NRS3201

Leadership and Management

Concepts for Health Professionals
Semester 2, 2020/21

Theme 4
Quality Improvement and Management

1
Objectives
At the end of this session, the you will be able to:
• Identify quality improvement (QI) & total quality management (TQM)
• Describe the aspects of healthcare to be evaluated in a QI program.
• Recognize the importance of QI at unit level.
• Discuss how continuous quality improvement (CQI) methodology
improves quality of care.
• Discuss the roles of leaders & managers in quality control.
• Identify the possible risks in your organization & manage them.

2
“Quality is never an accident; it is always the result of
intelligent effort.” John Ruskin (1900)

“In healthcare, we have a special obligation to strive

for perfection because instead of making products,
we serve people…” Edward Tenner

3
What is Quality

• Does product/service meet the requirements?

• Is it suitable, or fit for my purpose?

• Will the service delight me?

• Is the service/product of value (a function of

both quality & price)?

4
Quality is…

“Fully meeting the needs of those who need the service

most, at the lowest cost to the organization, within limits
& directives set by higher authorities & purchasers”
(Ovretveit, 1992)

5
Defined…

 Perceived (“You know it when you see it”)

 Product-based (“Superior product attributes”)

 User-based (“Fitness for use”)

 Operations-based (“Conformance to specification”)

 Value-based (“Best value for money for a purpose”)

(Garvin, 1988)

6
Quality Management (QM)

A QM program is based on an integrated system of:

• Information

• Accountability

(Sullivan, 2018)
7
Quality management programs
QM programs keep organizations
in compliance
with important standards, regulations, safety protocols & laws
by
performing monitoring activities, such as audits & tests
to
(1) Make customers safe & satisfied, (2) ensure excellence &
(3) detect areas of deficiency

(Sullivan, 2018)
8
Function of Quality Programs

• Obtain accurate feedback from patients

• Identifying & correcting any nursing deficiencies
• Motivating nursing staff to perform quality nursing care
• Evaluating current nursing practices
• Implementing effective education for improvement of
nursing care
• Conducting nursing research to identify innovate nursing
care models & practices

Kelly (2004) 9
Total Quality Management (TQM)
• Management philosophy
• Emphasizes a commitment to excellence

It means that the organization's culture is defined by &

supports the constant attainment of customer
satisfaction through an integrated system of tools,
techniques, & training.

This involves the continuous improvement of organizational

processes, resulting in high quality products & services.

(Sullivan, 2018)
10
What’s the goal of TQM?

“Do the right things right the first time,

every time”

At its simplest, TQM has 2 main objectives:

• Total client satisfaction through quality products &
services; &
• Continuous improvements to processes, systems,
people, suppliers, partners, products, & services.

(Sullivan, 2018)
11
TQM Characteristics

4 core characteristics:
• Customer/client focus
• Total organizational involvement
• Use of quality tools & statistics for measurement
• Key processes for improvement identified

(Sulivan & Decker, 2009)

12
 Tools, ex: PDCA
•Plan the test or observation, •Tryout the test on a small
including a plan for collecting data.
•State the objective of the test.
scale.
•Carry out the test.
•Make predictions about what will
•Document problems &
happen & why.
•Develop a plan to test the change. unexpected observations.
•(Who? What? When? Where? What •Begin analysis of the data
data need to be collected?)

•Setaside time to analyze the

data & study the results.
•Complete the analysis of the
•Refinethe change, based on data.
what was learned from the test. •Compare the data to your
•Determine what modifications predictions.
should be made. •Summarize & reflect on what
•Prepare a plan for the next test. was learned.

(Based on Shewhart, 1939) 13

Continuous Quality Improvement (CQI)

• TQM is the philosophy, whereas CQI is the process.

• It is an “ongoing effort to provide services that meet or
exceed customer expectations through a structured
systematic process”.

4 main players in the CQI:

 Resource group

 Coordinator
4 basic elements in CQI:
 Team leader  Teamwork
 Team  Patient perspective
 Resources available
 Measurement of work structures,
processes, & outcomes

(Sulivan & Decker, 2009)

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 CQI in Health Care
The purpose of CQI programs in health care is
to
improve health care
by
(1) Identifying problems, (2) implementing & monitoring corrective
action, & (3) studying its effectiveness (process)

For outcome studies, a CQI committee would ask whether health

services are achieving desired outcomes as far as patients'
conditions

(Sullivan, 2018)
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TQM vs. CQI
TQM = doing the same things better (through identifying & reducing
variation in the process)

CQI = builds on TQM through focus on organizational problems &

reducing error AND through seeking new & creative ways of
working which will be of benefit to all

Thus with CQI, all processes (even those working well) are believed
to be capable of further improvement …

…shifts from doing the same things better to do different things

(Parsley & Corrigan, 1999)

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Components of QM

A comprehensive QM program includes:

1. Comprehensive QM plan
2. Set standards for benchmarking
3. Performance appraisal
4. A focus on intradisciplinary assessment & improvement

(Sullivan, 2018)
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Comprehensive QM plan

Systematic method to…

• Design
• Measure
• Assess
• Improve
…organizational performance

(Sulivan & Decker, 2009)

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Set standards for benchmarking

Standards are “written statements that define a level of performance or a set

of conditions determined to be acceptable by some authorities”.

Standards relate to 3 major dimensions of quality care:

 Structure: relate to the physical environment, organization, &
management of an organization.
 Process: connected with the actual delivery of care.
 Outcome: involve the end results of care that has been given.

Structure Pressure ulcer risk assessment form

Process Assess risk for development of ulcer and
implement preventive measures
Outcome Skin intact at discharge

(Sulivan & Decker, 2009)

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cont…

An Indicator is a tool to measure the performance of

structure, process, & outcome standards.
It is measurable, objective, & based on current knowledge.

Once indicators are identified, benchmarking, or comparing

performance using identified quality indicators across institution or
disciplines, is the key to quality improvement.

….KPI (Key Performance Indicators)

(Sullivan & Decker, 2009)
20
KPI, Example

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Six Sigma

 It is a quality management program that uses

quantitative data to monitor progress
 Six Sigma is a measure, a goal , and a system
of management
 Six themes:
o Customer focus
o Process emphasis (improving efficiency and customer satisfaction or running the business)
o Data driven (improve information systems)
o Proactive management
o Boundaryless collaboration
o Aim for perfection, but tolerate failure
(Sullivan, 2018)
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DMAIC Method

 Six Sigma process improvement method

 It is an acronym for define, measure, analysis,
improve, & control

(Sullivan, 2018)
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Leaders Role in Quality
• Encourage active involvement in quality
control process
• Clearly communicates expected standards
of care to subordinates
• Encourage setting high standards to
maximize the quality
• Implement quality control proactively
• Act as a role model for followers in
accepting responsibilities
• Support & actively participate in research
efforts to measure client’s outcomes

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Managers Role in Quality
• Establish measurable standards of
care
• Select & use process, outcome, &
structure audits
• Determine discrepancies between
care provided & unit standards
• Use quality findings as a measure
of employees performance

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Equity is an essential component of
quality
To truly achieve quality, healthcare systems must focus on 6 key
elements:
1. Efficiency
2. Effectiveness
3. Safety
4. Timeliness
5. Patient-centeredness
6. Equity: is achieved by providing care that does not vary in quality
by characteristics such as ethnicity, gender, geographic location,
& socioeconomic status.

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JCI (Joint Commission
International)
JCAHO’s: Joint Commission on Accreditation of
Healthcare Organizations

 It is an accrediting body of hospitals, healthcare facilities,

psychiatric facilities, & home health operations.
 The first to mandate hospitals to have quality assurance
programs by 1981.
 By 1990, they shifted the focus of accreditation from
organizational structure to performance or outcomes.

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JCAHO’s 2007 Hospital National Patient
Safety Goals
• Improve the accuracy of patient identification
• Improve effectiveness of communication among caregivers
• Improve the safety of using medications
• Reduce the risk of healthcare-associated infections (HAIs)
• Accurately & completely reconcile medications across the
continuum of care
• Reduce the risk of harm from falls
• Active patient involvement in their own care as a patient
safety strategy
• Define a means for patient & families to report concerns
• Identify safety risks inherent in its patient populations

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Summary… TQM

 For TQM to be successful leaders

(YOU!) will need to maintain
commitment, keep the process visible,
provide necessary support, & hold
people accountable for results

 TQM encourages participation

amongst all staff & managers

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 Risk
Management

30
Risk Management
“Probability or threat of a
damage, injury, liability, loss,
or other negative occurrence,
caused by external or
internal vulnerabilities, &
which may be neutralized
through pre-meditated
action.”

Risk Management is the name given to a logical &

systematic method of identifying, analyzing, treating &
monitoring the risks involved in any activity or process.

31
Taking Risks – 10 concepts…
1. Risk is “uncertainty that matters”: different things matter to
different people to a different extent in different circumstances!

2. Risk includes both downside (threats) & upside (opportunities):

both types of risk need to be addressed proactively to minimise
threats AND maximise opportunities.

3. “Zero risk” is unachievable (undesirable?): all aspects of life

involve risk, thus risk-taking is inevitable - only take appropriate
risks in relation to the level of return we expect or require.

4. Risk has two key dimensions:

 uncertainty = “probability” or “frequency” of occurrence
 “impact” or “consequence” = how much it matters
(Hillson, 2008) 32
Taking Risks – 10 concepts…

5. Risk management requires understanding of both dimensions: if an

uncertain event is very unlikely or have negligible effect, it
requires less attention.

6. Risk management is affected by perception: answers to the

questions “How uncertain is it?” & “How much does it matter?”
are subjective.

7. Perception is affected by many factors: e.g. conscious rational

assessment, subconscious sources of bias & affective inner
emotions = the “triple strands of influences”.

(Hillson, 2008) 33
Taking Risks – 10 concepts…
8. Risk attitude is “a chosen response to uncertainty that matters,
driven by perception”: individuals & groups adopt risk attitudes
(subconsciously or consciously), ranging from “risk-averse” to
“risk-seeking”.

9. Risk attitude can be “consciously” managed : proactive rather than

reactive response - understanding & adopting which risk attitude
best meets the needs of a situation for an organisation.

10. Managed risk attitudes support effective risk management by

promoting appropriate risk-taking: by managing risk attitudes
proactively, individuals & groups can maximise organisational risk
management, allowing the appropriate amount of risk compared
to the rewards required.
(Hillson, 2008) 34
 Overview of a generic risk
management process

Risk Risk Risk Risk

Identification Analysis Evaluation Treatment

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 Risk Risk Risk Risk
Identification Analysis Evaluation Treatment

• Defining types of risk, for instance, ‘Strategic’ risks to

the goals & objectives of the organization.

• Identifying the stakeholders, (i.e., who is involved or

affected).

• Past events, future developments.

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 Risk Risk Risk Risk
Identification Analysis Evaluation Treatment

• How likely is the risk event to

happen? (Probability & Remember…
frequency?)
RISK
• What would be the impact, cost =
or consequences of that event (Probability of risk occurring)
occurring? (Economic, political, x
& social?) (Impact of risk occurring)

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 Risk Risk Risk Risk
Identification Analysis Evaluation Treatment

• Rank the risks according to management

priorities, by risk category & rated by
likelihood & possible cost or consequence.

• Determine inherent levels of risk.

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 Risk Risk Risk Risk
Identification Analysis Evaluation Treatment

Develop and implement a plan with specific counter-

measures to address the identified risks.

Consider:
• Priorities (Strategic & operational)
• Resources (human, financial & technical)
• Risk acceptance, (i.e., low risks)

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 Risk Risk Risk Risk
Identification Analysis Evaluation Treatment

 Prevent (terminate)
 Reduce (mitigate)
 Accept (tolerate)
 Contingency
 Transfer

Apply “controls” to manage unacceptable or residual risk

40
 Risk Risk Risk Risk
Identification Analysis Evaluation Treatment

Monitor
&
Review

Risk Managers must monitor activities & processes to determine

the accuracy of planning assumptions & the effectiveness of the
measures taken to treat the risk.

Methods can include data evaluation, audit, & compliance

measurement.

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High Risk Areas in Healthcare
• Medication errors
• Complications from diagnostic or
treatment procedures
• Falls
• Patient/family dissatisfaction with care
• Refusal of treatment or refusal to sign
consent for treatment

(Sulivan & Decker, 2009)

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References
Gomez-Mejia, Balkin, &Cardy (2007). Managing Human Recourses , (5th ed.). Upper Saddle River, NJ: Printice Hall
Inc.

Garvin, D.A. (1988). Managing Quality : The Strategic and Competitive edge. Freepress: New York

Ivancevich (2010). Human Resource Management (11th ed.). Boston, USA: Higher Education.

Kelly (2004). Essentials of Nursing leadership and Management. Thomson: USA.

Nankervis, Compton, & Baird (2005). Human Resource Management; Strategies and Processes (5th ed.). Australia:
Thomson.

Ovretveit, J. (1992). Health Service Quality: An Introduction to Quality Methods for Health Services. Oxford Blackwell:
Science

Parsley, K. & Corrigan, P. (1999). Quality Improvement in Healthcare: Putting evidence into practice. UK:
Stanley Thornes.

Sullivan, E.J. (2018). Effective Leadership and Management in Nursing. New York: Pearson

Shewhart, W. A. (1939). Statistical Method from the Viewpoint of Quality Control. New York: Dover.

Sullivan, E.J. & Decker, P.J. (2009). Effective Leadership & Management in Nursing (7th ed.). London: Pearson
Prentice-Hall.

Whitehead, D.K., Weiss, S.A., & Tappan, R.M. (2007), Essentials of Nursing Leadership and Management (4th ed.).
Philadelphia: F. A. Davis Company.

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