HEALTH CARE QUALITY CONCEPTS

1. Chapter 1 : HEALTH CARE QUALITY CONCEPTS

2. Quality Concepts
• "Quality is never an accident; it is always the result of high intention, sincere
effort, intelligent direction, and skillful execution. It represents the wise choice of
many alternatives." William A. Foster, Source Unknown "Quality must be the
number one priority of the organization. " Joseph M. Juran
• "What you do to make quality better makes everything better." (Juran's Quality
Control Handbook, 1988 )
• "Quality is the result of a carefully constructed culture; it has to be the fabric of
the organization-not part of the fabric, but the actual fabric. It is not hard for a
modern management team to produce quality if they are willing to learn how to
change and implement. " Philip B. Crosby
• "Quality in a product or service is not what the supplier puts in. It is what the
customer gets out and is willing to pay for." Peter F. Drucker
• "We are what we repeatedly do. Excellence, then, is not an act but a habit."
Aristotle

3. THOUGHTS ON QUALITY
Quotes ON QUALITY
• "Across the ',world, quality is fast emerging as the central focus for health care
policy maker. and service providers. (the International Society for Quality in
Health Care)
• "The only way to assure quality and excellence is to give people something to
believe in." (NAHQ)
• "Quality is free. It's not a gift, but it is free. What costs money are the unquality
(Philip B. Crosby),
• "It's easier to do the job right than explain why you didn't." Martin Van Buren
• "Quality in a product or service is not what the supplier puts in. It is what the
customer gets out and is willing to pay for." Peter F. Drucker

4. Definition
• Quality
• Doing the right things right the first time.
• “The right care for every person every time. “The Centers for Medicare and Medicaid Services·(CMS)
• The Juran Institute (1993) defines quality as both:
• 1. "Freedom from deficiencies": A deficiency means  any avoidable intervention
• 2. "Product features": the services meet customer expectations, and distinguish one practitioner or
organization from others.
• Quality of Care
• is the degree to which health services for individuals and populations increase the likelihood of desired
health. The Institute of Medicine (1990)
• Quality Healthcare
• healthcare that is " ... accessible, effective, safe, accountable, and fair .... "This means:
- deliver the right care to the right patient at the right time in the right way.
- Protect patients and identify risks and benefits

5. Thee aspects of quality in health (the MAP)
• 1. Measurable quality  can be defined as compliance with, or
adherence to, standards.  is generally driven by practice standards
and cost and risk concerns.
• 2 Appreciative quality  is the comprehension and appraisal of
excellence beyond minimal standard.  values the experiential and
the higher ethical
• 3 Perceptive quality is that degree of excellence that is perceived and
judged by the recipient or the observer of care rather than by the
provider of care.  respects the concerns and opinions of those
either most directly affected by the care or most objective regarding
its delivery.

6. • The ideal organization wide health care quality strategy is effective
in:
tracking measurable quality
understanding the value and necessity of appreciative quality and
actively fostering perceptive quality.

7. DIMENSIONS OF QUALITY CARE/PERFORMANCE
11 key dimensions  provide the framework for quality management activities in all
healthcare settings and a balanced and well integrated quality, cost, and risk perspective.
1. Appropriateness  Correct, and Doing the right things in accordance with the purpose.
2. Availability  the care is accessible and obtainable
3. Competency  The practitioner's ability to produce both the health and satisfaction of
customers and adheres to professional and/or organizational standards of care and
practice.
4. Continuity  availability of all practitioners and unbroken services
5. Effectiveness  care is provided in the correct manner, meet the desired outcome
6. Efficacy  potential, capacity, or capability of the care to produce the desired outcome
7. Efficiency  The relationship between (the outcomes (result of care) and the resources
used to deliver care, and outputs (services produced) to inputs (resources used to produce
the services).

8. DIMENSIONS cont.
8. Prevention/Early Detection  identification of risk factors, promote
health and prevent disease.
9. Respect and Caring  health care provider do so with sensitivity for
the individual's needs, expectations, and individual differences
10. Safety  minimizes risks of adverse outcome for both patient and
provider; and the organizational environment is free from hazard or
danger.
11. Timelines  "care is provided at the most beneficial or necessary
time" and accordance with customers perception of promptness.

9. THE QUALITY UMBRELLA
DEFINITION OF QUALITY MANAGEMENT/IMPROVEMENT
A planned, systematic, organization wide approach  to the
monitoring, analysis, and improvement of organization performance,
 to continually improving the quality of patient care and services
provided and the likelihood of desired patient outcomes.

10. THE QUALITY UMBRELLA cont.
AN INTEGRATED PERSPECTIVE
Activities associated with improving organization performance involve
much more than the clinical aspects of care.
There is increased emphasis placed on improving, in a prioritized
approach, all the interrelated processes and services that impact the
quality of care and affects patient outcomes.

11. THE QUALITY UMBRELLA cont.
• QUALIITY MANAGEMENT PRINCIPLES:
The healthcare quality umbrella framework is based upon some "Basic Principles", utilizing
Total Quality Management (TQM). These principles are:
1. "Productive work is accomplished through processes. include (Customer, Processor, &
Supplier)
• One huge issue that must not be forgotten or ignored in applying the industrial model of
TOM to healthcare, is that the patient is not just a customer in the process. The patient is
always a controlling, active participant and is as much a processor and supplier to the
process as a customer.
2. "Sound customer-supplier relationships are absolutely necessary for sound quality
management." . E.g Patients • Families and friends of patients • Physicians and other
3. "The main source of quality defects is problems in the process." "The old assumption is
that quality fails when people do the right thing wrong; the new assumption is that, more
often, quality failures arise when people do the wrong things right. "

12. 4. "Poor quality is costly."
5. "Understanding the variability of processes is a key to improving
quality."
6. "Quality control should focus on the most vital processes."
7. "The·· modern approach to quality is thoroughly grounded in
scientific and statistical thinking."  like medicine does to a disease:
8. "Total employee involvement is critical."  e.g encourage and
capture ideas from all employees.

13. Cont.
9. "New organizational structures can help achieve quality improvement.“
 e.g A steering committee or "quality council" develop the strategic
planning for the training, technical infrastructure, procedures for problem
selection, forms of recognition, and systems for evaluating and improving the
overall effort itself.
10. "Quality management employs three basic, closely interrelated
activities: Quality planning, quality control [quality measurement], and
quality improvement.“
• The Joint Commission defined a set of organizational and management
principles that are used to assess an organization's "'commitment to
continuously improve the quality of patient care.

15. • JCI assess organization commitment though
Organization wide Commitment:
1. The organizational mission statement clearly expresses a commitment to
continuously improve the quality of patient care and translates into
measurable objectives and action plans.
2. The organizational culture  All persons who use or provide services
participate in decision-making processes, self-assessment, and open
communications.
3. Opportunities for organizational change that will improve the quality of
patient care are  continuously assessed, recognized, and integrated into the
strategic, program, and resource planning processes. E.g Assessments
address: External environment; Access to care

16. Commitment and Education of Leaders
4. The role of governing board, managerial, and clinical leaders in
continuously improving the quality of patient care is expressed in
definitions of authority and responsibility, policy, and specific
objectives, and is evident in their articulation of commitment,
involvement in monitoring, and promotion of organizational integration
and coordination.
5. The governing board, managerial, and clinical leadership
qualifications, evaluation, and development for assessing and
continuously improving the quality of patient care are addressed. E.g.
Knowledge, Skills, Attitudes, Commitment.

17. Competency and Development of Practitioners
6. The qualifications, evaluation, and development of independent
practitioners are addressed. There is a sufficient number to provide
competent patient care. They are initially assessed and regularly
evaluated for clinical competency and performance
7. Human resources recruitment and retention policies and practices
assure adequate numbers of competent healthcare practitioners with
appropriate skills, attitudes, and knowledge

18. Commitment and Management of Resources
8. Sufficient support resources, including facilities, equipment, and
technology, are acquired, regularly evaluated, and maintained to
promote a good patient care environment.
Quality Improvement and Quality Planning
9. The monitoring, evaluation, and continuous improvement of
patient care are overseen by the governing board and managerial and
clinical leadership and involve appropriate individuals and
organizational units.

19. Organizational Coordination and Continuity of Care
10. Organizational integration and coordination is fostered by all
persons, clinical disciplines, and organizational units. Policies
consistently foster appropriate communication, coordination, conflict
management, and integration among relevant parties to effect changes
and improve the quality of care.
11. Continuity and comprehensiveness of care is improved through
effective linkages with external care providers.

20. The Joint Commission Principles for Quality Improvement
• The Joint Commission convened a Quality Improvement Task Force in
late 1988, during the "Agenda for Change" process, to assist in
developing revisions to the quality assurance standards. The Task
Force formulated a set of Principles for Quality Improvement.

21. The ISO 9000:2005 Quality Management Principles
• The International Organization for Standardization (ISO) issued the
original 9000 series of quality standards in 1987 and made minor
revisions in 1994. These standards were intended to facilitate the
development and maintenance of quality control programs in the
manufacturing industry.
• Originally three different sets of standards-ISO 9001, ISO 9002,
• and ISO 9003-were available for companies seeking certification.
• A fourth set of standards, ISO 9004, encouraged overall performance
improvement, but was not used for certification.

22. • The ISO 9000:2005 standards include eight Quality Management Principles, with standards for
each principle:
• Principle 1-Customer focused organization: Organizations depend on their customers and
therefore should understand current and future customer needs.
• Principle 2-Leadership: Leaders establish unity of purpose and direction of the organization.
• Principle 3-lnvolvement of people: full involvement enables their abilities to be used for the
organization's benefit.
• Principle 4-Process approach: A desired result is achieved more efficiently when related resources
and activities are managed as a process.
• Principle 5-System approach to management Identifying, understanding and managing a system
of interrelated processes as a system contributes to the organization's effectiveness and efficiency
in achieving its objectives.
• Principle '6-Continual improvement : should be a permanent objective of the organization.
• Principle 7-Factual approach to decision making : based on the analysis of data and information.
• Principle 8-Mutually beneficial supplier relationships An organization and its suppliers are
interdependent.

23. TOTAL QUALITY MANAGEMENT PHILOSOPHY
• Definitions of TQM
• 1. TQM is a broad management philosophy, espousing quality and leadership
commitment, that provides the energy and the rationale for implementation of
the process of Continuous Quality Improvement (CQI) within the Organization
wide Quality Strategy.
• 2. TQM is the "involvement of an entire organization in a process of customer-
driven quality improvement."
• 3. Working definition: An organization wide management philosophy and top-
level commitment to provide "value" to all customers through:
• • Creating an environment of continuous improvement; and
• • Building excellence into every aspect of the organization.

24. • 3.4.2 TQM as a Management Philosophy
• TQM is a management philosophy that enhances and benefits the
organization and all people associated with it by utilizing processes that
continuously improve the quality of all products, services , and
information, resulting in:
• • Increased customer satisfaction
• • Increased productivity
• • Increased profits
• • Increased market share
• • Decreased costs

26. key concepts of TQM
• Top management leadership
• Creating corporate framework for
quality
• Transformation of corporate
culture
• Customer focus .
• Process focus
• Collaborative approach to process
improvement
• Employee education and training
• Learning by practice and
teaching
• Benchmarking
• Quality measurement and
statistics
• Recognition and reward
• Management integration

27. • TQM fosters a belief in the value of:
• • Customers (Needs , Expectations, Opinions)
• • Employees/Staff ( Willingness and desire, Abilities and expertise,
Opinions, Access to top management, and Involvement in Decision
making, Problem solving , Goal setting, Planning]
• • Management (Commitment and visibility, Active leadership, -
Participation, Empowerment of employees, Accountability)
• • Teamwork (Unity, Ownership, More and better ideas, Openness, -
Encouragement, Mutual respect, Incentive and reward)

28. Edwards Deming's Fourteen Points for Managing Quality
1. Create constancy of purpose toward improvement of product and service
2. Adopt the new philosophy-that it is possible for things to be done right the first
time through effective training.
3. Cease dependence on inspection to achieve quality. Eliminate the need for
inspection on a mass basis by building quality into the product in the first place
4. End the practice of awarding business on price tag alone. Instead, minimize total
cost. Move toward a single supplier for anyone item, on a long-term relationship of
loyalty and trust.
5. Improve constantly and forever every process for planning, production, and service,
to improve quality and productivity, and thus constantly decrease costs.
6. Institute training on the job.
7. Adopt and institute leadership. The aim of leadership should be to help people and
machines and gadgets to do a better job.

29. 8. Drive out fear, so that everyone may work effectively for the company: people feel
secure.
9. Break down barriers between staff areas: Emphasize teamwork, not competition.
10. Eliminate slogans, exhortations, and targets for the work force: Concentrate on
improving the system to make it easier for the worker to do a better job.
11. Eliminate numerical quotas for the work force and numerical goals for management.
Emphasize quality and methods, not quantity.
12. Remove barriers that rob people of pride of workmanship. E.g. Eliminate faulty
equipment, and defective materials
13. Institute a vigorous program of education and self-improvement for everyone.
14. Put everyone to work to accomplish the transformation. Quality improvement means
all employees trying every day to do their jobs better, not merely trying to attain or
maintain a minimal level of competence to satisfy the manager or the QM department.

30. Total Quality Management Philosophy Promotes can:
- An increased top-down and bottom-up emphasis on quality,
- A decreased emphasis on inspection, surveillance, and discipline and a
focus on systems rather than individuals
- A substantially increased investment of managerial time, capital, and
technical expertise;
- An increased investment in education, study, and training at all levels in
order to: Understand the complex processes
• A steadfast, long-term vision;
• Cautious use of "minimal" standards of care.

31. CONTINUOUS QUALITY IMPROVEMENT PROCESS
• mean a management process or "approach to the continuous study
and improvement of the processes of providing health care services
to meet the needs of individuals and others.

32. history
1. Walter J. Shewhart (1920s-1967)): Statistical Process Control (SPC) and the control chart, also called "Shewhart Chart" the Cycle for Continuous
Improvement-Plan, Do, Check, Act, also called "Shewhart Cycle".
2. Armand V. Feigenbaum (1940s-present): Devised the concepts of "total quality control" and "cost of quality": Total Quality Control = quality
development + quality maintenance + quality improvement.
3. W. Edwards Deming (1930s-1950s-1994): Expansion of Shewhart's Cycle and statistical methodologies beyond manufacturing to sales and service;
constancy of purpose; leadership perpetuating continuous improvement; attainment of profound knowledge; understanding and harnessing sources
of variation.
4. Joseph M. Juran (1920s-1950s-2008) The Quality Control Handbook, first published in 1951 and now in its fifth edition as Juran's Quality Handbook
(1999), is considered the "bible" of the quality improvement movement): Stresses an "overall concern for the entire management" and a "project
approach" to quality improvement; pioneered use of "Pareto analysis" to prioritize; and developed the "Juran Quality Trilogy" and Quality
Improvement Process (QIP). Quality = "fitness for use". [Also see next Section]
5. Kaoru Ishikawa (1940s-1988): Use of Total Quality Control (TQC) for open communication, changing product design in accordance with customer
tastes and attitudes, probing minds and gaining knowledge, and company-wide quality assurance emphasizing the customer; quality first, not short-
term profit; respect for humanity as management philosophy, with full participatory management; and crossfunctional management to solve
problems.
6. Philip B. Crosby (1960s-2001): Focus on prevention, "doing it right the first time“ (DIRFT); Quality is Free (1979)-four main principles:
• The definition of quality is conformance to requirements
• The system of quality is prevention
• The performance standard is "zero defects"
• The measurement of quality is the price of nonconformance

33. The Responsibility of the Healthcare Quality Professional
• It is important for healthcare quality professionals to understand the
principles of both total quality management and continuous quality
improvement. Then he/she must articulate to all administrative and
governing body leaders how TQM philosophy; the processes of
performance measurement, analysis, and improvement; and the
development of an effective Healthcare Quality Strategy are
necessary, are compatible with the organization's financial health,
and, in fact, help make the Strategic Plan achievable.

34. THE JURAN MODEL OF QUALITY MANAGEMENT
• Joseph M. Juran describe three quality management processes - they
call the "Juran Trilogy" or "Quality Trilogy": 1- Quality Planning, 2-
Quality Control, and 3- Quality Improvement.
• Sometimes called the "Quality Management Cycle",

35. • 3.6.1 The Model

36. 1. Quality Planning
• Identifying and tracking the customers of a particular process;
• Identifying, measuring, and prioritizing customer needs and expectations
concerning the process and its outcomes;
• Identifying process issues critical to effective outcomes;
• Setting quality improvement goals (e.g., strategic quality initiatives);
• If no service or system currently exists, is ill-defined, or is ad hoc, designing a
function/service responsive to customer needs (e.g., autologous blood service or
sub acute nursing unit); and
• If no process currently exists, is ill-defined, or is ad hoc, defining and developing
the process(es) capable of producing the desired outcome (e.g., defining
specifications of diagnostic and/or therapeutic processes, developing a clinical
path, or translating scientific knowledge into practice guidelines).

37. 2. Quality Control Measurement
• Measuring the extent to which an organization and individuals achieve and
maintain desired outcomes;
• Measuring current performance and its variance from expected or intended
performance;
• Measuring key processes and outcomes, prerequisite to prioritizing for quality
impro"1ement and/or quality planning;
• Descripting variability in processes, understanding and properly interpreting that
variable, reducing or eliminating unnecessary or inappropriate variation, and
expanding or maximizing positive variation;
• Measuring and tracking important, customer-sensitive process and outcome
issues on an ongoing, routine basis, including adverse events and their rates in at-
risk populations, as well as positive events and their effects;

38. 3. Quality Improvement
• Using collaborative efforts and teams to study and improve specific existing
processes at all levels in the organization;
• Analyzing causes of existing process failure, dysfunction, and/or
inefficiency;
• Systematically instituting optimal solutions to chronic problems;
• Routinely analyzing and disseminating positive variance and/or "best
practice“ information (to patients and families through education, as well
as to staff); and
• Utilizing the scientific/problem-solving method to improve process
performance and achieve stated goals.

39. How It Works
• The Quality Management Cycle does not work in a linear, specific event or time order,
with, for example, quality planning always occurring first.
1. Quality Planning (like financial planning & budgeting) is performed by a group of
leaders looking at global issues, e.g., costly conditions-perhaps diagnosis-related
groups or DRGs-or by a work team focusing on a specific organization function, e.g.,
patient assessment.
2. In Quality Improvement (like cost reduction), teams/committees use Quality
Control/Measurement information, collecting additional information and performing
in-depth evaluation as necessary, either to achieve specific performance goals
determined in Quality Planning or to improve or further improve an existing process.
3. Quality Control/Measurement (like financial control), performed organization wide by
all departments or divisions, as well as by professional reviewers, encompasses all
ongoing activities designed to measure actual performance, including the
effectiveness of actions taken through Quality Planning and Quality Improvement.

40. STRUCTURE, PROCESS, AND OUTCOME
• Structure  Ieads to  Process  Ieads to Outcome

41. Structure:
• Structure is the arrangement of parts or elements of a care system
that facilitate care; the care "environment"; evidence of the
organization's capacity to provide care to patients,
• e.g.: available Resources, staff, Policies

42. Process
• Process refers to the procedures, methods, means, or sequence of steps for
providing or delivering care and producing outcomes.
1- Clinical processes- what practitioners do for patients and what patients do in
response
• E.g : Assessment, Treatment plan, Medication administration
2- Care delivery processes -the support activities utilized by practitioners and all
suppliers of care and care products to get the product to the patient:
- Services  e.g., registration, room cleaning, patient transfer OR
- Systems e.g., medication dispensation
3-Administrative and management processes -the activities performed in the
governance and management systems of the organization.

43. Outcome
• Outcome refers to the results of care (end), adverse or beneficial
Clinical: e.g. Complication rates - Adverse events - Mortality rates
Functional: e.g Longer-term health status - Activities of daily living
(ADL) status
Perceived: e.g. Patient/family satisfaction

44. The basic elements of process
• Inputs  by supplies
• A sequence of steps  by processors
• Outputs  to the customers

45. The Joint Commission Process Principles
• An organization can improve patient care quality (increase the probability
of desired patient outcomes, including satisfaction) by assessing and
improving the governance, managerial, clinical, and support processes that
most affect patient outcomes;
• These processes are carried out by clinicians, governing body members,
managers, support personnel, or jointly by more than one of these groups;
• The processes carried out by groups must be coordinated and integrated,
requiring the attention of managerial and clinical leaders;
• • Most staff are both motivated and competent to carry out the processes
well.

46. Three Types of Processes at Work in Healthcare:
• Patient flow processes: Moving people from place to place;
• Information flow processes: Creating and transporting facts and
knowledge that make for informed decisions; and
• Material flow processes: Moving equipment and supplies.

47. Process Improvement v. Reengineering
• In the Quality Management Cycle, process improvements take place
in Quality Improvement, with a team focused on incremental
improvements over a period of time.
• "Process reengineering," on the other hand, involves radical
replacements-starting over-and generally happens more quickly.
Reengineering occurs through Quality Planning.

48. Breakthrough Improvement
• Definition: A "breakthrough" is any sudden or significant solution to
a problem that leads to further advances.
• Stated another way, it may be a "significant or sudden advance,
development, achievement...that removes a barrier to progress."

49. THE CONCEPT OF PROCESS VARIATION
Definitions of Variation
• variation is "change or deviation in form, condition, appearance, extent, etc., from a former or usual state, or from an
assumed standard."
• A variance is "a changing or tendency to change; degree of change or difference; divergence; discrepancy."
Clinical Variation
• Variation can be either positive or negative. We in healthcare quality tend to think of variation as negative or adverse,
Process Variation
• Some variation is desirable, some is wasteful, and some may be harmful. So, we must understand the variation.
• process variation is of two types:
• 1. "Common causes" refer to situations, usually within patient care systems and processes :(within the normal, bell-
shaped curve)
• 2. Assignable or special cause: "special causes" refer to sentinel events, one-time occurrences,

50. Statistical Process Control
• Walter Shewhart's causes of variation led him to develop a
methodology to chart the process and quickly determine when a
process is "out of control."
• This ongoing measurement and analysis is known as "statistical
process control (SPC)."

51. The Pareto Principle: Prioritizing Variation
• In the 1920s Joseph Juran noted that approximately 80% of observed
variation in processes was generally caused by only 20% of the
process inputs.
• He called this phenomenon the "Pareto Principle,"

52. • Reliability in a process is the probability that each of the steps will
occur when, where, and how it needs to occur.
• Improving Reliability
• The Institute of Healthcare Improvement (IHI) states there are only
two ways to improve a process:
• 1) reduce the number. of steps and/or
• 2) improve the reliability of individual steps.

53. The Concept of Outcomes Management
• Outcomes Management refer to a "technology of patient experience
designed to help patients, payers, and providers make rational
medical care-related choices based on better insight into the effect of
these choices on the patient's life" [Ellwood, 1988].
• The resulting data, called outcome measures, are measures of
performance.

54. Measurement of Quality of life
• To Ellwood, "the centerpiece and unifying ingredient" of outcomes
management is the tracking and measurement of the patient's
functionality and well-being or quality of life.

55. Outcomes Management Principles
Outcomes management should consist of [Ellwood, 1988]:
• A common language of health outcomes, understood by patients;
• A national reference database containing information and analysis on
clinical, financial, and health outcomes
• • Opportunity for decision-makers to access analysis relevant in
making choices,

56. Dependence on Guidelines and Measures
Outcomes management is dependent upon four other techniques:
• 1. Practitioner reliance on standards and guidelines in selecting
appropriate interventions [Ellwood, 1988] [Quality Planning]
• 2. Routine and systematic measurement of the functioning and well-being
of patients, along with disease-specific clinical outcomes, at appropriate
time intervals (Ellwood, 1988) [Quality Control/Measurement];
• 3. Pooling of clinical and outcome data on a massive scale (Ellwood, 1988)
[Quality Control/Measurement]
• 4. Analysis and dissemination of results (outcomes) from the segment of
the database pertinent to the concerns of each decision maker (Ellwood,
1988) [QI]:

57. SYSTEMS THINKING
• "Systems Thinking" define as
- A body of principles, methods, and tools focused on the interrelatedness of forces in
systems operating for a common purpose.
- - The belief that the behavior of all systems follows common principles, the nature of
which can be discovered, articulated, understood, and used to make change.
• System: '~ perceived whole whose elements 'hang together' because they continually
affect each other over time and operate toward a common purpose".
• Systemic structure: Not just the organizational chart, but the pattern of interrelationships
among all key components of the system, e.g.: Process flows, Attitudes and perceptions
• Complex System Theory: A "complex adaptive system (CAS)", such as a healthcare
organization, is complex because it is diverse and comprised of many interconnected
elements and adaptive because it can learn from experience and change.

58. Health systems  considered "macro-systems."
Each clinical unit and support unit is  a "microsystem

59. Concept's OF SYSTEMS THINKING
• The Five Learning Disciplines
• Personal mastery: "Learning to expand our personal capacity to create the results
we most desire“
• Mental models: Internalized mind-sets and beliefs about the world, as well as short-
term perceptions that are part of everyday reasoning;
• Shared vision: Understanding the deep purpose-the destiny-of the organization that
articulate the organization's reason for existence;
• Team learning: The development of skillful listening, observation, and discussion,
suspending assumptions and accepting diversity, in order to achieve the team's
objectives, solve a problem, create something new, or foster new relationships
within the organization.
• Systems thinking: A practice used to envision how to change systems more
effectively

60. PROCESSES IN SYSTEMS THINKING
Four Levels in Systems:
• Events (occurrences)
• Patterns of behavior (trends over time)
• Systemic Structure (decisions, relationships, efforts, targets,
incentives, etc.)
• Mental models (beliefs; assumptions; mind sets about the ways work
gets done)

61. Steps in Systems Thinking:
1. Describe the problem (one that is chronic, limited in scope, with a known
history) as accurately as possible, without jumping to conclusions.
2. Tell the story; build the model, providing as many divergent ideas as possible.
3. Look for causality-causal relationships between events or patterns of behavior.
E,g, Ask The Five Whys
4. Apply an "Archetype" or pattern of performance to fill in gaps in thinking and
construct consistent hypotheses about the governing forces in systems. E.g.
Mov4ment toward a target, without delay,
5. Determine strategies for solution and their ramifications.
6. Redesign the system. You know you have a good intervention when you can see
the long-term pattern of behavior shift qualitatively as well as quantitatively.

62. Systems Thinking and Process Tools
• Systems thinking diagrams (e.g., causal-loop diagrams) represent cause
and effect relationships, between the labels (A, B, C, D), which are
variables (stated as nouns or noun phrases), not actions. The arrows
indicate influence or causality. The linking words are action verbs.
A => affects => B => affects => C => affects => D
• Process diagrams show a flow or sequence of activities. The labels (A, B, C,
D) are verbs, tasks, or steps. The arrows show sequence and chronology. A
change in one step or element in the process does not necessarily change
other steps or elements: Two well-known process diagrams are the
Shewhart Plan-DoCheck- Act and Deming Plan-Do-Study-Act cycles.
A => then => B => then => C => then => D

63. • 5.4 LEAN THINKING SYSTEM
• "Lean Thinking: A Look Back and a Look Forward,"

64. THE CONCEPT OF CUSTOMER
• A "customer" is one who receives goods or services.
• "External customers" include the patient, family, and others outside
the organization receiving services from the organization or vendors.
E.g. patietns , Physicians, Purchasers
• • "Internal customers" are those performing work, but dependent on
others performing work, within the organization. E.g
Admitting/reception/front office staff, HR staff.

65. TOOLS USED TO IDENTIFY CUSTOMERS AND THEIR NEEDS
• • Identifying customers:
• - "Wheel and spoke" or "sundial": ( Draw a circle in the middle of a page.
Draw lines at angles outward from the circle like the spokes of a wheel.
Use separate pages for internal and external customers, Use this tool
individually or as part of a group process to determine who your
customers are.
• - Customer lists by type: Internal and external
• Customer lists by category: Identify specific types of customers within
certain categories, e.g.: Patients and families, Practitioners/clinicians

66. Identifying customer needs:
• Surveys and interviews-Sample Issues: e.g Which services meet your
expectations?
• Assigned interview process: Each supervisor/manager calls 8-10
members/
• patients/clients per month for feedback on care and service.
• Focus groups:
• Research: Use of available data/information to identify needs.
• Brainstorming