IMPROVING HEALTHCARE QUALITY BY IMPLEMENTATION OF QUALITY IMPROVEMENT PROJECTS

1. IMPLEMENTATION OF
QUALITY IMPROVEMENT PROGRAM
IN HOSPITALS
Dr. Lallu Joseph
Quality Manager, CMC Vellore
Secretary General, CAHO

2. “Every problem has a solution. You just have
to be creative enough to find it”.
■ Travis Kalanick, Co-founder of Uber
“Problems will never be solved within the
culture in which they were created”.
Albert Einstein

3. Quality
■ Quality is meeting or exceeding patients/customers
expectations each time.
■ A better way to define quality is "Conformance to
requirements“
■ Degree to which a set of inherent characteristics fulfils
patients’ requirements, stated or implied

4. History of Quality
Quality in prehistoric era
Post world war Japan
 Deming, Juran
 Focussed on improving processes through
people who used them
 1980- NBC- “If Japan can… why can’t we?”
 The U.S. response- not only statistics but
approaches entire organization- TQM
 ISO 9000 series published in 1987

5. Quality Movement in Healthcare
India, China – 1st Century AD
(Standards on who should Practice)
Licensed Medical Practitioners in Italy
1140
US- 1917- American College of Surgeons-
minimum standards to eliminate poor
care- evolved into accreditation
Shift from Quality Assurance to CQI/ TQM

6. Surge of Accountability in Indian Healthcare
■ The staggering rise in healthcare costs
■ Search for cheaper alternatives- Competition
■ Loss of credibility of the professionals
■ Increased level of education and income
■ Quality awareness

7. Hospitals
“Healthcare Organizations are the most complex
organizations to manage”
Peter Drucker
“Running a Hospital isn’t Brain Surgery….
…..Its Harder

8. Patient interface in healthcare
■ Complex interactions
■ Many stakeholders involved
■ Every patient is different
■ Every situation is different
■ Highly sensitive and emotional
■ Errors cannot happen

10. Who is this? Why is he like this?
1. Little kingdoms
2. Territorial
3. Intrusion into the autonomy
4. Threat
5. Unnecessary

11. Who are these super hero ???

12. 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

13. Principles of Quality Management
■ Strengthen systems and processes
■ Encourage staff participation and teamwork.
■ Base decisions on reliable information
■ Improve communication and coordination
■ Measurement of Quality
■ Continuous Improvement
■ Optimum utilization of resources
■ Demonstrate leadership commitment.

14. Quality Improvement (QI)
■ Quality Improvement (QI) consists of systematic and continuous
actions that lead to measurable improvement in health care
services and the health status of targeted patient groups.
■ The Institute of Medicine (IOM), defines quality in health care as a
direct correlation between the level of improved health services
and the desired health outcomes of individuals and populations.

15. What is a QI Program?
■ Involves systematic activities that are organized and
implemented by an organization to monitor, assess, and
improve its quality.
■ The activities are cyclical so that an organization continues to
seek higher levels of performance.
■ A QI program typically envelops all QI activities within an
organization

16. Why do you need a QI Program?
■ Improved patient health (clinical) outcomes that involve both process
outcomes (e.g., provide recommended screenings) and health outcomes
(e.g., decreased morbidity and mortality).
■ Improved efficiency of managerial and clinical processes by reducing
waste and costs associated with system failures and redundancy.
■ Streamlined and reliable processes are less expensive to maintain.
■ Proactive processes making care, reliable and predictable.

17. STEPBYSTEPGUIDETO
IMPLEMENTQUALITY
IMPROVEMENT

18. Select a QI project
■ Choosing the right project is important.
■ First venture- choose one that will be successful and produce results to have buy-in
■ It does not have to be a large project; sometimes smaller projects that produce
results have a great impact
■ Ideas- Gemba Walk to gather ideas, accreditation results, financial performance,
client/staff satisfaction surveys, KPI.
■ Short time frame- small scale and show results within 3 months?
■ How confident are you that the project can be completed successfully?
■ Does the project have the “Wow! Factor”? Is it an area that desperately needs
improvement?
■ What is the resistance level from staff/managers/leaders? Choose an initial
project that has low resistance.

19. Assemble the QI team
■ Choose your team members based on their knowledge of, and involvement in, the
processes that will be affected by your selected improvement project.
■ Core team of 4-8 individuals, though "ad-hoc" team members can be added.
■ A Project Sponsor has executive authority and serves as a link to management.
Need not be a day-to-day participant but should review the progress on a
consistent basis.
■ QI Team Lead should have clout to implement changes and influence over areas
that are affected by the change. Ex: Medical Director, Nursing Director
■ QI Experts- Familiarity with all processes and QI tools
■ Local Experts- Front line staff
■ Outside Perspective- Fresh perspective to the project
■ QI Project Manager is the QI Team leader, driver, help the team stay on track by
developing timelines, monitoring progress, facilitating team meetings.

20. Develop an Aim Statement
(What are we trying to accomplish?)
■ An aim statement acts as your compass to guide and focus.
■ It is an explicit statement of the desired outcome of your improvement
project.
■ Specific, Measureable, Achievable, Relevant, and Time bound.
■ A good aim statement includes the following components:
– What are we trying to accomplish?
– Why is it important?
– Who is the specific target population?
– When will this be completed?
– How will this be carried out?
– What are our measurable goals?

21. Develop measures
(How will we know the improvement?)
Three types of measures, which are linked to your project aim and goals. These
measures include:
■ Outcome - the ultimate results you are trying to achieve
Examples: Overall wait time for outpatient visit
■ Process - what you do to achieve your outcome
Examples: Number of steps the patient takes during their visit.
■ Balancing - what could we “mess up” while trying to improve the process
Examples: Accuracy and completeness of a form when trying to
streamline a process, etc.

22. Identify change ideas
(changes to be made for the improvement?)
■ Understand the Current Condition
■ Document each step of the process
■ Record the time it takes to complete each process step (cycle time)
■ Record the time it takes to complete the entire process from start to end
(lead time)
■ Record any wait times between each process step or during the process step
■ Document any “waste” you see in the process from your customer’s point of
view.
■ Create a value stream map. This visual depiction of your process greatly
helps the team analyze the process, see where the flow is interrupted or
stopped, and highlight opportunities to reduce waste and improve the
process. Depending on your aim statement

23. Value Stream Map PVT/Current scenario
Pre-registration
Online filling/600
Collect
token
TRIAGE Payment Permission for PVT
Collect token
ISSCC Block
Payment
Permission for GEN
492
20 mins
30mins
10 mins 30 mins
10 mins 10 mins 5 mins
30 mins
10 mins
40 mins20 mins
10 mins
10 mins
10 mins
2 mins
2 mins
Process 1@ PVT
Total VA Time = 37 mins
Total NVA Time = 100mins
% VA Time = 37/137 = 27%
Process 2 (PVT to GEN)
Total VA Time = 54 mins
Total NVA Time = 160mins
% VA Time = 54/214 = 25%
early
appt
PVT
If no Pvt
available

24. Proposed Value Stream Map PVT
Pre-registration
Online filling/600 Collect token TRIAGE Payment
Permission for
PVT/Gen
20 mins10 mins 30 mins
10 mins 10 mins 5 mins
30 mins
10 mins
10 mins
2 mins
Process @ PVT
Total VA Time = 37 mins
Total NVA Time = 100mins
% VA Time = 37/137 = 27%
early
appt PVT

25. ■ Including focus groups, surveys, spaghetti diagrams, swim lane chart,
focus groups, and interviews with staff and customers.
■ Identify opportunities for improvement. Review current process through
the eyes of client
What activities are value added?
What activities are non-value added but necessary?
What activities are non-value added?
■ You want to focus your improvement efforts on eliminating non-value
added activities and reducing non-value added but necessary activities.
■ Do not put a “Band-Aid” on the problems, make sure to drill down to the
root cause of the problem using the 5 Whys or fishbone diagram.

26. Identify and Prioritize Change Ideas
■ Brainstorm ideas and use an affinity diagrams to organize
ideas
■ Identify evidence-based and promising practices
■ Collect feedback from staff and clients on ideas for
improvement
■ Prioritize the change ideas to work on first (e.g. changes that
are easiest to implement and will have the largest benefits to

27. Test change ideas
■ TEST, TEST, TEST before you implement any change ideas
on a large scale.
■ Due to potential staff resistance, it's important to test
changes on a small scale
■ Include feedback from customers and staff when
developing the tests of change

28. Sustaining project improvements
■ Involve and inform your senior leaders
■ Assign ownership to an individual (i.e., QI Coordinator, team lead—there is
not a right answer and may vary by project)
■ Hardwire improvements by involving all staff (i.e., training for staff, job
performance, hiring criteria, job descriptions, etc.)
■ Communicate improvements to clients and allow them to create
accountability
■ Continuously measure and monitor results to ensure your new process is
still working

29. Questionnaire
Agree (%)
Jul-12 May-14 May-16 Jul-17 Aug-18
I have adequate CSSD items for use in my ward/area 91 90 93 96 95
I am comfortable with collection time of un sterile items by the CSSD attenders 83 84 88 95 88
I am comfortable with the delivery time of sterile items from CSSD 90 81 75 89 86
The trolley that delivers sterile items is clean 93 90 93 95 91
The trolley are smooth and noise free 28 28 44 53 61
Items delivered by CSSD have
 no stains
78 93 95 92 94
 no damage 61 58 70 83 83
 are completely sterile 80 88 91 91 93
 are in working condition 52 55 60 71 67
I am satisfied with the packing 77 94 94 87 89
Expiry dates are available in all CSSD items 92 95 100 92 99
The quantity of items present in dressing packs is adequate and are not wasted once opened 73 79 75 79 85
Items are not missing in the packs 40 47 39 54 52
The exact number of items sent for sterilization are received back from CSSD (No due) 20 15 55 68 65
CSSD attenders wear gloves and masks while handling un-sterile items in my ward/area 9 15 27 34 47
CSSD attenders are polite and approachable 52 49 59 77 79
Office staff in CSSD respond to queries promptly 78 80 81 89 79
CSSD is innovative and updates to latest technologies/techniques 60 55 74 69 72
CSSD provides regular updates on handling items, pre cleaning etc. 47 47 66 75 74
I am aware of CSSD practices that are being followed in CMC 95 93 94 97 98
I am fully satisfied with the service provided by CSSD 54 47 66 83 81

30. 28 28
44
53 61
0
10
20
30
40
50
60
70
80
90
100
2012 2014 2016 2017 2018
Percentage
Year
Smooth and noise free CSSD trolleys

31. Smooth and Noise Free
■ Many complaints from patients in the patient feedback surveys about noise
■ Same was echoed by the nurses in the CSSD user satisfaction survey of 2012 with
72% of the nurses endorsing that the trolleys were noisy.
■ Quality improvement team- Mechanical engineering department along with the
CSSD department and Quality Management Cell
■ Nylon to heavy duty polyethylene wheels. Body of the trolleys- reengineered a
sample trolley from stainless steel body to corrosion free aluminium alloy folded
body.
■ A central rib structure running through the trolley was made to support the body
and reduce the vibration of the large trolleys.
■ The interventions helped to bring down the level of noise which was visible from
the response of the nurses, 72% responding that the trolleys were noisy in 2012 to
39% responding that the trolleys were noisy in 2018.

32. Quality of the delivered items
78
93 95
92 94
61 58
70
83 83
80
88 91
91 93
52 55
60
71 67
0
10
20
30
40
50
60
70
80
90
100
2012 2014 2016 2017 2018
Percentage
Year
no stains no damage are completely sterile are in working condition

33. Interventions taken
■ Problem of stains, the pre-wash items from the wards were manually
washed in CSSD, and checked for stains. If stains persisted, they were
soaked in stain remover, washed again with running water before they
were sent to washer disinfector.
■ The washed and dried instruments are checked again for stains before
they are assembled, packed for sterilization. If found to be stained, the
entire cleaning process is repeated.

35. Sharpness check
Sharpness protection Patency check

36. Wastage of items
■ Reduced usage of drums
■ Disposables used for dressing and small procedures was less. Decided
to go for single use disposable packs for consumable like cotton balls,
dressing pads, bandages and roller pads.
■ Dialogued with the users and reduced the consumable and instruments
according to their usage
■ Custom made sets, for ex: Perm Cath insertion set for dialysis and
small suture pack for MICU

37. Custom made set
73
79 75 79 85
0
10
20
30
40
50
60
70
80
90
100
2012 2014 2016 2017 2018
Percentage
Year
Figure- 8: Satisfaction with quantity of items present in dressing packs
adequate and are not wasted once opened

38. Number sent for sterilization (No due)
■ Due to shortage, the damaged items and missing items were often
replaced with delay, which amounted to CSSD having dues with the ward
supplies.
■ The buffer stock in the wards and also in CSSD were increased which led to
the reduction in dues from CSSD.
■ The number of dues was made as an indicator for CSSD and continuously
monitored.
■ With the monitoring and active intervention, the feedback improved from
20%in 2012 to 65% in 2018

39. S. NO ITEMS 2015 2016 2017 2018
1. PER MONTH 143 61 14 6
2. PER YEAR 1716 732 168 72
20
15
55
68
65
0
10
20
30
40
50
60
70
80
90
100
2012 2014 2016 2017 2018
Percentage
Year
Figure 10: Satisfaction with exact number of items sent for sterilization are received back
from CSSD (No due)
REDUCED

40. Usage of PPE
 Continuous training and reiteration on universal precaution,
occupational hazards and infection control practices.
 Discussion of day to day incidents with the attenders and all staff
with frequent department meetings and explaining the hazards
 Trolleys were fabricated with slots for having gloves, hand-rub to
have them accessible for the attenders as they move from ward
to ward, thereby increasing compliance

42. 9
15
27
34
47
0
10
20
30
40
50
60
70
80
90
100
2012 2014 2016 2017 2018
Percentage
Year
Figure- 11: Satisfaction with usages of PPEs (gloves and masks)

43. Attenders behaviour
■ CSSD department took up various measures over the years to engage with the
attenders and to make them polite and approachable.
■ The staff training department organized in-service programs covering soft
skills and professional etiquettes every year focussing on continuous
reiteration.
■ The attenders were encouraged to speak out with supervisors and in the CSSD
department meetings about their feeling and experiences at the user end and
were given solutions for handling such situations. These interventions started
showing gradual improvement in the behaviour of the attenders.

44. 52 49 59
77 79
0
10
20
30
40
50
60
70
80
90
100
2012 2014 2016 2017 2018
Percentage
Year
Figure- 12: Satisfaction with politeness and approachability of CSSD attenders

45. Old
New

46. Overall satisfaction with the service provided by CSSD
■ The overall satisfaction of the
users with the CSSD services
increased from 54% in 2012 to
81% in 2018.
■ The difference between 2012
and 2018 is 27%.
■ It is statistically significant with p
value =0.022 (95% CI: -0.38, -
0.03).
54
47
66
83
81
0
10
20
30
40
50
60
70
80
90
100
2012 2014 2016 2017 2018
Percentage
Year
Figure- 17: Overall satisfaction with the service
provided by CSSD

47. BME Management
■ Data split into two parts; before calibration (2007-2010) and
after (2011-2014)
■ Electrosurgical units, Ventilators, Defibrillators, Infusion
Pumps and ECG Machines were taken

48. Breakdown in percentage
0
50
100
150
200
250
300
350
400
450
500
2007 2008 2009 2010 2011 2012 2013 2014Percentageofbreakdown
Year
Infusion
Ventilators
Defibrillator
ESU
ECG
Breakdown of
• Electro Surgical Units (ESU)
reduced from 453% in 2007 to
54% in 2014
• Ventilators decreased from
455% to 140%
• Defibrillators reduced from
116% to 29%
• ECG from 183% to 77%
• Infusion devices reduced from
379% to 196%

50. TEDS Audit: How many patients have been
given TEDS stockings after they were
prescribed?

51. Introduction
■ TEDS stockings are well-documented to prevent the occurrence of
DVTs and PE’s both in surgical and medical, non-mobile patients (VTE
reducing the risk (June 2015) NICE guidelines CG92)

52. Audit Criteria
■ 100% of patients should receive TEDS stockings if they are prescribed
■ If TEDS stockings are not given to patient, there should be a reason why
they are not given
The audit was performed between 12th June to 18th June

53. Method
■ Auditor checked:
– Are TEDS prescribed on drug chart
– Are they worn by the patient?
■ Patient criteria
– TEDS must be prescribed to be included in audit
– Patient should be under general surgery, located in CMC in
P1,P2,P3 Ward

54. Cycle 1 results
Ward Standard Achieved Not achieved
P1
100% of patients should receive prescribed TEDS
stockings
36/44
81.8%
8/44
18.8%
P2
100% of patients should receive prescribed TEDS
stockings
20/25
80%
5/25
20%
P3
100% of patients should receive prescribed TEDS
stockings
37/44
84.09%
7/44
15.9%
Total
100% of patients should receive prescribed TEDS
stockings
93/113
82.3%
20/113
17.6%

55. Changes implemented in order to re-audit the TEDS
audit
■ Discussion with Sisters in charge at CMC
■ Nurses stated these problems:
– The storage of TEDS stockings in the right size and quantities are not available at
pharmacy
– Doctors do not document clearly whether TEDS should be given
– Patients are not checked for TEDS stockings
■ Suggestions:
– To bleep the admitting doctor to ask whether TEDS should have been prescribed or not
– To include a TEDS tick box in the vascular section of the proforma
– To check patients for TEDS prior to departure from CMCH casualty or OPD to the
inpatient wards
– To try and give TEDS stockings within the first hour of admission, when the other paper
work is being done.

56. Cycle 2 results
Ward Standard Achieved Not achieved
P1
100% of patients should receive prescribed TEDS
stockings
42/44
95.45%
2/14
4.5%
P2
100% of patients should receive prescribed TEDS
stockings
25/25
100%
0/25
0%
P3
100% of patients should receive prescribed TEDS
stockings
43/44
99%
1/44
1%
Total
100% of patients should receive prescribed TEDS
stockings
133/136
97.79%
3/136
2.3%

57. Changes between cycles 1 and 2
Cycle 1 Cycle 2 Percentage difference
Total prescribed and
given TEDs
82.3% 97.79%
15.49%
(more than double
percentage)

58. For future auditing
■ Another re-audit to assess for long-term improvements
■ Implementation of suggestion listed above (following
discussions with the ward sisters), namely:
– To bleep the admitting doctor to ask whether TEDS should have been prescribed or
not
– To include a TEDS tick box in the vascular section of the Doctors Order Sheet
– To check patients for TEDS prior to departure to the inpatient wards from CMCH
Casualty/OPD
– To try and give TEDS stockings within the first hour of admission, when the other
paper work is being done.

59. Systems awareness and systems design are
important for health professionals, but are not
enough. They are enabling mechanisms only.
It is the ethical dimension of individuals that is
essential to a system’s success.
Ultimately, the secret of quality is love.
You have to love your patient…., you have to love
your profession, you have to love your God.
If you have love, you can then work backward to
monitor and improve the system.
Avedis Donabedian