Korea is in a pilot stage, drafting a new Health is essential because of its prestige
law including the specific codes creating a in emerging countries, and the capability
core accreditation organization. of transferring resources within the process
of national hospital accreditation.
In almost all countries in Latin America
and the Caribbean, the process began to
be implemented through national meetings, THE LATIN AMERICAN
primarily after the II Conference on Hospital
Accreditation (1992). In the Andean sub- ACCREDITATION MODEL
region, Bolivia, Colombia and Peru
obtained significant success; all these The basic reference mechanism in Latin
countries already have their respective American countries was the Accreditation
manuals of Standards and Indicators for Manual, published by PAHO/WHO in
Hospital Accreditation. In Central America, several languages, with adaptations for
Guatemala achieved the most success and each country, province or state (3). This
in the Caribbean, the Dominican Republic instrument was designed keeping the reality
is in the process of accrediting all its private of the developing countries and, hence,
hospitals. Cuba had hoped, by the end of Latin American hospitals, in view.

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 Hospital Accreditation in Developing Countries

Nearly 70% of the hospitals in Latin national experts and adaptations were
America and the Caribbean (16,000 made as needed.
hospitals with 1 million beds) have fewer
than 70 beds, including Brazil (65% of All standards were organized by
6,000 Brazilian hospitals) (4). Although there increasing the related degrees of satis-
are prominent public and private medical faction (or complexity) in such a way that
centres, comparable to the most advanced to attain a superior level of quality for a
in any other nation, a large number of these specified hospital service, the standards for
hospitals would not withstand the minimum inferior levels necessarily would have to be
evaluation to guarantee a permanent level satisfied. The standards sought to evaluate
of quality. Currently, these hospitals reflect - within a single service - aspects of
deep discrepancies in quality among structure, processes, and results through
different services of the same hospital, qualitative and dynamic evidence of
independently of the number of beds. performance or indicators that reflect the
quality of services provided. To establish a
Faced with this scenario, PAHO/WHO given level for each item, the evaluation
developed a hospital accreditation model, should begin at inferior levels, until finding
with the support of Member countries, the level whose requirements are not
appropriate for this region, to be discussed completely satisfied.
extensively at the country level, that is
flexible enough to allow for adaptations of Qualitative indicators, or evidence of
major differences between one sub-region performance, are described for each
and another*. standard and designed to ascertain the
degree to which measures prescribed by
The first step in developing the Hospital standards are carried out and their effect
Accreditation Manual was to convene a on patient care. The data collection process
small group of two or three specialists in for observing qualitative indicators was
hospital management to devise standards designed to be as simple as possible. The
and qualitative indicators for these results should offer information useful to
standards (or evidence of performance of those in decision-making or managerial
the standards) for each of the units of a positions to help them make necessary
general community hospital. During this changes. For countries that do not have
preliminary activity, the group consulted sufficient valid or reliable information for
scientific entities and various specialists. This statistical analysis, or where adequate
document was later thoroughly reviewed by numerical data have not been collected, the
indicator for each standard will be

* ‘Hospital’ is defined by PAHO/WHO as an establishment, having at least five (5) beds, that admits patients
and guarantees basic diagnostic care and treatment with organized clinical equipment, proof of admission,
and continued care provided by physicians. Also included are 24-hour nursing services and therapeutic care
provided directly to patients, with availability of laboratory, radiology, surgery, and/or obstetrics services, as
well as organized medical records for rapid observation and following of cases.

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Health Care Quality: An International Perspective

determined by qualitative observation using As a hospital is not comprised of

surveyor consensus. In the future, and to independent or isolated services, it is
the extent that data are collected and necessary that all of its services, from the
analysed, one will be able develop statis- laundry to the operation room, or to staffing
tical interpretations to establish quantitative of the intensive care unit, for example, have
indicators or indices for standards. reached at least the level one standard to
Currently, qualitative indicators point to be accredited and receive the resulting
sources where surveyors can seek evidence, reputation for good quality medical care.
or where a hospital can show surveyors that
it is, or is not, complying with the stated An isolated service is not 'accredited'.
standard(s). These sources might be Even if a hospital unit is fully equipped and
documents, interviews, medical reports, is of exceptional quality in some units or
patient's records, etc. services, with levels of sophistication at three
or four, the institution will continue to be
The model of the Accreditation Manual accredited at the first level if the other
for Latin America and the Caribbean covers services do not exceed the first level. In the
all services of a general hospital for treat- case of Chile, there is a national organ of
ment of acute cases. It was published to the Health Ministry, that 'accredits' hospital
serve not as a set of paradigms, but rather infection control units in hospitals. We have
as an illustrative guide for national multi- been recommending that they avoid using
institutional commissions when formulating the term 'accreditation' for this type of
their own evaluation tools. surveillance activity, because often the
Increasingly complex standards, or infection control organ or commission exists
those that evolve continually, were estab- but many other hospital services are not
lished for each hospital service, from an satisfactory.
initial threshold to more sophisticated
This methodology attempts to reinforce
levels. These standards represent the
the fact that hospital structures and
expected level of desired care, practice,
processes are so integrated that poor
or method defined by national experts
functioning in one component interferes
and/or professional associations. In each
throughout the system, and in the final
situation, the initial standard is the required
result. Thus, a hospital is or is not accredited
minimum limit of quality. No country's
as a whole, indivisible unit. Distinct levels
hospital hopes to find itself below this level,
within a specified period of time, for of accreditation are not established for each
example. As these initial standards are type of service. It is commonly observed that
met, subsequent steps are addressed to hospitals perform complicated clinical
reach successive standards. Thus, when procedures; however, the surgical centre,
the standard for level 1 is met, the next for example, must interrupt its activities for
step is to reach level 2, then 3, lack of linens; or hospital services are good
progressively(5). but the nutrition department leaves much
to be desired(6).

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Latin America's hospital accreditation a hospital is not accredited by one entity, it

is a method of ongoing consensus, may be accredited by another, under
rationalization, and hospital organization. different standards. It is essential to have
The first instrument for the explicit and uniformity; therefore there must be a
objective technical evaluation of quality is National Commission that applies uniform
the Accreditation Manual, and the second, accreditation standards to be followed by
of great importance, is the Accreditation State or provincial entities.
Commission, which should be apolitical,
multi-representational, and should under- During many meetings, sponsored by
take its work quietly and periodically. When PAHO/WHO in various countries (7), we
under exclusive governmental control, this observed that the best recommendations for
Commission endures frequent distortions setting up these commissions always
because of the innumerable political involved the participation of (i) providers,
pressures placed on government officials, (ii) buyers of services, and users, along with
and, as a result, hospitals either do not representatives from the public sector
undergo the correct accreditation process (especially the Ministry of Health and Social
or do not implement corrective measures Security), and (iii) the private sector (hospital
recommended by the Accreditation associations), and technical support from
Commission. non-medical professional associations as
well as country's most distinguished medical
The private sector in Latin America, for associations or academies.
all its cultural tradition of dependence on
the public sector, will still need State The discussion at these meetings of the
incentives for some years for the develop- profile of suggested surveyors concentrated
ment of social actions, of which health is on professionals of unquestionable prestige
an important part, and which frequently and experience. Individuals with these
requires subsidies to correct programme qualities would be needed to carry out
deficiencies, especially those for medical relevant recommendations and assess
care for the more underprivileged in the improved hospital functioning through visits
population. If Accreditation Commissions lasting several days, followed by internal
are regulated exclusively by the private discussions to resolve challenges
sector they will lose the force of incentives encountered. Accreditation is always
that, in Latin America, almost always result periodic, confidential, and established with
from government initiatives. deadlines for correction of flaws.
Accreditation in Latin America, in reality, will
Another threat is the appearance of be a process of permanent education for
multiple accreditation entities, competing hospital management.
among each other, and setting different
standards, priorities, and fees. This can Physicians in Latin America, as in other
affect the entire accreditation process countries, frequently use implicit, subjective
negatively, leading to the possibility that if criteria to judge the quality of medical care.

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Health Care Quality: An International Perspective

Each hospital, locally, should develop its mainly with structural standards (physical
own explicit criteria to guarantee quality, infrastructure, human resources, technology
carefully established by its medical, nursing, updates) and procedural standards for the
and health authorities. Examples of main processes in key areas of productivity,
proposed explicit criteria include examina- such as promoting the preparation of
tion when undertaking a particular surgery; organizational and procedural manuals,
how a diagnosis of streptococcus could including detailed description of practices,
only be confirmed by microbiological patient and material flows, as well as patient
culture; or that time frames for submitting admissions, medical records, drugs and
laboratory tests be the minimum acceptable food distribution. Only in a subsequent
for obtaining results. These explicit criteria phase can we proceed to evaluate proce-
facilitate evaluation by non-medical dural standards for clinical services,
personnel, simplifying future processes for standards or clinical protocols.
accreditation. When the preliminary procedures are
As an initial focus for implementing and under way, it will be possible to implement
guaranteeing hospital quality, the use of a quantitative data collection system for all
accreditation programmes contributes to a services - non-existent until then in most
planned and progressive change in habits. hospitals of the region - and begin to assess
Professionals in all units and services are the outcomes and impact of medical care.
prompted to evaluate institutional strengths It is unsustainable to recommend to these
and weaknesses by establishing clear goals countries that they should begin their
and constantly mobilizing the work force, accreditation programmes through output
thus improving objectives to guarantee standards when serious structural and most
better quality medical care. Accreditation essential procedural processes have not yet
should precede any other initiative for been resolved.
evaluating quality, such as 'Total Quality', Our methodology proposes that each
'Continuous Quality Monitoring', 'ISO service or hospital department standard
9000', etc. Already, there are hospitals in reflects increasing satisfaction, depicting an
Latin America trying to implement the ISO environment of continuous improvement,
9000 methodology in one unit, while other because there will always be standards of
services exhibit quality levels incompatible higher complexity to pursue. Before, during
with reasonable hospital functioning(8). and after an evaluation for accreditation,
officials must gradually develop items to
Critics of accreditation methodology, identify and distinguish discrepancies
especially those with little experience in
between practices and acceptable stan-
developing countries, are not aware of the
dards of quality, finding ways to correct or
serious problems faced by these institutions. reduce deficiencies through the institutional
During the initial years of this model of
prestige rewarded to the one who brings
'continuous quality improvement
forward the most challenges and presents
programme', it will be necessary to work appropriate solutions.

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 Hospital Accreditation in Developing Countries

New channels of communication must and independent, which is always the

be pursued, prompting needed changes goal to be reached, although it is not
and overcoming resistance to the imple- easy to achieve a consensus among the
mentation of quality standards, made different actors in the public and private
compatible with the value system of the health sectors to work together with a
hospital community. In this process, nurses common goal.
play an essential role for they are, out of
all those who work in hospitals, the only 3. The role of public or private social
professional group with a permanent security and private health insurance is
presence, having learned managerial and vital for implementation since the link
clinical auditing concepts during and after among accredited hospitals in their list
academic training in Latin America, and of providers characterizes the impor-
with unique skills to help in the assessment, tance of hospital accreditation as an
implementation, and monitoring of the instrument to ensure quality of care for
entire accreditation process. the clients of these institutions. Private
businesses are beginning to analyse this
situation although, unfortunately, no
country until now has had a process to
MAJOR CHALLENGES tie national accreditation to contracts
for hospital services.
The major challenges we faced in imple-
menting hospital accreditation in Latin 4. The non-application of minimum
America were: standards, as opposed to optimum
standards. The need to implement
1. Legal considerations such as executive
basic accreditation standards still exists
orders, laws, or regulations of the
in this phase of development of the
Ministry of Health that are important
16,000 hospitals in Latin America. This
and useful but not the paramount
seems to be the most rational approach
factor. In some cases, such as
since no country would have satis-
Colombia or Guatemala, the change
factory human and financial resources
in health ministers hindered the
to correct deficiencies throughout all of
implementation policy, even having just
its hospitals, whether structural or
been announced by decree, regula-
process-related, using optimum stan-
tions, etc., if the new minister did not
dards. Because the methodology
consider it a priority to encourage the
anticipates that each hospital service
national process of accreditation for
will have increasingly complex stan-
political reasons. Thus, the initiative was
dards, it is possible to expect that the
delayed until another minister pressed
highest standards would be considered
the issue.
ideal. Generally, professional associa-
2. Lack of a national commission on tions, for example, of medical or
hospital accreditation, inter-institutional nursing category, always strive to

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Health Care Quality: An International Perspective

establish optimum standards, although 7. Misuse of utilization indicators. Utiliza-

when starting to implement the accredi- tion indicators such as 'length of stay'
tation process, they convince them- or 'occupancy rate' are not indicators
selves that it is not possible to begin of quality for accreditation since the
with very sophisticated levels. Conse- 'case mix' is unknown. These data
quently, very few hospitals, in the short describe the use of services or
term, manage to be in a position to productivity, not their quality.
implement optimum standards.
8. Confusing licensing with accreditation
5. Standards for ALL hospital services or categorization. Until now, some
instead of for a few units. Approval of countries, such as Haiti and Nicaragua,
particular units or isolated programmes have not instituted a national hospital
has been supported by some groups, licensing system, or an initial health
such as in Chile or the state of Paraná, permit for construction or renovation,
Brazil, by those in charge of the that is generally issued by municipal
Program for Prevention and Control of authorities, and that almost always
Hospital Infections, as mentioned deals only with observable structural
above, or isolated accreditation of features (licensing). Other countries,
hospital laboratories as proposed in such as Argentina, classify their
Brazil, Dominican Republic or Mexico. hospitals by categories, where one
A hospital may have a good hospital could perform a given proce-
programme in place to control infec- dure but others could not. This classifi-
tions or clinical laboratory, but this does cation (categorization) is usually done
not always ensure that other services in an area of regionalized services in
are in a position to be accredited, even an attempt to rationalize the use of the
using minimum standards. same. When a country tries to use
accreditation as a tool for licensing and
6. Risk of assigning points, or giving a categorization, such complexity is
precise value or numerical score to created so as to render accreditation
findings. This approach resulted in impractical.
problems because in some cases, the
sum total of points fell within a category 9. Incentives and sustainability of a
of 'excellent' or 'good', while masking national accreditation programme.
an area 'with lesser points', having Although accreditation is voluntary on
serious problems (false positives). the part of hospitals, these institutions
Instead of giving a score, the surveyors, must have some incentive for accepting
by consensus, agreed at the end of the the accreditation process. In the United
accreditation visit, whether the hospital States, the vast majority of hospitals
was or was not accredited, or if some survive as a result of patients covered
time was required to correct by MEDICARE, or social security for the
deficiencies (partial accreditation). elderly. For a hospital to be contracted

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 Hospital Accreditation in Developing Countries

under MEDICARE, it must have prior of specialized consultants helping the

accreditation from the National hospital to overcome its managerial or
Accreditation Commission; in essence, technical difficulties. Assessment teams
'voluntarism' being relative... similar generally include a physician recog-
incentives for sustainability of this nized for his/her skills, a nurse with far-
process will be required in Latin reaching experience in hospitals, and
America. an administrator with a solid back-
ground in hospitals. In Latin America,
10. Role of a leader. The presence of a most of the hospital administrators are
leader who strongly supports accredi- physicians, but in the surveyor team
tation and promoting and implemen- they are only 'administrators', leaving
ting its concepts, is essential in any the clinical side to be observed by the
country. physician on the team (Figure 1).
11. Role of surveyors. The accreditation
process must always be viewed as an
auxiliary and permanent educational PRIMARY LEVEL OF HEALTH CARE
activity for hospital staff; never a
bureaucratic inspection or critical audit Upon reviewing proposed changes,
in search of victims. The basic role of hospitals in Latin America should not lose
surveyors should always be seen as that sight of the fact that they are part of a social

Figure 1 : Features of the accreditation model in Latin America

1. INCREASINGLY COMPLEX STANDARDS
(Constant encouragement for continuous improvement)

2. ABSENCE OF POINT SYSTEMS

(To avoid the appearance of false positives)

3. NON-CATEGORIZATION
(System not tied to classifications)

4. QUALITATIVE INDICATORS or EVIDENCE OF PERFORMANCE

(Use of these indicators until reliable data exist)

5. UPDATES EVERY TWO YEARS

(Always seek to update the manual for new circumstances)

6. ESTABLISHMENT OF REGIONAL COMMISSIONS

(Regional adjustments without compromising the national model)

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Health Care Quality: An International Perspective

context where other health services always maintaining constant balance between
exist, and that although more resources and short- and long-term objectives. New
materials are committed toward improving programmes developed from the current
quality, a considerable number of emphasis on quality aspects contribute to
challenges remain to be solved in spite of new ideas, replacing outdated concepts or
successes achieved from within the institu- habits. True hospital leaders, who know
tion. It is noteworthy that in Latin America, how to take advantage of this impetus, will
50 to 70% of medical care in emergency introduce 'new' concepts about the social
hospitals is for primary care, and these mission of the organization to offer services
services are overwhelmed and care of excellent quality in which responsibility
disorganized. Such cases could be treated falls on the hospital as a 'family' and not
with greater ease and quality at reasonably on an individual, as seen in the 'Luis Calvo
well-equipped health posts, centres, or Mackenna' Hospital, in Santiago, Chile(10).
clinics in close proximity to a hospital(9).
The establishment of precise short- and
Investment of resources at these long-term measurable objectives, and
primary levels, even before considering frequent monitoring, will transform plans
humanistic aspects, is related to the into actions, establish organizational
functional survival of the hospital as a highly strategy, and implement these programmes
complex, expensive, and well-respected or solutions. During the designing of
medical care facility. Investments in strategic planning of the hospital mission,
diagnosis and care of cases, treatable at the need to interpret all aspects of the
primary level health care facilities, represent sociology of medical care, analysing the
significant savings for hospitals that need environment outside the hospital, patient
not care for these more simple pathologies. access to the institution, and the ability of
A serious side-effect is that hospitals are the hospital to meet community demands,
not able to devote quality medical care to will surface naturally (Table I).
these cases because of pressures from
demand; they are forced to concentrate
exclusively on a patient's chief complaint, THE CASE OF HOSPITAL
not emphasizing important aspects such as
health promotion and prevention of ACCREDITATION IN BRAZIL
disease. This can be addressed with greater
efficiency in a network of health posts or Brazil represents an interesting case study
centres. of the hospital accreditation process in
emerging countries. In March of 1997, the
For a hospital to implement a President of the Republic of Brazil and the
programme to guarantee quality, it should Minister of Health launched the programme
be under permanent managerial scrutiny, '1997/98 - The Year of Health in Brazil'.
redistributing resources according to This included a formidable array of priority
priorities contingent upon services, and government policy directives, actions, and

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Table 1. Summary of the hospital accreditation situation

in Latin America*

Initiative of Existence of
Existence of Process of
hospital a national
Country manual of implemen-
accredi- joint
standards tation
tation commission

Argentina Yes Yes No Limited

Bolivia Yes Yes Yes N/A
Brazil Yes Yes No Yes
Chile Yes Yes No In public
hospitals
Colombia Yes Yes No On stand-by
Costa Rica No No No No
Cuba Yes Yes Yes Yes
Dominican Yes Yes Yes Yes
Republic
Ecuador No No No No
El Salvador No No No No
Guatemala Yes Yes Yes Yes
Honduras No No No No
Mexico Yes Yes No No
Nicaragua Yes Yes No Limited
Panama No No No No
Paraguay Yes No No No
Peru Yes Yes Yes Yes
Uruguay Yes Yes Yes Limited
Venezuela No No No No
*The author will be pleased to inform the names of institutions in the above-mentioned countries for further
information.

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Health Care Quality: An International Perspective

goals. For the first time, the Ministry of patients are aware that criteria for quality
Health, among the activities to improve are the same in any state in the country.
quality of health services, proposed to
coordinate the process of evaluating the As neighbouring nations of
quality of client care in public and private MERCOSUR, the sub-regional intercountry
hospitals through an initiative known as agreement among Argentina, Brazil,
Hospital 'Accreditation'. Paraguay and Uruguay, have already
begun their accreditation processes, these
This term was introduced in Brazil at a procedures will facilitate future care of
seminar, organized by the Pan American patients in accredited hospitals in Member
Health Organization (PAHO/WHO) in countries. They will be assured that medical
1992(11), in Brasilia, three years after the I care adheres to similar standards of quality.
Latin-American Conference on Hospital All these initiatives should follow the basic
Accreditation (PAHO/WHO, Washington, criteria proposed during the meetings
D.C., 1989)(12). The objective for intro- organized by PAHO/WHO so that future
ducing this word into Portuguese was to clients may be confident of receiving the
give it the same meaning as in other same treatment independent of where that
countries since 'accredited' hospitals deserve treatment is delivered, provided they seek
all the credits, inspire confidence, or are hospitals accredited under the same
incontestable. methods.

Four accreditation initiatives were The Brazilian proposal for a national

implemented in four states of Brazil in mid- commission structure, approved by the
90s. The first, in São Paulo, was developed Ministry of Health, features a board of
by the São Paulo Association of Medicine directors, made up of three main compo-
and the Regional Board of Medicine; the nents: (i) representatives of private hospital
second, in the State of Rio Grande do Sul, providers, as hospital associations,
was led by the private sector through its federation of hospitals (unions), university
Hospital Association Program; the third, in hospitals, and entities representing chari-
the state of Paraná, was started by the State table or religious hospitals; (ii) Private buyer
Health Department, and the fourth, in Rio representatives, such as HMOs, insurance
de Janeiro, is an association of the National companies, medical cooperatives, etc.; and
Academy of Medicine, Brazilian College of (iii) the public sector, as the Ministry of
Surgery, and the Institute for Social Health, National Committee of municipal
Medicine of the State University of Rio de or state health secretaries, etc.
Janeiro. This current proposal by the
Ministry of Health seeks to consolidate these In addition to this board, there are
different groups, recommending the use of representative groups that will make up the
common criteria to evaluate quality. This future consultative board, composed of (i)
methodological conciliation among health professional associations, such as
Brazilian initiatives is essential so that medical associations, associations of

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 Hospital Accreditation in Developing Countries

nurses, and other professional entities; for inclusion in the accreditation and
(ii) academic organizations that will support evaluation manuals; and
the executive branch of the national
commission with ongoing recommen- 5. To consult regularly with public and
dations for improvement and updates of private institutions responsible for
standards and preparation of training medical-hospital care.
material for hospital administration; and
(iii) representatives from state accreditation
agencies. TASKS FOR ACCREDITATION
Financing for the national commission PROGRAMME IMPLEMENTATION
is expected to be through the Health IN BRAZIL
Ministry and health service provider and
buyer resources. These different sources will 1. Conceptual and methodological
assure political independence of the consolidation of the programme, with
commission and its sustainability. participation of state surveyors.

2. Establishment of a commission to
OBJECTIVES OF THE BRAZILIAN review/revise the accreditation manual.

PROGRAMME 3. Consultation meetings at the state level.

4. Consultation meetings at the national

1. To promote the introduction of a
level.
permanent accreditation process at the
national level, with the establishment 5. Consolidation of the principles of the
of the National Commission on accreditation manual and of surveyor's
Hospital Accreditation, to improve tools. Pilot study in hospitals repre-
quality of care through periodic senting private and public sectors, with
accreditation of hospital systems; small and large number of beds, in all
sub-regions of the country, with twelve
2. To encourage the establishment of
experienced surveyors.
multi-institutional commissions, at the
state level, for hospital accreditation, 6. Review of legislation and proposals for
based on national criteria; the establishment of a programme and
a national accreditation organization.
3. To institute mechanisms at the hospital
level for self-assessment and conti- 7. Standards for the establishment/
nuous quality improvement of medical formulation of state organizations for
care; hospital accreditation.
4. To establish standards and qualitative 8. Proposal for financial sustainability of
indicators (evidence of performance) state and national programmes.

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Health Care Quality: An International Perspective

9. International seminar to present the on the medical structure and quality of care
Brazilian Program on Hospital are found in the US, legal suits against
Accreditation sponsored by the Ministry physicians for malpractice or negligence
of Health. distort the entire quality assurance system,
causing medical care to be extremely
defensive and forcing hospitals to enact true
FINAL WORDS preventive 'habeas corpus' to defend
themselves against possible lawsuits.
No quality programme could ever be
Unless mechanisms are implemented
introduced into an unqualified clinical
urgently through hospital accreditation in
facility. Aspects related to the training,
the not too distant a future, Latin American
certification and re-certification of the
countries will have to contend with the same
medical profession in Latin America will
punitive legal actions because of their
likely be the greatest challenges for the
vulnerability to hospital or physician's
health sector in the new century.
negligence or malpractice. This must be
Recruitment, development, evaluation and
avoided at all costs, long before the current
retention of hospital staff, but more
absence of quality evaluation mechanisms
importantly, the knowledge and skills of
leads to legal intervention or financial
those in a clinical environment, are inherent
pressures, not felt in the current system. The
in quality programmes. It would be
other threat is that, instead of the implemen-
inexcusable to continue passively accepting
tation of self-assessment methods, followed
the situation in which medical teaching is
by external assessment by the state joint
carried out by medical schools without
commission surveyors, the accreditation
adequate training services, 'medical
process will be imposed by independent
residencies', or schools not providing
HMOs or private health insurance.
guidance and preceptorship, or in a
situation with lack of appropriate legislation As a view toward the future, we
on periodic assessment of medical visualize accreditation not only for
practices. hospitals, but for the entire health service
network, at primary, secondary and tertiary
The United States, with more than
levels. In this regard, the W. K. Kellogg
5,000 accredited hospitals, is undoubtedly
Foundation is developing a pilot project for
the most advanced country in terms of
the accreditation of health service networks
control of medical and hospital care.
in two municipalities in Brazil and two in
Various evaluation mechanisms are used,
Colombia. Accreditation is performed
based on rigorous quality standards in its
based on 19 broad and important areas
respective structures, processes, and results.
or dominions, that need to be observed by
All these tools do not, however, prevent the
a health service network, within a specific
health industry from being a target of legal
geographical area or local health system.
suits. Although the world's main paradigms
Five standards and five sub-standards,

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 Hospital Accreditation in Developing Countries

including their respective qualitative the accreditation commission, which should

indicators, are proposed for each area or be apolitical and multi-representational,
dominion. going about its work quietly and
periodically.
If this pilot project runs according to
expectations, the Network Accreditation After the II Conference on Accreditation
Manual will be implemented in other (1992), PAHO/WHO sponsored a number
community health service development of national meetings in Latin America and
projects, supported by the W. K. Kellogg the Caribbean, covering practically all
Foundation. Currently, health ministries countries of the region. In Brazil, most of
allocate funds to the local levels without any the progress was observed in the states of
instruments to verify accountability and Rio Grande do Sul, São Paulo, and Paraná.
whether these resources are being applied In the Andean sub-region, the success
appropriately, making a positive impact on achieved by Bolivia, Colombia and Peru
the health of the population served. This was impressive. In Central America,
will be another approach benefiting Guatemala achieved the most progress. In
emerging countries in their efforts to assess the Caribbean, the Dominican Republic is
the use of financial resources allocated to going through a full accreditation
municipalities, within the policy of govern- programme of its private hospitals and
ment decentralization that is occurring in Cuba intended to have 60 accredited
all Latin American countries. hospitals by the end of 1997.

If quality control mechanisms are not

implemented urgently through hospital
SUMMARY accreditation, countries will find that, in the
near future, they will be facing punitive legal
The process of hospital evaluation through
consequences because of their vulnerability,
accreditation is characterized by the need
whether as a result of hospital negligence
for standardizing all services according to
or malpractice. This should be avoided at
recognized quality standards. Accreditation
any cost, long before the current absence
is a method of consensus and rationaliza-
of quality evaluation mechanisms leads to
tion of hospital operations. The first tool for
legal intervention or financial pressures, not
the explicit and objective technical evalua-
felt in the current system.
tion of quality is the accreditation manual,
and the second, of overall importance, is

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Health Care Quality: An International Perspective

Annex

Chronology of the Guatemalan hospital accreditation process*

1. 1990 - Presentation of the Accreditation Manual prepared by the Pan-American Health
Organization/World Health Organization - PAHO/WHO for national authorities, representing
the private and public sector.
2. 1991 - Establishment of the National Accreditation Commission.
3. 1992 - Review and adaptation of the PAHO/WHO manual for Guatemala.
4. 1993 - National Seminar on Hospital Accreditation and validation of standards and evidence
of performance (qualitative indicators).
5. Pilot self-assessment evaluation in the 'Hospital San Juan de Dios' and validation of strategies
5.1 Contact with hospital authorities
5.2 Training of staff on concepts of accreditation; presentation of the Manual to governing
bodies and hospital committees
5.3 Configuration of the Hospital Accreditation Committee
5.4 Self-evaluation, based on the proposal standards of services and tasks by managers
5.5 Design of situational profile
5.6 Plan of action to improve the standards that did not reach the minimum level
5.7 Training and monitoring the plan of action
5.8 Assessment of services by the internal accreditation committee
5.9 Report to the hospital authorities
5.10 Continuation of the cycle...
6. Self-assessment in four hospitals, belonging to the Public Social Security, Ministry of Health,
Ministry of Defense and private sector, respectively.
7. 1994 - II National Seminar on Hospital Accreditation
8. Self-assessment in 16 national hospitals
9. 1994 - Participation in the Sub-regional Meeting of Central America and the Caribbean,
with participation by nine countries (PAHO/WHO, Mexico, D.F.)
10. Continuation of the process with establishment of an internal hospital committee, plans of
action, and evaluation of the accreditation process
11. 1995 - Reformulation of some standards and indicators
12. Continuation of cycle....

* This model also was followed by other countries.

** This scheme was presented at the XII Annual ISQUA Conference in St John's, Newfoundland, Canada

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 Hospital Accreditation in Developing Countries

References 6. Novaes HM. Calidad Total - Nuevo Recurso para

los Hospitales de America Latina: El Ingeniero
1. Pan American Health Organization. Informes Gerencial. Rev. Educ Med y Salud 1994;
finales: Reuni?nes Sub-Regionales de 28(4)90-505.
Acreditaci?n de Hospitales. Cone Sur: Rio de 7. Novaes HM. Programas de Garantia de Calidad
Janeiro: PAHO/WHO, March, 1994; Sub-Regi?n a través de la Acreditaci?n de Hospitales en
Andina, Bogotá: PAHO/WHO, May, 1994; Sub- America Latina e el Caribe. Rev. Salud Pública
Regi?n Mexico, Centro America y Caribe; PAHO/ de México 1993, 35,(3)248-258.
WHO< August, 1994. 8. Novaes HM. Estarán Preparados los Hospitales
2. Pan American Health Organization. Informe final; Latinoamericanos y del Caribe para la
iii Conferencia Regional de Acreditaci?n de Reingenieria? Rev. Educ. Med y Salud 1995;
Hospitales. Washington, D.C.; PAHO/WHO, 29(3/4)27-45.
1995. 9. Novaes HM. Quality in Hospital Care. World
3. Paganini JM, Novaes HM; La Garantia de Health Forum 1993; 14:367-375.
Calidad - Acreditaci?n de Hospitales para 10. Artaza, B.O. et al. Hospital Juis Calvo Mackenna:
America Latina y el Caribe. Series Adesarrollo y Como preparar a una organizaci?n pública para
Fortalecimiento de los Sistemas Locales de Salud, funcionar en un modelo de Aautogesti?n ;y
@ Public. HSD/SILOS No 13. 190p., satisfaccion usuaaria@? Cuad. Méd Soc.
Washington, D.C., Pan American Health XXXVIII,3,1997;28-37.
Organization; 1992.
11. Pan American Health Organization. Informe
4. Pan American Health Organization. Direct?rio Final: I Reuni?n Nacional de Acreditaci?n de
Latino Americano e del Caribe de Hospitales. Hospitales. Brasilia:PAHO/WHO; 1992.
Washington, D.C., Pan American Health
12. Pan American Health Organization. Informe final:
Organization; 1996.
I Conferencia Regional de Acreditaci?n de
5. Gilmore C, Novaes HM. Gerência da Hospitales. Washington, D.C.:PAHO/
Qualidade. Series PALTEX/UNI, Volume III, WHO;1992.
Washington, D.C., Pan American Health
Organization; 1996.

Page 257
 15
15
The Effectiveness of Quality Assurance*
Avedis Donabedian, M.D.

B
efore I begin, let me specify my terms so as to influence indirectly the behavior
of reference. I take it that there are of providers and recipients.
two ways to safeguard and improve
the quality of health care. In this paper, I shall be thinking of the
quality of clinical care, which should be the
One is to design and operate the central concern of quality assurance.
system of health care in a way most
conducive to good performance. And, of the two kinds of quality
assurance, I shall have in mind mechanisms
Another is to have in place a mecha- that review performance and act to adjust
nism to constantly review performance, find it.
out why it does not meet expectations, and
take action to improve it. Finally, I shall conceive of the effective-
ness of such mechanisms as a kind of
Exactly what action is taken depends process, consisting of several steps:
on what one determines or believes the
difficulty to be. First, introduction and implantation;
Then of implementation;
And that action can be of two kinds. Then of modifications in behaviour;
And then, finally, of progress toward
First, one can engage in educational health.
and motivational activities that directly
influence those who provide or receive care; What do we know about the prospect
and second, one can modify system design of success at each of these steps? What do

* This chapter comprises a paper presented by Dr Avedis Donabedian at the 1st Oklahoma Conference on
Managing Care and Quality in Oklahoma City, USA, in February 1997. The paper was so refreshing and
had a number of valuable concepts and lessons that we thought it would be befitting to use it as the closing
chapter for this book. This paper is intended to keep the discussion on quality open and to encourage the
reader to continue learning more about it. – Ed.

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Health Care Quality: An International Perspective

we know about the factors that influence The contextual factors are the situation
success or failure? in which quality assurance is to be
introduced and implemented. I shall
The answer, alas, is that we know very mention four such factors.
little. There are very few controlled studies.
There is, mostly, a large number of 1. Perhaps the most general and most
anecdotal reports, of stories of experience: fundamental principle of effectiveness
"We did so and so, and look what is to be found in the concept of
happened!" "culture".

From such reports we could conclude By "culture" we mean what one believes
that almost every method of performance and values; how reality is seen and
review and readjustment can be successful, interpreted; how it is proper to behave; how
to some degree, in some situations. things are done. This includes how quality
is defined, who is responsible for it, and in
And yet, we find that these same what ways.
methods, under other circumstances, fail to
succeed; and that there is no one method It is often said that some forms of
regularly superior to the others. quality assurance amount to a "thought
revolution," one that requires corresponding
From these stories of experience, I cultural change. Some features of that
conclude that success or failure does not change include assumption of responsibility
depend on the method of review and for quality at the highest reaches of an
readjustment, in itself, but on an interaction organization; the diffusion of that responsi-
between the method and the circumstances bility throughout the organization; a
of its application. corresponding empowerment of care-giving
Unfortunately, we do not have now a personnel; and a less authoritarian form of
theory that can explain and predict these governance.
interactions. Rather we have many theories, 2. But, one might ask, how is this cultural
and have also a number of eclectic change to come about?
formulations, total quality management
(TQM) for example. The usual answer is, "through
leadership," which is the second of my
Nevertheless, guided by experience, contextual factors.
theory and some speculation, one can
extract from the literature on effectiveness Leadership can be exercised not only
certain themes that I shall now try to present. at the top of an organization, but at every
level, and in every group. Partly it is
In order to do so in an orderly fashion, associated with positions of authority, but
I shall divide the factors believed to other things matter as much, if not more:
influence effectiveness into two large
groups: "Contextual" and "Operational."

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These include the ability to persuade; • Something can be done to meet

to motivate; to inspire trust; to set a the need.
personal example. For that reason, most • That which will be done, or is done,
clinicians want to have in charge of the is the right thing done in the right
quality assurance apparatus one of their way.
own: a clinician senior in rank, and of
unquestioned competence. • There are demonstrable, useful
results, free of unforeseen, harmful
3. This preference is related to a third consequences.
contextual factor — that of
I shall say a few words about each of
"sponsorship".
these.
In clinical practice, sponsorship by the
One: There is a demonstrable,
relevant professional association (of
consequential, legitimate need.
physicians, of nurses, and so on) is a key
resource. A genuine conviction that performance
needs to be improved is the indispensable
4. Both leadership and sponsorship imply
first step in the process of quality assurance.
still another determinant of effective-
Such conviction must exist in the
ness, that of "formal organization".
organization, in the group, and, ultimately,
Within formal organizations leadership in each individual, insofar as that
can be exercised, interpersonal interactions individual's own performance is concerned.
are intensified, and cultural change
Many things contribute to the
hastened. Where such organization is
attainment of this conviction:
lacking, as in the private practice of
ambulatory care, a substitute has to be • External requirements and
created. standards

My four contextual factors, therefore • Group discussions within an

are: "culture," "leadership," "sponsorship," organization
and "formal organization." • Credible data that document
performance
I now turn to the second category of
factors: the ones I have called "operational". • Comparison of performance with
professional standards
In order to present the operational • Comparison of performance
factors in systematic fashion, I shall use a among similar institutions and
model of health behaviour that offers the among colleagues.
following steps:
• Self-imposed goals, especially as
• There is a demonstrable, to expected improvements in health
consequential, legitimate need.

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Health Care Quality: An International Perspective

• Personal participation in need Here, several "principles" come into

identification, standard setting, play.
data collection, and interpretation
of data. 1. The first is the principle of "congruence."
This means that what is done, or
• And face-to-face discussion with a proposed, should fit existing values and
trusted senior colleague, in small norms. It should be seen not as a
groups, or privately as individuals. foreign intrusion, but as a return to the
The second step in the progression I purer, more authentic traditions of the
have postulated is as follows: Something health care professions.
can be done to meet the need.
Therefore, the purposes of the quality
In addition to the availability of assurance enterprise should be to advance
resources, the general principle here is that patient welfare, to reinforce professional
of "empowerment". responsibility, and to serve the need of
professionals to know and to continue to
Groups and individuals who become learn.
aware of needs to improve, or of oppor-
tunities for improvement, should feel able As to the methods of review, these
to act, either to bring about change directly, should be as similar as possible to the ways
or by communicating with responsible in which professionals think and practice.
persons. It is disturbing to ask professionals to adopt
concepts and methods borrowed from the
If needs and opportunities are identi- industrial sector. And it is unnecessary to
fied, but no one listens, or nothing is done, do so, since much of what seems new in
cynicism and apathy result. The quality such concepts and methods is indigenous
assurance enterprise is doomed! to and traditional in the health care
professions.
The third step in the progression of the
model is as follows: That which will be Here are some examples:
done, or is done, is the right thing done in
• Professionals wish to monitor their
the right way.
own work
The introduction of performance review • Led by a colleague they respect
can be very threatening. It is essential, and trust
therefore, that those who are to be
• To study patterns of performance
subjected to such review know in advance
rather than individual mistakes
that there will be proper respect for what
they believe to be right and proper, and that • To identify failures in underlying
what ensues will be, and is, good and useful processes and structures
to themselves and to their clients. • And to rely on education and
motivation rather than punishment.

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 The Effectiveness of Quality Assurance

2. These, and similar, preferences are in bringing about cultural change

related to still another principle, that of or redefinition; as it reinforces
"ownership". existing norms it can create new
ones as well.
Professionals wish the quality
assurance enterprise to be theirs rather than And now I am ready for the fourth step
someone else's – and that (as I have already in my model, as follows: there are
said) by virtue of: demonstrable, useful results, free of
unforeseen, harmful consequences.
• cultural congruence
• professional leadership We could call this the principle of
"fruition".
• professional sponsorship, and
• personal participation. It must be clear that, as a result of
performance review, something is done,
3. And through ownership we move on to and that the consequences are right, good,
two other principles: and useful.
• of "relevance," and
It is utterly destructive to have quality
• of "utility." assurance become merely a tissue of
ostentatious pronouncements, or only busy
I mean that the quality assurance
work: onerous, boring, unrewarding,
enterprise operates in areas of interest to
useless.
professionals; where they work; where they
exercise responsibility; where they can bring Even worse, if it should lead to dilution
about change. of professional responsibility, distortion of
professional responsibility, stereotyping of
Performance review must aim to
practice, discouragement of innovation,
accomplish what professionals should wish
legal hazard, fearfulness, evasion, conceal-
to be done in any case.
ment, and ultimate demoralization.
Two further observations remain to be
Fortunately such evils do not often
made:
occur, but we must always be on our guard
1. I believe that what I have described against them.
as congruence with professional
culture and preferences applies And now I am ready to conclude my
also to every other group subject sketchy account of what I believe influences
to performance review. effectiveness or ineffectiveness in
performance review and readjustment.
2. And, secondly, although the quality
assurance enterprise must seek I have kept to the last the single most
congruence with the prevailing important factor of all.
culture, it is, itself, a powerful force

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Health Care Quality: An International Perspective

To my mind, the single most important Let us leave this place determined to
condition for success in quality assurance hold the stewardship to quality as a sacred
is the determination to make it work. If we trust.
are truly committed to quality, almost any
reasonable method will work. If we are not, Once again, we dedicate ourselves to
the most elegantly constructed mechanism that high calling.
will fail.

Page 264
 Index
A B
Abraham Flexnor 3, 81 Bagus Mulyadi, H 239
acceptable quality levels 24 Baird R 110
Access to Voluntary and Safe Contraception Barnette JE 132
227 Barriers to Success Model 112
Achmad Harjadi 238 Bassett M 209
Action-taking 113 Batalden 83
Activity-Based Costing (ABC) 146
Batalden PB 91
acute respiratory infection (ARI) 33
Beckhard R & Harris RT 131
Adaptation 117
Affinity Diagram 35 bed occupancy rate 200
Aga Khan Foundation 230 Bell Laboratories 5
Agency for Health Care Policy and Research benchmarking 197
11, 37 Benneyan JC 110
Ahmad Sarji Abdul Hamid 209 Benson 37, 53
Al-Assaf 9, 26 Berwick 19, 32
Al-Farsy F 176 Berwick DM 53, 209
Al-Mazrou Y 176 Blood utilization 180
Algorithms 36 Blumenfeld SN 110
allocation of resources 135 Blumenthal D 110, 210
Alma-Ata Declaration 163 Boerstler H; Foster RW 110
Amburgey TL 131
Bohr D; Bader B 91
American College of Physicians 241
Boles KE 161
American College of Surgeons 3, 241
American Hospital Association 241 Bolivia 242, 251
American Medical Association 37, 241 Boyce N 91
ante-natal care 230 Brassard 34
Antibiotic Prophylaxis project 89 Brassard M 53
applicability and reality 40 Brazil 243, 251
Appraisal Costs 148 Brook 13
Argentina 248, 251 Brotowasisto 239
Arikian V 161 Brown L 142
Artaza, B.O. et al 257 Brown LD 110
Asmah Abdul Hamid 209 Bull 13
Assumptions 113
Bunker JP 92
Asthma project 89
Burke WW 131
average length of stay 200

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Health Care Quality: An International Perspective

C Coronary Artery By-pass Graft

(CABG) 36
care maps 37 cost-containment 24
Caribbean 242 cost-reduction 8
Case management plans 36 cost-saving 18
Cause-and-effect diagrams 77 Costa Rica 251
CDD 174 Couch JB 110
census sample 61 council of national representatives 137
Chan, YC 161 Cretin S 83
Check sheets 66 Critical paths 36
Chile 11, 251 critical paths of care 37
China 11 critical pathways 37
Chloroquine-resistant malaria 234 Crosby PB 26, 110
Chronic Health Evaluation II Cuba 251
(APACHE II) 83 cultural devices 129
Clark 46 Culture 114
Clean Surgical Wound Infection 223
Clinical care protocols 37
clinical practice guidelines (CPGs) 11
D
Coch L & French JRP 131 Daigh RD 161
Codman 13 Daley 13
Codman E 92 Dalkey NC et al 54
Coffey RJ 92 Daniel Longo et al. 239
Coffey RJ et al 54 Dawkins 42
Coker M 132 Dawkins, Brian 54
Colombia 242, 251 Decision-making 113
Comatose Patient Management Decision-making matrices 78
Algorithm 36 defect-prevention paradigm 5
communicable diseases 190 Delaware Valley Hospital 88
communications and secure Delineation of responsibility 135
commitment 103 delivery system 144
compliance measurements 135 Deming 26, 32
Comprehensive Cardiovascular Deming Cycle 90
project 89 Deming EW 110
Comprehensive Health Planning Act 7 Deming WE 54, 80, 142
Computer-based learning (CBL) 46 Deming W. Edward 5
Computerized Severity Index (CSI) 83 Deprete-Brown L 110
concept of quality 103 Diagnosis Related Groupings (DRGs) 8
Congress 11 DiPrete-Brown L et al 54
Continuing Medical Education 183 discontinuous change 116
Continuous Quality Improvement (CQI) 42 Disease Staging Tools (DSTs) 83
continuous quality improvement (CQI) 84 Dissemination materials 45
Control charts 76 District Health Systems 11
Control of diarrhoeal diseases 174 Dodge 4
Convenience Sampling 62 Dominican Republic 248, 251
coordinator of health care quality 99 Donabedian 7, 32

Page 266
 Index

DPR Korea 11 G
Drucker 17
Duncan WJ 161 Geehr 83
Dynamic complexity 113 General MacArthur 5
Gillem T 161
Gilmore C, Novaes HM. Gerência da
E Qualidade 257
Eastern Mediterranean Regional Office Ginn GO 131
163 goal-setting theory 126
Ecuador 251 Goal/QPC 110
Eddy 32 Grossman 36
Edwin Chadwick 2 Guatemala 251
Egypt 11
El Salvador 251 H
Ellwood 83, 88
Emory Grove 3 Hagan JT 161
EPI 164 Haney 42
Epstein A 92 Harrington JH 161
Ernest Codman 3 Harry Feirman et al. 239
Establishing appropriate transitional Hart MK 80
devices 125 Hart RF 80
European Region of WHO 11 Harvey G 210
External stakeholders 113 HC4 88
HCFA standards 33
Health Care Financing
F Administration 242
face-to-face interview 63 Health Care Quality Improvement Program
Failure Costs 24, 151 (HCQIP) 89
false negatives 59 Health Maintenance Organizations 8
false positives 59 health maintenance organizations (HMOs)
family planning 227 89
Farr W 92 Health Management Information System 197
Feasibility 34 Health plan Employee Data and Information
Feedback mechanisms 126 Set 90
Ferguson B 210 health services 8
Finison K S 80 Health Status Questionnaire 83
Finison L J 80 HEDIS 13, 90
Flood AB 92 Heidemann EG 210
Florence Nightingale 2, 81 Hernandez SR 131
Flowcharts 72 Hersey, Paul 53, 54
Flu project 89 Hess P 131
Foster G 161 high-risk cases 232
four 'absolutes' of quality 24 high-risk pregnancy 232
Franco LM 110 Histograms 68
Honduras 251
Hornbrook M 83, 92

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Horngren CT 161 K
Hospital accreditation 227
hospital gross fatality rate 200 Kaluzny AD 161
Hospital Standardization Programme 3 Kaoru IshiKawa 25
hot line on patient education 61 Karjadi W. 238
human resources 126 Kartonon Mohammad 238
Keidel RW 131
Kellogg W. K. Foundation 254
I Khoja TA 176
Impact 34 Kilmann RH 131
Imparato A, Rites T 32, 53 Kilmann RH 131
implementation assessment 105 King Hamourabi 2
Implementation stages 106 Koesno Martoatmojo 238
Importance 34 Kotter JP 131
improvement opportunities (IOs) 56 Krczal A 210
Inbasegaran K 210
indicators 39 L
Indonesia 11, 217
Infection control 180 laboratory specimen rejection rate 201
infectious diseases 190 Latin America 241
inpatient services 8 leadership paradigm 2
Institute of Medicine 11 Leebov W 80
Institutionalization 134 Lezzoni 83
interview 63 Lezzoni L 92
IshiKawa 26 life expectancy 190
Ishikawa’s diagram 77 Lim ES 210
ISO 45 Linder J 83, 92
IUD insertion 46 Lippitt GL 131
Lohr KN 46, 92
Longo DR 80, 92, 93
J Luft HS 93
Jablonski JR 110
JCAHO 33 M
Jenks SF 89, 92
Jennings BM 92 M. C. Lorenz 73
Jick TD 131 Magnusson P 93
Joiner Associates 26, 110 Mahar 93
Joint Commission on Accreditation of Health mail survey 63
Care Organizations 4 Maimunah AH 210
Joint Commission on Accreditation of malaria 235
Hospitals (JCAH) 4 Malaysia 189
Jones GR 131 Malcolm Baldrige National Quality Award 25
Jordan 11, 177 malnutrition 190
Joseph M. Juran 23 malpractice insurance 145
Juran JM 24, 26, 110 Management information systems 83
Management skills 113

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 Index

Management's commitment 97 Nafisah AH 211

Managing resistance 119 NAHQ 26
Mapping health care quality Narine L 131
intervention 102 Nash, D. 83, 93
Markson 83, 93 National Association of Quality Assurance
Martin J & Powers 131 17
Martin J 131 National Demonstration Project 10
McLaughlin CP 161 National Health Quality Improvement
mechanism for incentives 105 Act 9
Medicaid 7 National Library of Medicine 46
Medical Outcome Study 83 National Maternal Mortality Review 201
Medical records 180 National Social Security Act 4
MEDICARE 248 National Technical Information Service 46
Medicare 7 NCQA 13
Medicare Hospital Mortality NCQA’s Standards for Accreditation of
Information 10 MCO’s 36
Medication Errors 59 neonatal care 232
Medication utilization 180 Neumann BR 161
Medis Group and Acute Physiology 83 Nicaragua 251
Meisenheimer C 110 Nicholas 21, 26
Meltzer R 93 Niger 11
methodology for setting standards 33 Nominal Group technique 69
methods for evaluation 105 non-probability sampling method 62
Mexico 248, 251 not-for-profit organization 9
Michael Bernhart 239 Novaes HM 257
Mick SS 161
Mills 33
Ministry of Health 101
O
mission and vision statements 100 objectives of quality 104
mission statement 136 obstetrics emergency cases 232
monitoring/quality control 17 O'Dowd TC 211
Morale 113 O'Leary DS 13, 93
morbidity 167 Omachonu VK 80
Morehead 4 Omachovu 26
Morris KF 131 Omaswa F 132
mortality 167 On-the-job training 203
Mortality and morbidity 180 Operational planning for quality in health
Moses LE 93 care 97, 103
Multi-media 45 Optimal service delivery 223
Multiple Voting technique 69 organizational behaviour 135
Muthler 161 organizational structure 104
myths of quality 17 Outcome specification process 83
Outcomes Management 81
N Ozeki K 80

Nadler DA 131

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Health Care Quality: An International Perspective

P Q
Paganini JM 257 QA professionals 9
Pan American Health Organization QISMC 89
241, 242 quality 1, 15
Panama 251 quality assurance (QA) 11
paper airplane 28 Quality Assurance Project 55
Paraguay 251 quality assurance, reassessment
Pareto Analysis 73 and improvement (Q) 89
Pareto concept 73 quality council (QC) 99
Pareto diagram 73 Quality Cycle 55
Pathmanathan I 211 quality improvement 17
Patient Management Categories quality improvement system for
(PMCs) 83 managed care 89
Payne 4 Quality Quest 83
Pedro JS 211 Quota Sampling 62
Peer Review Organizations (PROs) 8
Pennsylvania Health Care Cost Containment
Council 88
R
percentage of urgent laboratory RAND Corporation 83
tests 201 Rank Ordering technique 71
percentage of X-ray films rejected 201 Re-creation 118
performance measurement 12 Reger RK 132
Peru 242, 251 Regional Medical Program Act 7
Peterson 4 Reinke J 80
Pettigrew A 131 Renshaw LR 132
Philippines 11 Reorientation 117
Pie charts 66 report cards 12
pilot projects 102 Republic of Korea 242
Plan-Do-Check-Act (PDCA) 90 Reward system 113
Plsek PE 80 Rewarding supportive behaviours 121
post-natal care 232 Roberts JS 93
postnatal care 232 Roemer MR 93
Prevention Costs 150 Roemig 4
primary health care (PHC) 11, 163 Roitman DB 132
private medical sector 190 Rouse LW 132
Problem management 113
process improvement teams 102
process improvements 135 S
Professional Standards Review Organizations
(PSROs) 8 Safety regulations 200
progress reporting mechanism 105 Sahney 26
Promoting participation 121 Salancik GR 132
Psyches 113 Sample size 62
Purposive Sampling 62 sampling 62
Sampling methods 61
Saudi Arabia 163

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 Index

Scatter diagram 67 Tertiary 225

Scholtes 35 tertiary health care 167
Scientific management 22 test validity 59
Scott WR 92 Thomas JW 93
Sebai ZA 176 Thompson L 132
Secondary 225 Tompkins P 132
Sequenced leverage points 124 Topology of Costs 144
Shewhart 4 Total Costs 154
Shortell SM 93, 132 total quality management (TQM) 1
Simple Random Sampling 62 TQM 6
Simpson 161 traditional healers 190
Sirchia G 132 training requirements 104
Slee DDA 161 Trend and run charts 71
SleeV 161 Tuning 117
Social Security Act 7 two-way (dual) communication 168
Specialized 225 TyPE (Technology of Patient
standard operating procedure (SOP) 32 Experience) 83
Standardization of outcome measurement
instruments 83
standards 39
U
standards for clarity 39 U.S. Air Force 80
standards for reliability 39 UNICEF 164
standards for validity 39 Uniform Clinical Data Set (UCDS) 89
Statements 36 University Research Corporation 11
statistical process control 4, 22 Uruguay 251
steering committee 137 US Agency for International Development
Stewart AL 83, 93 (USAID) 11, 55
Stiles RA 161 US Congress 11
strategic planning 97
Strategic planning for health care
quality 97 V
Strategy 114
Strategy-structure 113 Van Maanen J & Barley S 132
Stratified Random Sampling 62 VanAmringe 46
Structure 114 Venezuela 251
supportive supervision (POSS) 172 Vinod K. Sahney 239
sustainability 134 voluntary sterlization 227
Suver 19 Vroom VH 132
Suver JD 161 Vuori H 211
Systematic Sampling 62
W
T waiting time at out-patient services 201
Taiwan 242 Walter A. Shewhart 5
Taylor D 211 Walter G 132
telephone survey 63 Walton M 110
Warden 26

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Health Care Quality: An International Perspective

Ware JE Jr 93 World Health Organization (WHO)

Watson GH 53 11, 37, 163
Weighted Voting technique 70 Wuthnow R 132
Weingarten 43, 53
Whitehead TP 211
Wiadnyana, IGP 238
Z
Williams WH 53 Zero defect 21
Williamson JW 211

Page 272
 Index

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