Quality, Role of Quality Manager and Implementation of Quality Management System

Quality

•“Doing the right things, for the right patient, at the right time, in the right way to achieve the best
possible results”-AHRQ

•Quality is meeting or exceeding the stated and implied needs of the patients every time

Quality Management in Healthcare –differing views…

1. 1.Quality management is accreditation

2. 2.Accreditation should solve all problems
3. 3.Documentation and documentation-How can documentation improve quality??
4. 4.Unnecessary expenses
5. 5.Its for nurses and support staff, not for doctors
6. 6.It’s a show on the day of assessment
7. 7.Not my job, leave me alone…
8. 8.Who are these fellows to tell us what to do and how to do…
9. 9.Waste of time…

Reasons……….. for this

• Lack of proper understanding of the principles of quality management

• Implementing without understanding the right intent and spirit
• Not evidence driven
• Trying to copy, paste
• Policing rather than facilitating
• Trying to be prescriptive
• Short term benefits

Quality Manager…

1. Knowledgeable
2. Team player
3. Team leader
4. Assertive
5. Listener
6. Perseverance
7. Learner
8. Work around people
9. Communicator
10. Trainer
11. Presenter
12. Manipulator
13. Always smiling
14. Should remain calm
15. Public relations
16. Impartial
Four absolutes of Quality Management

• Quality is simply conformance to requirements.

• The system for causing quality is prevention.
• The performance standard must be zero defects, not “that’s close enough.”
• The measurement of quality is the price of nonconformance.

Cost of Quality

The American Society for Quality defines the cost of quality as “a methodology that allows an
organization to determine the extent to which its resources are used for activities that prevent poor
quality, that appraise the quality of the organization’s products or services, and that result from
internal and external failures”.

CoGQ (cost of conformance)

Prevention costs: incurred to prevent or avoid quality problems (examples: quality planning. training
and developing and maintaining a Quality Management System)

Appraisal Costs: incurred for measuring and monitoring activities related to quality (examples:
competency assessments, calibration, quality control, internal audits, inspections)

CoPQ (Cost of non-conformance)

Internal failure costs: incurred to remedy defects discovered the product or service is delivered to
the customer (examples: instrument downtime, data entry errors, missing specimens, retesting,
repair)

External failure costs: incurred to remedy defects discovered by the customer (examples: customer
complaints, misdiagnosis, harm to patients, lawsuits)

Total Cost of Quality

Good Quality (the cost you see)

• QA & Test Best Practices

• Internal & External Test Resource
Poor Quality - 80% of true cost (hidden costs)

• Data / Security Breaches

• Under Billing or Improper Billing
• Government Fines & Penalties
• Patient Dissatisfaction
• Customer Churn or Loss
• Suboptimal Business Outcomes
• Litigation
• Provider Dissatisfaction
• Harm to Brand
• Software Fix / issue Remediation
• ...and more!

We can all agree the practice of medicine was simple, maybe relatively ineffective but safe.

TODAY.....The practice of Medicine IS HIGHLY COMPLEX but effective

Way Forward...

Accreditation

• Best possible tool for achieving quality and patient safety.

• Accreditation is a process in which certification of competency, authority, or credibility is
presented to an organization.
• A self-assessment and external peer assessment process used by healthcare organizations to
accurately assess their level of performance in relation to established standards and then to
implement ways to continuously improve it.

Focus of Accreditation Standards

• Patient Safety
• Staff and employee safety
 • Environment and community safety
• Information Education and Communication
• Measurement of Performance
• Organized around important functions

A doctor’s tool kit for quality care and patient safety…

Simple measures saves lives…..

Patient Identification

•ID Bands

•UHID

Use of WHO Surgical Safety Checklist

Safer Medication

NATIONAL ACCREDITATION BOARD FOR HOSPITALS AND HEALTHCARE PROVIDERS (NABH)

NABH is a Constituent Board of Quality Council of India (QCI)

HCO and SHCO

Health Care Organization (HCO) -More than 50 beds

Small Health Care Organization (SHCO) -Up to 50 beds

•Entry level accreditation –HCO & SHCO

•Full accreditation –HCO & SHCO

NABH Standards Entry Level Full Certification
SHCO HCO SHCO HCO
(1stEdn.) (1stEdn.) (2ndEdn.) (5thEdn.)
Chapters 10 10 10 10
Standards 41 45 61 100
Objective 149 167 289 651
Elements
COP.3

Ambulance services ensure safe patient

transportation with appropriate care

Objective elements:

a. The organization has access to ambulance services commensurate with the scope of the
services proved by it.
b. There are adequate access and space for the ambulance(s)
c. The ambulance(s) is fit for purpose and is appropriately equipped
d. The Ambulance(s) is operated by trained personnel
e. The ambulance(s) is checked daily
f. Equipment is checked daily using a checklist
g. A mechanism is in place to ensure that emergency medications are available in the
ambulance
h. The ambulance(s) has a proper communication system
i. The emergency department identifies opportunities to initiate treatment at the earliest
when the patient is in transit to the organization

Chapter 1 - AAC (Access Assessment and Continuity of care)

• Scope of services- Define and display

• Documented registration, admission and discharge
• Established Initial Assessment
• Regular Reassessments
• Lab services as per scope and safety requirements
• Imaging services as per scope and radiation safety
 • Discharge process and discharge summary

Chapter 2 - COP (Care of Patients)

• As per accepted norms- time, dated, signed

• Emergency services- as per law and statutory requirements
• Rational use of blood and blood products
• Management of ICIJ and HDIJ patients
• Management of OBG patients as per scope
• Management of paediatric patients as per scope
• Administration of anaesthesia
• Theatre and surgical patients management

Chapter 3 - MOM (Management of Medication)

• Documented policies- Purchase, storage, prescriptions and dispensing.

• Implantable prosthesis
• Storage of medications
• Prescription of medication
• Safe dispensing of medications
• Administration of medication
• Monitoring of adverse drug events
• Usage of radioactive drugs

Chapter 4 - PRE (Patients rights and Education)

• Patient rights Documented and displayed

• Information and education about healthcare needs

Chapter 5 - HIC (Hospital Infection Control)

• Infection control manual

• Conducts surveillance activities
• Prevent or reduce the risks of HAI
• Biomedical waste management as per norms

Chapter 6 - PSQ ( Patient Safety and Quality Improvement)

• Structured quality improvement

• Continuous monitoring programme
• Key indicators to monitor the structures, processes and outcomes (5 Indicators)

Chapter 7 ROM (Responsibilities Of Management)

• ROM Defined
• Leaders in an ethical manner
• Multidisciplinary committees to oversee

Chapter 8 - FMS (Facility Management and Safety)

• Ensure safety of patients, their families, staff and visitors

 • Clinical and support service equipment management
• Safe water, electricity , medical gas and vacuum system
• Plans for fire and non fire emergencies

Chapter 9 HRM (Human Resource Management)

• Staffing with patient care needs

• Professional training and development of staff
• Disciplinary and grievance handling procedure
• Addresses the health needs of the employees
• Personal record for each staff member

Chapter 10 – IMS (Information Management System)

• Complete and accurate medical record for every patient

• Medical record reflects continuity of care
• Maintaining confidentiality, integrity and security of records, data and information.
• Retention time of records, data and information

Challenges in implementation

• Lack of awareness of standards

• Fear of the unknown
• Fear of exposing their vulnerabilities
• Old infrastructure and licenses
• Manpower requirement
• Standard Operating Procedures and Manuals
• Training of all categories of staff
• Inadequate resources

1. Strong Management Commitment

• Top management should actively involve

• Prepare the strategy for implementation
• Responsibility for implementation should lie with the top management

2. Quality Coordinator

Choose the right person

Who are these super heroes???

Quality Manager..

1. Knowledgeable
2. Team player
3. Team leader
4. Assertive
5. Listener
6. Perseverance
7. Learner
8. Work around people
9. Communicator
 10. Trainer
11. Presenter
12. Manipulator
13. Always smiling
14. Should remain calm
15. Public relations
16. Impartial

3. Quality Team

Multi-disciplinary Team

4. Training on the Standards

• Attend in-depth training program on NABH Standards

• Nominate three members atleast to attend the program — doctor, nurse and administrator
• Understand the intent of every objective element

5. Form Committees

• Multidisciplinary team for NABH implementation

• Form Committees
o Quality Committee
o Safety Committee
o Infection Control
o Pharmacy
o Transfusion
• Form sub-committees depending on issues

6. Baseline assessment to identify gaps

Conduct baseline assessment

Scoring pattern: 0, 5, 10

• Fully met : 10

• Partially met : 5

• Not met : 0

Focus on "not met"

Improve on "partially met"

Monitor "fully met"

7. Assign Responsibilities
8. Ensure Involvement of Staff

• Identify Key Personnel in each area

• These individuals can be made as quality champions
• Train on the requirements of their areas

9. Prepare Implementation Checklist

10. Statutory and legal requirements

• Identify which are the relevant licenses to be obtained/renewed

• Hospital Registration
• Biomedical Waste authorization, Air, Water Consent
• AERB licenses
• Pharmacy licenses
• Blood bank licenses
• PC PNDT
• MTP
• Transplant licenses (if applicable)
• Identify what are the requirements to be fulfilled as per prevailing laws
• Assign responsibilities

11. Identify Infrastructural requirements

• Adequacy of fire detection, alarms and fire fighting systems

• Patient and material flow in CSSD and OT
• Special provisions like baby care room, play room, handicapped toilet as per the scope of the
hospital
• Adequacy of equipments as per scope
• Prepare the plan for addressing them
12. Documentation

• Help the relevant stake holders in preparation of the policies and procedures that comply
with the NABH standards
• Many sample documents available customize to your hospital
• Standardize
• Keep them simple
• Trial and implement

13. Training

• Prepare the Training Matrix and Training Calendar

• Identify and implement training requirements

Identify Faculty

Plan training calendar, roll out training

• Interact / educate the end users regarding the same

Including doctors

Train, Train, Train

14. Initiate Audits

CHART DOCUMENTATION AUDITS

QUALITY TEAM
STAKEHOLDERS
15. Continuous Follow up

By Quality Manager

Quality Team

Committees

Documented

Presented to the Top Management

Follow up, Follow up, Follow up

16. Capture Indicators

Start capturing basic and relevant indicators

Explain the indicators and their relevance to the stakeholders

Involve the stakeholders and analyze the data

17. Keep updating the champions and all staff

Continuous update to all staff on overall progress-through meetings, newsletters etc.

Keep them engaged

Update the departments and stakeholders on the levels of compliances

Celebrate successes
18. Do an internal assessment/ invited external assessment

Submit Your Application

Points to Remember

• Every Non-Compliance is an opportunity for improvement

• Accept NCs and improve on them
• Do not close NCs for the sake of closure
• Never get disheartened -Change in culture/ practice takes years
• Always remain positive –“Never give up”
• Continue to learn
• Establish the system for continuous monitoring and sustainability