Health Management

(540163)

Lecture 7: Quality: the basics

Quality Definitions
• “The degree or grade of excellence”.

• “Degree to which a set of inherent characteristics fulfils

requirements”.

• The result of a system with interpedently parts that must

work together to achieve outcomes.

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Quality Definitions
• “The degree to which health care services for individuals and
populations increase the likelihood of desired health
outcomes and are consistent with current professional
knowledge.“ IOM,1990

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Quality Definitions
Doing
– the right thing,

– at the right time,

– in the right way,

– for the right person

– and having the best possible results.

IOM

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Quality in different areas of society

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Quality
• Subjective
• Different meaning for different people
• Mandates by
Needs
Context
Personal perceptions
Resources
Expectations

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Dimensions of Quality
1. Effective (evidence based, needs based)
2. Efficient(maximizes resource, avoids waste)
3. Accessible (timely, geographically, skills and
resources are appropriate to medical need)
4. Acceptable/patient-centred(expectations,
culture)
5. Equitable
6. Safe

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Terms of quality according to Avedis Donabedian,
1966:
• structures (material and human resources)
• Processes (the way care is delivered and managed)
• Outcomes (resulting health outcomes)

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 Why focus on quality?
• Health expenditure in industrialized countries has doubled in
the last 30 years
• The highest-spending countries are not always those with the
best results.
 increased know-how and increased resources will not
necessarily translate into the high quality of health care
 How HC is organized and the delivery of care has become
important
• There is undersue, oversuse or misuse of the resources.

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Internal and External Benefits of
Quality

Internal Benefits External Benefits

Customer gets correct
Reduces costs product or service
Increases dependability
Increases speed Correct specifications
Boosts moral Appropriate intangibles
Increases customer retention
Increases profit Customer satisfaction
Customer retention

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 QUALITY DOES NOT
OCCUR BY ACCIDENT
• What does the customer actually want?
– Identify, understand and agree
customer requirements

• How are you going to meet those

requirements?
– Plan to achieve them

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The IOM Committee’s first report.
September 1999

 Health care in the United States is not as safe as it

should be and can be.
 44,000 people to 98,000 people die in hospitals
each year as a result of medical errors that could
have been prevented.
 High costs: in terms of money and in terms of
loosing trust in HC system for patients and
professionals.

Violation of ethical principal: “First, do no harm.”

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 Patient Safety
• “The prevention of harm to patients.” IOM
• The system of care delivery that prevents
errors; learns from the errors that do occur;
and is built on a culture of safety that involves
health care professionals, organizations, and
patients.

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 Errors are caused by
faulty systems, processes, and
conditions that lead people to
make mistakes or fail to prevent
them.

Can be prevented by designing

the health system at all levels to
make it safer to make it harder
for people to do something
wrong and
easier for them to do it right.

Quality Assurance and Quality Control

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 Swiss Cheese Model of system failure

Every step in a process has the potential for failure, to

varying degrees.
The ideal system is analogous to a stack of slices of
Swiss cheese : Consider the holes to be opportunities
for a process to fail, and each of the slices as
“defensive layers” in the process.
An error may allow a problem to pass through a hole
in one layer, but in the next layer the holes are in
different places, and the problem should be caught.
Each layer is a defence against potential error
impacting the outcome.

James Reason, 1990. The book reference is:

Reason, J. (1990) Human Error. Cambridge:
University Press, Cambridge.
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 Swiss Cheese Model of system failure

For a catastrophic error to occur, the holes need to align for each step in the process
allowing all defenses to be defeated and resulting in an error. If the layers are set up
with all the holes lined up, this is an inherently flawed system that will allow a
problem at the beginning to progress all the way through to adversely affect the
outcome. Each slice of cheese is an opportunity to stop an error. The more defenses
you put up, the better. Also the fewer the holes and the smaller the holes, the more
likely you are to catch/stop errors that may occur.

James Reason, 1990. The book reference is:

Reason, J. (1990) Human Error. Cambridge:
University Press, Cambridge.
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 APPROACHES OF QUALITY
• Quality Control (QC)
• Quality Assurance (QA)
• Total Quality Management (TQM)
• Continuous Quality Improvement (CQI)

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Evolution of Quality

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 Evolution of Quality I

 Finding mistakes/errors

 External assessment/control  Inspecting

 Culture of mistrust
the past

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 Evolution of Quality II

 avoid mistakes
 Looking into
 personal responsibility /
ownership
the past and
plan for the future
 culture of trust

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 Evolution of Quality III

 Systematic fulfillment of
customer requirements

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 Evolution of Quality IV

 Participation of all members of

an organization

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 Quality Management
Quality Management System: Management system to direct and control an
organization with regard to quality – ISO 9000:2000

Quality Management

Quality Planning Quality Assurance Quality Control

Criteria driven Prevention driven Inspection driven

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Quality Management Components
• Quality Planning
– It identifies the standards and determines how to satisfy those
standards.
– It lays out the roles and responsibilities, resources, procedures,
and processes to be utilized for quality control and quality
assurance.

• Quality Assurance
– It is the review to ensure aligning with the quality standards. An
assessment will be provided here.
– Planned and systematic quality activities.
– Provide the confidence that the standards will be met.

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 Quality Control – Inspection Driven

• Quality Control
– It addresses the assessment conducted during
Quality Assurance for corrective actions.
– Measure specific results to determine that they
match the standards.
– Use of Statistical Process Control (SPC) : a
methodology for monitoring a process to identify
special causes of variation and signal the need to
take corrective action when appropriate.
– SPC relies on control charts.

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TOOLS IN QUALITY

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 Plan-do-study-act (PDSA)
• Deming Cycle
• Most commonly used method in health care
• Tests a change by planning it, trying it,
observing the results, and acting on what is
learned

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 Plan-do-study-act (PDSA)
Step 1: Plan
• Plan the test or observation, including a plan for collecting data.
• State the objective of the test.
• Make predictions about what will happen and why.
• Develop a plan to test the change. (Who? What? When? Where?
What data need to be collected?)
Step 2: Do
• Try out the test on a small scale.
• Carry out the test.
• Document problems and unexpected observations.
• Begin analysis of the data.

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 Plan-do-study-act (PDSA)
Step 3: Study
• Set aside time to analyze the data and study the results.
• Complete the analysis of the data.
• Compare the data to your predictions.
• Summarize and reflect on what was learned.
Step 4: Act
• Refine the change, based on what was learned from the test.
• Determine what modifications should be made.
• Prepare a plan for the next test.

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 LEAN methodology
• The goal is to provide long-term success for an
organization and for everybody involved –
customers, employees, owners, suppliers, and
other stakeholders.
• Aims:
1-produce better outcomes for customers
2- create more value with less wasted time ,
efforts , and resources
3- speed delivery while reducing cost.
4- lay less burden on the people doing the
work.

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Dr souad belkebir
 5S
• It is a philosophy and a way of organizing and
managing the work place.
• The key impacts of 5S is upon work place
morale and Efficiency. How?
• By ensuring everything has a place , and
everything is in its place , then time is not
wasted looking for things , and it can be made
immediately obvious when something is
missing

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 5S
• The real power of this methodology is in
deciding what should be kept and where , and
how it should be stored.

• Its based on the Japanese words that begin

with (S)
• The 5s philosophy focuses on effective work
place organization , and standardized work
procedures.
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 5S
• 5S simplifies your work environment , reduces
waste , and non-value activity while improving
Quality , Efficiency , and Safety.

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 Six Sigma
Six Sigma is a powerful approach to quality improvement that can be used in
healthcare organizations to meet needs and expectations of patients.

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Dr souad belkebir
Brainstorming
• Everyone participates
• Go round robin and only one
person speaks at a time
• No discussion of ideas
• There is no such thing as a
dumb idea
• Pass when necessary
• Use “BIG” yellow sticky notes
and write only 1 idea per
sticky note
• One person assigned as scribe
• For a complicated issue, the
session could last 30-45
minutes…or longer!

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Nominal Group Technique
•Use a Nominal Group Technique To focus brainstorming results

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 Flow Diagrams

Why is flow diagramming helpful?

• Build a common understanding of a
whole process
• Develop process thinking
• Improve a process
• Standardize a process

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Week4_4
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Week 4_5
Investigate the Root Causes

Understand the root causes of a problem

BEFORE you put a “solution” into place

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 Cause & Effect Diagrams
Why are cause and effect
diagrams helpful? • Identify and display many
different possible causes
Root cause Root cause for a problem

• See the relationships

Focused between the many causes
problem

• Helps determine which

data to collect
Root cause Root cause

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 How To Construct Cause & Effect
Diagrams
•Clearly define the focused problem
•Use brainstorming to identify possible causes
•Sort causes into reasonable clusters (no less than 3, not more than 6)
•Label the clusters (consider people, policies, procedures, materials if you have not already
identified labels)
•Develop and arrange bones in each cluster
•Check the logical validity of each causal chain

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Dr souad belkebir
 Building a Cause & Effect Diagram

Materials Policies
Lack of office Minimal
space Location
benefits
Restrictive budget No policy on staff
screening Turnover in
staff
“Back-biting”
Escorting clients to environment Lack of
appointments and supervision
having to wait
Paperwork Burnout
overwhelming Inadequate
training
Procedure People
s

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Dr souad belkebir
Cause & Effect Diagrams
 Bones should not include solutions

 Bones should not include lists of process steps

 Bones include the possible causes

Better understand the current

situation…..
Now begin to develop a change.
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How to track Quality in Healthcare?

• Regulations
• Certification (ISO)
• Accreditation (JCI)
• Grading, rating (EFQM)
• Quality awards (Baldrige award criteria)

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Dr souad belkebir
International Organization for Standardization

• ISO 9001 requires an organization to identify, define,

document, implement (follow), monitor/measure,
and continually improve the effectiveness of its
processes.

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 ISO - Certification
• ISO develops International Standards and does not itself
certify organizations
• External certification bodies perform the certification

Procedure:
1. Preliminary Audit (optional)
2. Documentation Review
3. External audit by an external certification
4. Issue of certificate  valid for 3 years
5. Surveillance Audits  internal auditing by trained internal
staff  every year
6. Certification Renewal
Source: www.iso.org
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 Certification versus Accreditation
Certification
• written assurance (the certificate) by an independent
external body that processes or products conform to the
requirements specified in the standard

Accreditation
• Is a formal recognition by an accreditation body that a
person or institution is competent to carry out the
certification in specified business sectors (= certification of
the certification body)

• Terms accreditation and certification are often used

incorrectly synonyms
Source: www.iso.org
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 ISO

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 European Foundation for Quality
Management – EFQM
» Founded in 1989 by 14 European organisations, in order to
increase the competitiveness of European organisations
» Not-for-profit membership foundation based in Brussels
» Creater of „The EFQM Excellence Model“
» The aim of the Model is to improve performance in order to
reach „Excellence“
» 2012: more than 30 000 organisations in Europe use the Model
» Provide training, assessment tools and recognition for high
performing organisations  EFQM Excellence Award

Source: http://www.efqm.org
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European Foundation for Quality
Management (EFQM)

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 Joint Commission International - JCI
Joint Commission International – JCI
• Created in 1994
• Implements the goals of the JCAHO at an international level
• Supports health care organizations through accreditation,
education and technical assistance
• Accreditation of an organization: Is a recognition given to
the healthcare organization, which meet the
JCI standards
• JCI has a presence in organizations in
more than 90 countries

Source: www.jointcommissioninternational.org
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Why quality improvement efforts fail?
1- resistance to change
2- need to learn
3- defensiveness( changes mean that I was doing
things wrong)
4- loss of status or functions

Dr souad belkebir